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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15HealthcareInterval Appendectomy vs Conservative Management Alone - A Therapeutic Dilemma - A Retrospective Comparative study at Chennai Medical College Hospital and Research Centre - Irungalur, a Rural Tertiary Care Centre in South India
English0106R. MuruganEnglish S. PadmaEnglish M. SenthilkumaranEnglishBackground: Acute appendicitis is the most common cause of “acute abdomen.” In the 2 to 6 % of cases if not treated early it may develop in to an appendiceal mass. Conventionally conservative treatment followed by interval appendectomy is so far followed. Recent studies discourage the role of interval appendectomy. Hence our study is focused on the pros and cons of interval appendectomy.
Methods: One hundred and fifty patients with the clinical diagnosis of appendicular mass admitted in our hospital from Jan. 2013 to Dec. 2016 - 4years are divided in to two groups I and II. The group I treated with conservative management followed by interval appendectomy. The group II was treated with conservative management alone with continued follow up. In each the age and sex incidence, rate of the recurrence, complications are studied, statically analysed and interpreted.
Results: The age and sex distribution in both groups 1 and 2 showed no much deviation. . In the group I recurrence was observed in 13 (17.3%) and in group II 10 patients (13.3%) that means the rest of (83.7%) and (86.7%) does not need any surgical intervention. Major complications like adhesive obstruction (4%), incisional hernia (1.3%), enterocutaneus fistula (2.6%) and sepsis(6.6%)were observed in interval appendectomy group showing the more morbidities following interval appendectomy. Other pathologies like carcinoma caecum (1.3%), mucocele of appendix (1.3%) and chron’s disease (1.%) were also encountered.
Conclusion: In our study for appendiceal mass management, conservative management with interval appendectomy showed the incidence of appreciable major complication and the incidence of recurrence is low. In conservative management alone with continued follow up the incidence of recurrence is less and the complications are not much. Hence we conclude that the conservative management with continued follow up is the management of choice.
EnglishEnterocutaneous fistula, Interval appendectomy, Mucocele of appendix, PhlegmonINTRODUCTION
Acute appendicitis is the most common surgical emergency which may be complicated by development of an appendiceal mass. The appendiceal mass is formed around the perforated appendix and it consists of an inflammatory mass of the inflamed appendix, adjacent viscera and the greater omentum [1].
An appendiceal mass varies from phlegmon to abscess [2,3] and it develops in 2% to 6% of cases following acute appendicitis [4]. Appendiceal mass is more commonly seen in elderly males [5]. For decades there have been conflicting opinions in the appendiceal mass management. Three modes of management practised now are (1) immediate appendectomy before the resolution of the mass [6, 7, 8], (2) conservative management with interval appendectomy in 6to 8 weeks [9, 10, 11]. (3) An entirely conservative approach without interval appendectomy with regular follow up [12,13,14,15]. Conservative management for appendicular mass initially as described by Oshner [16] has so far been followed routinely by surgeons worldwide. Oschner-Sherren regime includes hospitalisation, bowel rest, broad spectrum antibiotics, hydration and percutaneous drainage of abscess until the mass gets resolved.
Traditionally following conservative management of appendicular mass interval appendectomy (6-8weeks later) is done. Surgeons suggesting interval appendicectomy claim that recurrence of appendicitis is more common and by doing interval appendicectomy the underlying pathology like chron’s disease, mucocele or malignancy can be dealt with in time [3, 13, 17, 18, 20, and 21].
The need for interval appendicectomy after successful conservative treatment has recently been questioned and increasing number of studies on this aspect are pouring in. [22, 23, 24]. The advocates of conservative management alone with prolonged follow up without interval appendectomy, substantiate that the rate of recurrent appendicitis is low (6-20%) and point out that even the potential recurrences have mild clinical course. More over complications include wound and intra-abdominal sepsis, adhesive small bowel obstruction [25].
Immediate appendectomy following resolution of mass may look like easily feasible, safe, cost effective allowing early diagnosis and treatment of unexpected pathology. However it has higher complication rate 36% leading to dissemination of infection, intestinal fistula formation with misdiagnosed of cancer may end up in right hemicolectomy. Sometimes a malignant mass may be mistakenly under treated by appendectomy[26,27]. Because of these complication this method is not practiced nowadays unless there is no response to conservative treatment [28, 29].
Hence we have restricted our study in the management of appendiceal mass to retrospective comparative study on conservative management followed by interval appendectomy against conservative management alone with regular follow up.
MATERIALS AND METHODS
Study settings:
Patient who were admitted in Chennai medical college hospital and research centre Tiruchirappalli a rural tertiary medical care centre were taken up for study.
Design of study:
Retrospective study was conducted in patients admitted in general surgery department Chennai medical college hospital and research centre. The detailed particulars recorded included date of admission, demographics, clinical history, investigation, type of treatment and date of discharge in addition their follow up records with regard to recurrence, and complication during their subsequent visit or through telephonic communication.
Period of study:
Patient admitted to hospital for appendiceal mass from January 2013 to December 2016. Follow up made for minimum 1 year after their discharge.
Sample size:
Hundred and fifty patients admitted with appendiceal mass were selected for the study. Among them one group of 75 patient ( group I ) treated with conservative management followed by interval appendectomy in 6 to 8 weeks time and another group of 75 patients (group II ) were treated with conservative management alone with regular follow up for minimum one year.
Ethics:
The study was preceded after getting approval from institutional ethical committee of CMCH&RC.
Informed consent was obtained from patient or their relatives
Inclusion criteria:
All patients with clinical findings and investigation report in favour of appendiceal mass were included
All age group from 10 to 80 years
Both male and female patient were included
Exclusion criteria:
Patients with generalised peritonitis were excluded.
Patients with other comorbid condition like severe cardiac illness, chronic respiratory diseases, chronic renal failure, and bleeding disorder were excluded.
Non cooperative patients for regular follow up.
Data collection techniques: The patients history clinical findings, investigation reports, mode of management, operative findings, prognosis and follow up details are collected and recorded in Performa prepared.
METHODS
A retrospective study was performed on all the 150 patients admitted with clinical diagnosis of appendicular mass. For all patients the following investigations were done:
Urineroutine 2. Complete blood count 3. Blood sugar/urea/creatinine 4. Serum electrolytes
.X-ray chest / Eletro cardio gram 6 .Ultrasound Abdomen 7.Computed tomography(CT) Abdomen
Initially all were treated conservatively as described by Oshner& Sherren .
After successful management of appendiceal mass patients, group I were advised tocome for interval appendectomy in 6 to 8 weeks. On their readmission they were performed appendectomy either by open or laparoscopic procedure. All were followed up for minimum one year for any complication and to assess prognosis.
In group II patients were advised to come periodically for review or as soon as any recurrence of symptoms appear. Patients with recurrence were admitted and appendectomy done either by open or laparoscopic procedure. Patients who did not turn up for review were closely followed up by telephonic conversation and their complaints if any present were recorded. They were followed up for one to two years. Patients in this group who were anaemic and more than forty years of age were performed contrast enhanced computed tomography(CECT) abdomen, colonoscopy to rule out any other pathology like Cancer caecum, chrons disease.
RESULTS
Outcome of our study are shown in the tables attached. The age and sex distribution in each group are as follows.
With regard to age in groupI the patients at the age of 10 to 20 years were 16 (21.3%) ,21 to 40 yrs 27 (36%), 41 to 60 yrs 30 (40%),and >60 yrs 2 (1.3%). In group II 10 to 20 yrs 14 (18.6%), 21 to 40 yrs 32 (42.6%), 41 to 60 yrs 21(28%), and >60 yrs 8 (10.6%) Table1.
In group I male were 52 (69.3%) and female 23 (30.6%). In group II male were 44 (58.6%) and female 31 (41.3%) Table 2.
The incidence of recurrence in group I based on HPE report was seen in 13 patients (17.3%). In groupII3 (4%) patients came with recurrent appendicitis in 3 months, 5 (6.6%) in 6 months and 2 (2.6%)in 1year. Table3.
With regard to complications in groupI our study reveals that in group I the incidence of complications include sepsis 5 (6.6%),. enterocutaneous fistula 2 (2.6%), incisional hernia 1 (1.3%) and adhesive obstruction 3 (4%). In group II the main complication like bowel obstruction in 3 patients (4%) and intra abdominal sepsis 1 (1.3%) are encountered. Table 4.
Occasional missed pathological conditions seen were Ca. Caecum 1 (1.3%), mucocele of appendix2 (2.6%) and Chron’s disease 2 (2.6%) mostly in group I patients.
DISCUSSION
Early appendectomy is the treatment of choice in acute appendicitis. Once mass has formed the line of management is controversial subject. Current study mostly favours conservative management for appendiceal mass16]. Following conservative management to go for interval appendectomy in 6 to 8 wks period or conservative management alone with regular follow up is still a debatable question.
Following conservative management the intension for doing interval appendectomy is mainly to avoid recurrence. The prospective study done by Youssuf et. al. revealed that interval appendectomy done at 6 and 12 weeks had prevented 10.6% and 6.7% of recurrent appendicitis respectively. [30,31] that means that in 89.4% and 93.3% the interval appendectomy done was unnecessary. In literature the reported rate of recurrence after conservative management alone was 6.2% which was more common during the first six months. The one year recurrence rate was low. (1.9—2.2%) [24,32]. In another random perspective study conducted by Kumar and Jain the recurrence was only 10% where conservative management with regular follow up alone was done [30].
In our study out of the 75 patients in the group I only 13 patients had evidence of recurrent appendicitis on HPE (17.3%) that means rest of the 62 patients (82.7%) has not developed recurrent appendicitis. In the group II out of 75 patients 3 patients came with recurrent appendicitis in 3 months (4%) , 5 patients in 6 months (6.6%) and 2 patients in 1 year (2.6%). that means only 10 patients (13.3%) totally in 1 year period. It shows that the rest of the 65 patients (86.7%) has not developed recurrence. Based on these observations doing routine interval appendectomy is not mandatory to prevent recurrent appendicitis since the results clearly show the recurrence rate is considerably less to go for interval appendectomy straightaway. Moreover recurrence after conservative management has mild clinical course and surgical treatment has little complications.
Another important point to study is the complications related to conservative management with interval appendectomy and conservative management only with regular follow up. In a series of studies the complications following interval appendectomy was 12% to 23% [11,14, 27 ,31 ] which included sepsis, bowel perforation, ileus, fistulas and adhesive obstruction [32] . The relative occurrence was equal to the complications occurring while doing immediate appendectomy for appendiceal mass[4]
Our study reveals that in groupI the incidence of complications include sepsis in 5 patients (6.6%), enterocutaneous fistula 2 (2.6%), incisional hernia1 (1.3%) and adhesive obstruction 3 (4%). In group II the main complication like bowel obstruction in 3 patients (4%) and intra abdominal sepsis 1 (1.3%) are encountered. It clearly shows since the morbidity is more (14.6%) after interval appendectomy it is better to go for conservative management with regular follow up and plan for surgery if recurrence occurs.
In addition , review of literature exposes the occasional findings of missed pathological conditions like Meckel’s diverticulitis, Chron’s disease, malignancy and mucocele of appendix [33,34,35] .In our study we encountered different pathologies like Ca. Caecum (1), mococele of appendix (2) and Chron’s disease (2).
CONCLUSION
Recent studies in literature are mostly not in favour of routine interval appendectomy following conservative management of appendiceal mass. Based on the results of our study recurrence rate in both interval appendicectomy group and conservative management alone group are comparatively less and the complication rate more in the interval appendicectomy group , we conclude it is better to go for conservative management with regular follow up and intervene only when recurrence occur in case of appendiceal mass.
LIMITATIONS
Single centre study may not reflect the general population
Small sample size
Several surgeons with varying experience were involved in the management.
Acknowledgement:
The Authors acknowledge with thanks the great help rendered by DEAN and the Department of GENERAL SURGERY in CMCH & RC for providing access to the records for analysing the data for this study.
The Authors thank the colleagues at CMCH&RC for the encouragement and support provided for bringing out the study in a fruitful manner.
The Authors are grateful to the Authors, Editors and Publishers of all those articles and Journals from where the literature for this article has been reviewed and discussed.
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 - NI
Englishhttp://ijcrr.com/abstract.php?article_id=2443http://ijcrr.com/article_html.php?did=2443
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15HealthcareComparative Evaluation of Salivary pH Using Herbal, Conventional and Remineralizing Toothpaste: In vivo Study
English0714Palak JindalEnglish Sanjyot Anvay MulayEnglish L. RajpurohitEnglishObjective: The purpose of the study was to compare salivary pH of herbal, conventional and remineralizing toothpaste at various time intervals.
Materials and Methods: 45 study participants were selected and divided into 3 groups (15 participants in each group). Resting salivary samples were collected before brushing, immediately after brushing i.e. at 0 minutes and at intervals of 10, 30 and 60 minutes respectively, in sterile beakers and evaluated using a digital pH meter.
Results: The difference in mean salivary pH after brushing was found to be statistically significant for each of herbal, conventional and remineralizing toothpaste at different time intervals. There was a rise in pH seen in all three groups, the least being in herbal toothpaste. However, there was no significant difference in intergroup comparison of different toothpaste at various time intervals.
Conclusion: The pH of saliva increases after brushing in each of the commercially available toothpaste. Herbal toothpaste presented the least change in salivary pH after brushing.
EnglishHerbal, Conventional, Remineralizing, Ph, SalivaIntroduction:
Despite advancements in oral disease science, dental caries continues to be a worldwide health concern affecting humans of all ages, covering over 65% of the population around the world.1 It is critical to comprehend the oral environment so as to bring down the occurrence of caries in a community. Although acid generating bacteria are the etiologic agents, dental caries has been thought of as a multifactorial disease as it is not only influenced by dietary factors but host factors as well.1,2,3 In addition, the role of saliva as a defense system against dental caries is well documented. Saliva plays an important role in optimal oral health and research proposes that salivary pH is even more critical to the development and progression of dental caries than once thought. Low salivary pH promotes the growth of aciduric bacteria which then allows the acidogenic bacteria to proliferate with the production of lactic acid, causing demineralization i.e. initial carious lesion. By controlling pH it is possible to alter the plaque biofilm, remineralize existing lesions, and perhaps prevent the disease altogether.4
Due to the widespread and regular use of toothpaste, they serve as the most effective tool for oral disease prevention and control. A variety of toothpaste is available on the commercial front these days, out of which herbal toothpaste are becoming very popular amongst the masses due to their composition of natural active ingredients and properties such as antioxidant, antiseptic, antimicrobial, and analgesic.5 Preventive remineralizing professional treatments are quite expensive, thus strategies to remineralize the initial carious lesion, as well as prevention of progression of disease, should be given significance.
So the purpose of this study was to evaluate whether herbal, conventional and remineralizing toothpaste has an influence on salivary pH and their comparison at various time intervals after brushing.
Objectives:
To evaluate the pH of resting saliva before and after professional brushing at 0, 10, 30, and 60 minutes, with an herbal toothpaste (Dant Kanti, Patanjali).
To evaluate the pH of resting saliva before and after professional brushing at 0, 10, 30, and 60 minutes, with a conventional toothpaste (Colgate Strong teeth).
To evaluate the pH of resting saliva before and after professional brushing at 0, 10, 30, and 60 minutes, with a remineralizing toothpaste (Vantej, Dr. Reddys).
To compare the pH of resting saliva before and after professional brushing at 0, 10, 30, and 60 minutes, with an herbal, conventional and remineralizing toothpaste.
To compare the alteration of salivary pH at 0, 10, 30, and 60 minutes between that of an herbal, conventional and remineralizing toothpaste.
Methodology:
Type of study– Clinical study with randomized allocation.
Sampling technique – convenient sampling.
Sample selection
Ethical clearance was obtained from the institutional ethics committee.
Patients were screened from the outpatient department of Dr. D.Y. Patil Dental College and Hospital, Pimpri, Pune.
Participants were selected as per the inclusion and exclusion criteria.
A detailed case history was taken.
Written consent was taken from the participants after explaining the procedure to them.
A diet counseling of the participants was done.
Selection Criteria
Inclusion criteria
Patients with carious teeth 3-8.
Patients with OHI- index ranging from 1.3-3.0.
Gender-both males and females
Age group between 20-35 years.
Systemically healthy patients.
Patients with at least 28 teeth.
Exclusion criteria
Smokers and chronic alcoholics.
Patients on any medication within 48 hours.
Pregnant and lactating women.
Patients undergoing orthodontic treatment.
Sample Size
A total of 45 participants were selected and divided into three groups on the basis of different toothpaste used:
Group I Herbal toothpaste (Dant Kanti) N=15
Group II Conventional toothpaste (Colgate Strong teeth) N=15
Group III Remineralizing toothpaste (Vantej) N=15
Standardization of the saliva collection technique
The participants did not eat or drink 2 hours before saliva sample collection which was done between 9-11 am. Saliva collected was at least 4 ml.
The participants did not perform any physical exercise before collection.
Resting whole saliva was collected over a period of 5 minutes.6
Method
After collection of resting saliva, the participants underwent professional brushing for 1-2 minutes per arch using a standardized quantity of toothpaste and polishing brush. The participants were then asked to rinse mouth with 20 ml of water swishing around for 20 seconds. Salivary samples were collected before brushing, immediately after brushing i.e. at 0 minutes and at intervals of 10, 30 and 60 minutes respectively, in the sterile beakers. pH was evaluated using a digital pH meter ( PNS digital pH meter).
The procedure was repeated for each group I, II, III using respective toothpaste.
Salivary pH readings were recorded, tabulated and analyzed statistically.
Statistical analysis
Repeated Measures ANOVA was used to compare the alterations in the mean salivary pH after brushing in each group. Post hoc Bonferroni’s test was used to compare the changes in mean salivary pH after brushing at various time intervals. One Way ANOVA was used to compare the mean of different groups together at various time intervals.
Results:
In the following given tables, the time intervals are denoted as:
Before brushing (bb) = 1
0 minutes = 2
10 minutes = 3
30 minutes = 4
60 minutes = 5
The data was found to be normally distributed and comparisons were analyzed by Repeated Measures ANOVA. Intragroup comparisons made between table 1, table 3 and table 5, showed a statistically significant difference in the mean salivary pH (P-value Englishhttp://ijcrr.com/abstract.php?article_id=2444http://ijcrr.com/article_html.php?did=2444
Dwitha Animireddy, Venkata Thimma Reddy Bekkem, Pranitha Vallala, Sunil Babu Kotha, Swetha Ankireddy, Noorjahan Mohammad. Journal of Contemporary Clinical Dentistry, 2014 Jul-Sep; 5(3): 324–328.
Loesche WJ. Role of streptococcus mutans in human dental decay. Microbial rev. 1986; 50 (4): 353-80.
Van Nieuw Amerongen A, Bolscher JG, Veerman EC. Salivary proteins: Protective and diagnostic value in cariology? Caries Res. 2004; 38: 247–53.
California Dental Hygienist’s Association, Winter 2010; 25(1): 9-14.
Jacob George, Shashikant Hegde, Rajesh KS, Arun Kumar. The efficacy of a herbal- based toothpaste in the control of plaque and gingivitis. Indian Journal of Dental Research, 2009; 20(4): 480-482.
Navin Anand Ingle, Reenu Sirohi, Navpreet Kaur, Amit Siwach. Salivary fluoride levels after tooth brushing with dentifrices containing different concentrations of fluoride. Journal of International Society of Preventive and Community Dentistry, 2014; 4(2): 129-32.
Chand S, Gulati P, Dhingra S, Swatika. Estimating the pH of commercially available dentifrices and evaluating its effect on salivary pH after brushing. Journal of Oral Health and Community Dentistry, 2013; 7(1): 12-16.
Surdacka A, Stopa J. The effect of xylitol toothpaste on the oral cavity environment. The Journal of Preventive Medicine, 2005; 13(1-2):98-107.
Florestano HJ, Myron A Elliott, JE Faber Jr. The effect of citrus juices and various mouth prophylaxes on the oral flora and saliva. J Bacteriol, 1941; 41(5): 605-25.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15HealthcareCorrelation of Liver Transaminases with Platelet count in Dengue patients from Tertiary Care Hospital in Western India
English1522Rajni R. ShivkarEnglish Meghana K. PadwalEnglish Akanksha VaidyaEnglishAim: Dengue is the arboviral febrile illness, which affects the vascular, muscular and hematological systems. Thrombocytopenia is one of the criteria used by WHO guidelines as a potential indicator of clinical severity of infection. Along with that hepatic dysfunction is a well-recognized feature of dengue infection characterized by hepatomegaly and increased serum transaminase levels. Aim of this study was To Assess the liver involvement in dengue infection during critical period of illness by correlating liver transaminase enzymes levels with platelet count in Tertiary care hospital in Western India.
Methods: 80 dengue patients were divided into Group A of 40 cases of dengue with platelet count less than 100000/cmm and Group B of 40 cases of dengue with platelet count more than 100000/cmm. 40 age and gender matched healthy controls were taken into Group C. Under all aseptic precautions, 2 ml of blood sample was collected from ante-cubital vein without occlusion in EDTA vacutainer and 1 ml in plain vacutainer. Separated serum was subjected for measurement of serum AST (Aspartate Transaminase) and ALT (Alanine Transaminase). Whole Blood from EDTA was used for Platelet Count Measurement.
Results: In our study we found levels of AST and ALT were higher in Group A and Group B compared to group C. Mean AST and ALT levels were much higher in group A as compared to group B. Also abnormality in AST levels is higher than ALT in both group A and group B. AST and ALT level > 1000 IU/L were recorded only in group A and not in group B which suggests that severe hepatic dysfunction in terms of rise in AST and ALT are mostly seen in patients with platelet count EnglishDengue, AST, ALT, Platelet CountIntroduction
Dengue or break bone fever is an important and most widely distributed mosquito born viral infection causing febrile illness in tropical and subtropical region (1, 2). Dengue virus (DENV) is a single stranded RNA virus of flaviviridae family and consists of 4 serotypes as DEN- 1, DEN-2,DEN -3, DEN-4.(1) The virus is transmitted by the bite of Aedes aegypti mosquito (1,3). Manifestations of dengue virus infection vary from no symptoms, dengue fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS).(2,4,5) Around 100 million cases of DF and between 2, 50,000 to 5, 00,000 cases of DHF are annually reported to World Health Organization (WHO). (4) Classic dengue fever is characterized by fever, retro orbital headache and severe myalgia. (5) A more severe form of disease is DHF and dengue shock syndrome. (5,6) Abnormal hemostasis and plasma leakage are characteristic features of DHF which are clinically manifested as thrombocytopenia, spontaneous hemorrhage and haemoconcentration near the time of defervescence, typically after 5 days of fever (4,5,7). Thrombocytopenia is one of the criteria used by WHO guidelines as a potential indicator of clinical severity of infection. Also in the most recent WHO guidelines the definition generally describes rapid decline or a platelet count less than 1,50,000 per microliter of blood.(8) Dengue infection has effect on vascular, muscular and hematological system. (9)
WHO 1997 classification categorizes dengue infection as Dengue Fever (DF), Dengue Hemorrhagic Fever (DHF) and Dengue Shock Syndrome (DSS). (10)
DF classification requires fever and at least two of the following: headache, eye pain, myalgia, arthralgia, rash, bleeding, and leukopenia. (10)
Dengue hemorrhagic fever requires all of the following: fever, platelet count ≤100×109/liter, bleeding, and plasma leakage. (10)
Dengue shock syndrome is a case of DHF with either tachycardia or pulse pressure 0.05).
For AST also we found negative correlation (r =-0.42) with that of platelet count in group B and it was statistically significant (P value > 0.05). (Table 6) (Fig3, 4).
When we correlated platelet count with AST and ALT in all dengue patients irrespective of platelet count, we got not only negative correlation between AST(r =-0.36) and ALT (r =-0.39) with that of platelet count but also this correlation was statistically significant (P value 3×ULN) and 24 (60 %) cases had AST level > 200 IU/L (> 5×ULN). While 9 cases (22.5 %) had AST level > 400 IU/L (> 10×ULN) in group A. (Table 2)
(ULN- upper limit of normal)
2 cases (5%) had AST level more than 1000 IU/L with highest enzyme level recorded was 3174 IU/L in group A.
28 (70%) cases had ALT level more than 120 IU/L (> 3×ULN), 9 (22.5 %) cases had ALT level > 200 IU/L (> 5×ULN). While only 2 cases (5 %) had ALT level > 400 IU/L (> 10×ULN) in group A. (Table 2)
Only 1 patient (2.5%) had ALT level more than 1000 IU/L with highest enzyme level recorded was 1079 IU/L in group A.
In this study, 5 (12.5%) cases had AST level more than 120 IU/L (> 3×ULN), 2 (5 %) cases had AST level > 200 IU/L (> 5×ULN) in group B. (Table 3)
Where as in the same group B, 5 (12.5%) cases had ALT level more than 120 IU/L (> 3×ULN), 3 (7.5 %) cases had ALT level > 200 IU/L (> 5×ULN). (Table 3)
Not a single enzyme level was recorded more than 400 IU/L (> 10×ULN) for AST as well as ALT in group B.
As AST and ALT level > 1000 IU/L were recorded only in group A and not in group B, our findings suggests that severe hepatic dysfunction in terms of rise in AST and ALT are mostly seen in patients with platelet count 1000/L is also one of the criteria by WHO 2009 to indicate dengue disease severity.
Our findings are supportive to that of Lee L.K. who studied clinical relevance of AST and ALT for DHF and severe dengue and concluded in their study that aminotransferase levels increased with dengue severity. They also recorded maximum AST and ALT levels during febrile and critical period of dengue illness. (21)
Our findings are also consistent with Dinh the trung et al. where they studied liver involvement associated with dengue in adults of Vietnam and found that transaminase levels increased in virtually all dengue patients and correlated with other markers of disease severity where they studied coagulation profile in particular. (2)
Similarly in Brazil, Luiz José de Souza et al in their study evaluated the impact of dengue virus infection on liver function by measuring aminotransferase in blood samples from serologically diagnosed dengue patients. Aminotransferase levels were used to classify the degrees of liver damage as grade A – normal enzyme levels; grade B – increased levels of at least one of the enzymes; grade C – increased, with at least one of the enzymes being at levels higher than three times the upper reference values; grade D – acute hepatitis, with aminotransferase levels at least ten times their normal values. Of the 169 serologically confirmed cases of dengue 65.1% had abnormal aminotransferase levels and 81 cases were classified as grade B, 25 as grade C and 3 as grade D. They concluded that Liver damage is a common complication of dengue infection and aminotransferase levels are a valuable marker for monitoring these cases. (12)
Further in our study, we found negative correlation between AST (r =-0.26) and ALT (r =-0.29) with that of platelet count but that was not statistically significant (P value >0.05) in group A. (Table 5) (Fig 1, 2)
We found negative correlation between ALT (r =-0.28) and platelet count which was not statistically significant (P value >0.05) in group B.
For AST also we found negative correlation (r =-0.42) with that of platelet count in group B and it was statistically significant (P value > 0.05). (Table 6) (Fig 3,4)
When we correlated platelet count with AST and ALT in all dengue patients irrespective of platelet count, we got not only negative correlation between AST(r =-0.36) and ALT (r =-0.39) with that of platelet count but also this correlation was statistically significant (P value Englishhttp://ijcrr.com/abstract.php?article_id=2445http://ijcrr.com/article_html.php?did=24451) Jayanta Samanta and Vishal Sharma. Dengue and its effects on liver.World J Clin Cases. 2015 Feb 16; 3(2): 125-131.
2) Dinh The Trung, Le Thi Thu Thao, Tran TinhHien, Nguyen The Hung, Nguyen Ngoc Vinh, Pham Tran DieuHien et al. Liver Involvement Associated with Dengue Infection in Adults in Vietnam. Am J Trop Med Hyg. 2010 Oct 5; 83(4): 774-780.
3) Gibbons RV and Vaughn D.W. Dengue: an escalating problem. BMJ. 2002 Jun 29; 324(7353): 1563-1566.
4) Villar-Centeno L.A., Fredi Alexander Díaz-Quijano, Ruth AralíMartínez-Vega. Biochemical Alterations as Markers of Dengue Hemorrhagic Fever.Am J Trop Med Hyg . March 2008; 78 (3 ) :370-374.
5) S. Kalayanarooj, D. W. Vaughn, S. Nimmannitya. Early Clinical and Laboratory Indicators of Acute Dengue Illness. The Journal of Infectious Diseases 1997;176:313–21.
6) Nivedita Gupta, Sakshi Srivastava, Amita Jain.Dengue in India. Indian J Med Res. 2012 Sep; 136(3): 373–390.
7) Libraty DH, Paul R. Young, Darren Pickering, Timothy P. Endya, SiripenKalayanarooj, Sharone Green. High Circulating Levels of the Dengue Virus Nonstructural Protein NS1 Early in Dengue Illness Correlate with the Development of Dengue Hemorrhagic Fever. Oxford Journals.Medicine and Health. The Journal of Infectious Diseases; 2002; 186 (8):1165-1168.
8) Elzinandes Leal de Azeredo . Review Article:Thrombocytopenia in Dengue: Interrelationship between Virus and the Imbalance between Coagulation and Fibrinolysis and Inflammatory Mediators . Mediators of Inflammation Volume 2015 (2015), Article ID 313842, 16 pages.
9) Seneviratne SL, Malavige GN, de Silva HJ. Pathogenesis of liver involvement during dengue viral infections. Trans R Soc Trop Med Hyg. Jul 2006; 100(7):608-14.
10) World Health Organization. Dengue Hemorrhagic Fever: Diagnosis, Treatment, Prevention and Control. Geneva: 1997.
11) World Health Organization. Dengue: Guidelines for diagnosis, treatment, prevention and control. Geneva: 2009.
12) Luiz José de SouzaI, Rita Maria, Ribeiro Nogueira, Leandro Cordeiro Soares I, Carlos Eduardo Cordeiro Soares I et al. The impact of dengue on liver function as evaluated by aminotransferase levels. Braz J Infect Dis . Aug. 2007; 11 (4 ): 407-410.
13) Guzmán, MG and Kourí G.: Advances in dengue diagnosis. Clin. Diagn. Lab. Immunol. 1996; 3:621-627.
14) Tietz N W: Fundamentals of Clinical Chemistry; Eds Burtis CA, Ashwood ER, Bruns DE, 3rd Edn, Philadelphia, WB Saunders Co., 1987; pp372
15) Bergmeyer HU, Bowers GN Jr., Hørder MH, Moss DW: Provisional recommendations on ifcc methods for the measurement of catalytic concentrations of enzymes part 2. Ifcc method for aspartate aminotransferase. Clin Chem 1977; 23:887-899
16) Bergmeyer HU, M. Horder and R. Rej: Approved Recommendation (1985) on IFCC Methods for the Measurement of Catalytic Concentration of Enzymes Part 3. IFCC Method for Alanine Aminotransferase. J. Clin. Chem. Clin. Biochem. Vol. 24, 1986, pp. 481-495
17) Vajpayee N, Graham SS, Bem S: Basic examination of blood and bone marrow; Eds, McPherson R, Pincus M: Henry's Clinical Diagnosis and Management by Laboratory Methods. 23rd Edition, St. Louis, Elsevier, 2017; pp519
18) Kuo C.H., Tai D.I., Chang-Chien C.S. et al. Liver biochemical tests and dengue fever. Am J Trop Med Hyg .1992;47(3):265-70.
19) Wong M, Shen E. The utility of liver function tests in dengue. Ann Acad Med Singapore. 2008;37:82–3
20) Nguyen T.H., N.T. Tieu The impact of dengue haemorrhagic fever on liver function. Research in Virology. July–August 1997; 148 (4): Pages 273-277.
21) Lee LK, Victor C. Gan, Vernon J. Lee, Adriana S. Tan, Yee Sin Leo,and David C. Lye. Clinical Relevance and Discriminatory Value of Elevated Liver Aminotransferase Levels for Dengue Severity. LoSNegl Trop Dis : v.6(6); 2012 Jun.
22) Pancharoen C., Rungsarannont A., Thisyakorn U. Hepatic dysfunction in dengue patients with various severity. J Med Assoc Thai2002;85Suppl1:S298-301.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15HealthcareInvestigation of the Efficiency of Endotracheal Aspiration by Sheep Lung Modeling: Experimental Study
English2329Faruk CicekciEnglish Ata OzturkEnglish Inci KaraEnglishBackground: The clinical and radiological evaluation of endotracheal suctioning (ETS), which is performed as a blind procedure has incapacities. The purpose of this study was to indicate that angulation of the ETT tube tip to both lung sides is an important factor in the progression and orientation of the ETSC in the bronchial system.
Method: The five sheep lung was dissected to reveal bronchial system. anesthesiologist inserted the catheter into the endotracheal tube at neutral tube tip position. Then tube tip was rotated 30º and 45º to the right and 30º and 45º to the left respectively. The advancement and orientation of ETSC in the tracheobronchial system were dynamically observed with 625 insertion done by 5 different anesthesiologists.
Results: The sheep tracheobronchial system can be used as a model in morphological studies. The known access limitations of an ETSC were documented in the animal model by dynamically observing the advancement and orientation of an ETSC.
Conclusion: It can be entered both bronchial systems by obtaining a least 30° of angle to ETT tip position towards each lung side.
EnglishSheep lung modelling, Endotracheal suctioning catheter, Selective endotracheal suctioning, Intubation tube positionINTRODUCTION
Endotracheal suctioning (ETS) is one of the most common supporting prevention in intensive care units (ICU) to suction overage respiratory secretions and improve respiratory function 1,2. The “blind” nature of advancing the suction catheter may be one of the major limitations to the procedure, and may lead to less efficient suctioning. However, failure to aspirate both sides of the bronchial system can have numerous detrimental effects 2-4. The effectiveness of tracheal suctioning is directly proportional to the advance and orientation of the suction catheter to both sides of the tracheobronchial tree and the vacuum characteristics 1. Although generally single-sided suctioning is performed in ETSC, practitioners believe that they have completely performed the procedure because they do not take into consideration the complex morphological characteristics of the bronchial system. Connection of the developed complications to nonstandard techniques or causes such as removing from the ventilator rather than single-sided suctioning results in delays in diagnosis and interventions 1-5. In order for ETSC to be effective, it constitutes a necessity to enter the right and left bronchial system. Since the control of ETSC through imaging techniques is not possible for every patient, it is necessary to determine the effectiveness of the procedure on a model consistent with the human.
Therefore, this study aimed to indicate that angulation of the ETT tube tip to both lung sides is an important factor in the progression and orientation of the ETSC in the bronchial system.
MATERIALS AND METHODS
The study protocol was reviewed and approved by the ethical review board of Selcuk University, Veterany Medicine (Ref No:2015-06-29). Sheep lung were supplied from Konya municipality slaughterhouse a day before experiment.
The five sheep lung was dissected to reveal bronchial system. Bronchial tissue, 2x1 cm from the carina and 1x1 cm from the bronchial branching areas was removed to open windows to observe the movement of the ETSC (Fig 1). The sheep lung was placed on the table so that the membranous part of the trachea faced the dorsal. The trachea was intubated by using a size 8.5 endotracheal tube (B?çakç?lar I.D 8.5, Istanbul, Turkey) so that the tip of the tube was 1 cm above the carina and the cuff was inflated with 20 cm water pressure. In order to indicate the orientation, the blue line on the endotracheal tube was fixed precisely on the middle anterior-posterior line of the trachea. This position was designated the neutral position. An aspiration catheter (B?çakç?lar 16 Ch, Istanbul, Turkey) was used for ETS. Primarily, anesthesiologist inserted the catheter into the endotracheal tube at neutral tube tip position. Then tube tip was rotated 30º and 45º to the right and 30º and 45º to the left respectively. Each anesthesiologist inserted the catheter five times for each tube tip position for each sheep lung. Each anesthesiologist conducted 25 insertion on each of the five lungs. Thus a total of 625 insertion were performed on five different sheep lung. The side (left or right sheep lung) and the final point that the catheter reached were noted.
The data were loaded on Statistical Package for Social Science (SPSS, 20.0 SPSS FW, SPSS Inc., Chicago, IL., USA), which assessed the frequencies and percentages of categorical variables.
RESULTS
After rotation of ET left (30°- 45°) or right (30°- 45°) the intubation tube tip faces to lateral walls of trachea instead ventral. This leads the first contact of ETSC after ET tip to lateral wall rather than medial wall of any main bronchus as in neutral position. After initial contact, catheter advancement was similar as in neutral position. In either rotation, the ultimate point of advancement were the relevant dorsal basal segment of the diaphragmatic lobe.
A total of 625 insertions were conducted. At neutral position of ET, the catheter was entered to the left in 117 (93.6%) insertions and to the right in 8 (6.4%) insertions. In neutral position, unlike other anesthesiologists, the anesthesiologists 4 and 5 entered to the right in lung 2 and 3.The ETSC was oriented left bronchial tree (100%) in all left oriented positions of ET (30º or 45º). Similarly the ETSC was oriented right bronchial tree (100%) in all right oriented positions of ET (Table 1).
DISCUSSION
The primary objective of this investigation was to evaluate the ETSC advancement and orientation in the tracheobronchial tree and the factors responsible for differences.
Considering that it is necessary to enter and clean each lobe bronchus for the effective aspiration6,7, it should be presented how successfully this can be performed through current aspiration techniques.
Detecting the access limitations of ETSC on the patient brings along a number of difficulties. It is almost impossible to check through radiological examinations performed during the procedure whether both bronchial systems are accessed for an effective ETSC5. In conventional radiological studies that constitute the basis of control, the image is masked by lung parenchyma. Right and left main bronchus can be viewed up to 3-4 cm after the carina and then the image gets lost inside lung parenchyma. Another disadvantage of conventional imaging is that it is two dimensional and does not provide any information regarding the position of ETSC in the lumen. In this case, the position of ETSC and its relationship with the lobar bronchial orifices opening to the main bronchi cannot be determined although they are on the same plane. Pathological appearances that are frequently observed in intensive care patients such as atelectasis, pleurisy and infiltration make the radiological follow-up of ETSC much more complicated.
According to observations on sheep model, the access limitations of an ETSC can be divided into three problematic areas. These are the space distal to the intubation tube cuff, the bronchial system that cannot be accessed and the bronchi that cannot be aspirated in the successfully accessed bronchial system.
The space between the tube cuff and the contact point of ETSC at right or left main bronchial lumen is the most proximal problematic area. The main source of the secretions that accumulate around the cuff is the bronchial system that cannot be accessed. In addition, the late aspiration of the accessed side also contributes to the accumulation of secretions. ETSC is suspended between the tip of intubation tube and the point where contact with bronchial wall. The carina is bypassed in almost all cases. This means not only the cuff region but the carina and most proximal part of (first cm) of main bronchi are not aspirated. This differs from the orientation that occurs after contacting the carina in the case of foreign-body aspiration 8.Then catheter is directed from medial to posterior aspect of bronchial lumen in the few millimetres of advancement where the effective aspiration come on because the secretions accumulate on posterior surface of bronchial lumen because of gravity (Fig 1).
While one of the lungs is aspirated, only rarely can the other lung be aspirated with the current form of ETS. Right is dominant side in ETSC advancement in human lung (80-92%). Therefore, advancing ETSC into the left is difficult (8-20%), which means that one side cannot be aspirated easily 2,3,5,9,10. Even in cases performed by experienced practitioners, with the head positioned and a special catheter used, the left bronchial system can be accessed at a rate of 50% 3,5,7,9,11.
Only bronchoscopy guarantees the aspiration of the tracheobronchial system by entering both sides 5,12. Entering into the left bronchial system does not guarantee successful entry into the right bronchial system in the same session, which means that the bronchial system is usually aspirated in one side only during ETS. In our study, it was achieved a rate of 86% dominancy on one side in neutral position, which is close to the rate of 80 – 92% stated for humans in the previous studies (Fig 2).
The blind nature of procedure and the estimation that the main bronchi is reservoir of accumulated secretions result in whether lobe bronchi were reached during ETS was left out of the clinical evaluation. The drainage of both upper lobes and the right middle lobe while the patient is in a supine position, without any problems in most cases, has made the clinical examination of these lobes unnecessary. In this study, the catheters reached the diaphragmatic lobe bronchi in the sheep lungs, which are considered the equivalent of the lower lobes in humans, in all of the experiments (100%). However, the apical, cardiac intermediate and apico-cardiac lobes in sheep could not be accessed in any of the insertions (0%), which supports the idea that the right upper, middle and left upper lobes in humans cannot be accessed with the ETSC (Fig 3).
The factors that affect the access facility of an ETSC can be grouped into four main categories. These are endotracheal tube tip position, morphological structure of the tracheobronchial system, factors related to the practitioner and the material characteristics of the catheter.
First of all, intubation tube tip position was not evaluated as a factor but it is stated that the orientation of the ETSC progressed depending on the angulation of the carina. During the observations through the windows opened to the tracheobronchial system, the intubation tube tip angulated toward the ventral side of the trachea. This situation results from the curved body structure of the intubation tube, which becomes straight in the tracheal lumen and (tip portion after cuff preserve its natural form) then has its tip propped up after the cuff, causing a slight curve toward the ventral side. As ETSC was directed ventrally just after ET tip, the accumulated secretions on dorsal surface of lumen around ET cuff and carina was impossible (Fig 4,5,6).
Since the ET tip ended in angulated manner after cuff, the rotational movement of ET changes the position of ET tip13. After rotation of ET to left (30°-45°) or right (30°-45°) the intubation tube tip faces to lateral walls of trachea instead ventral (Fig 7). This leads the first contact of ETSC to lateral wall rather than medial wall of any main bronchus. In real situation deviation of ET from neutral position is not uncommon14. Minor position changes such as fixing of ET to left or right side of mount, the stirring of patient head, the burden of auxillary pipes on ET are few of agent that may facilitate the change of neutral position of ET and may lead inevitable effects on ETSC orientation13,15,16. The access rates of 30o and 45o rotation to left and right displays in Table 2. The entrance rates at 30o and 45o for oriented side were %100. Both bronchial systems can be accessed by rotation of ET even 30o to left or right. Considering that it is stated in the previous studies that access to the left occurs at rates between 8–15% with the aspirations performed by conventional methods, our method (rotation of tube at 30o or 45o) which provides full access to both systems, will prove to be highly useful.
Although there is no intervention facility for ETSC after ET, the path of ETSC is determined by morphologic features of tracheobronchial tree (as latter mention practioners factor can effect just before first contact).The morphology of the tracheobronchial system in the study implies lumen dimensions, lobar bronchial orifice position and as well as their angles17,18. ETSC movement will continue until the lumen dimension becomes equal to or smaller than the catheter size. It was observed that lumen dimensions in the study did not have any effect on the catheter movement.
Solid objects, such as a catheter, resist to change their shapes and move in the direction of the applied force. The main axis in the bronchial system is the plane that the right of left main bronchi constitutes extending from the proximal to the distal. Due to its material characteristics (hardness and stiffness) and absence of guiding mechanism, an ETSC cannot advance at right or near-right angles19. Unreasonable efforts result in bending and kinking of the catheter20. In the study, the ETSC could not access the apical, cardiac intermediate and apico-cardiac lobes in sheep due to their right angle to the right and left main bronchial system (0%). Right upper and middle lobes and left upper lobes in humans, which are considered to be the equivalent of the aforementioned sheep lobes, also intersect at which shows a similar angulation an angle of approximately 90° to the main bronchus, making catheter access impossible.
The ultimate point of that the ETSC reaches in the bronchial system is the dorsal basal segment of the diaphragmatic lobes in sheep (100%). This is consistent with the morphologic features mentioned above. Taking into account of sheep model, the ultimate point of advancement in human will be medial or posterior segments of the lower lobes.
Four out of five lobes in single-sided ETS and three out of five lobes in bilateral ETS cannot be aspirated because of the difficulties presented above. Considering that it is necessary to aspirate all the lobes for effective aspiration, it can be concluded that effective aspiration cannot be performed even with bilateral ETS.
Although access to the left bronchial system at neutral position was dominant in the study (93.6%), some anesthesiologists (6.4%) entered the right bronchial system. We postulate that personal factors caused experimenters 4 and 5 to enter the right bronchial system in all experiments on lungs 2 and 3 at neutral position; these personal factors include which hand they used, catheter pushing speed, manoeuvres to the right or left while pushing and other skills they gained before hand. Regardless, the fact that all anesthesiologists consistently accessed the same side in all tube positions supports our assertion.
The AARC report21 mentions scarcely on aspiration competence. The rational of the report is at functional manner that satisfactory aspiration means sufficient oxygenation of blood. The estimation is based on two consideration; the ciliary motion can afford to carry the secretions of even the most distal parts of bronchial system to proximal and just after the tip of ET, the ETSC contacts with secretions and aspiration takes place22,23. Contary to assertions in AARC, the experiment revealed the central regions such as carina and cuff periphery was not aspirated.
AARC recommends swallow aspiration because of less traumatic potential than deep aspiration21 but neither technique is superior for removing secretions. The secretions of unaspirated side inevitably accumulate and may result in devastating complications1. The current guidance on endotracheal suctioning may need to be investigated the optimal methods to aspirate more central parts of tracheobronchial tree such as mucus slurper24, mucus shaver 25 or modification of ET tip confugration to maintain contact just after ET tip rather than to major on present tecniques and strategies.
The scope of the modelling focused on the first two factors; the tube tip position and morphological structure of the tracheobronchial system. The third and fourth factors, based on the practitioner and the physical and material characteristics of the catheter, were not included in this study. Further studies could be designed for evaluating the effects of these factors.
CONCLUSION
In our study, by using a sheep lung model, we endeavoured to show that the ETSC was not located sufficiently. We believe this is because the tracheobronchial system anatomy are not well understood and catheter movement cannot be foreseen by most clinicians26. The influence of the intubation tube tip position and practitioner factors on the effectiveness of ETS are points that have not been discussed in the previous studies properly. Direct observation of the procedure on a dynamic model will help to identify previously ignored factors in clinical and radiological evaluations. The fact that ETSC does not have a guidance mechanism causes ET tip position to become the main determinants in guiding the ETSC. Therefore, we consider that it can be entered both bronchial systems by obtaining a 30° of angle towards each side.
The authors role and responsibilities:
F.C: Data collection, study design, literature search, analysis of data, review of manuscript
A.A.O: Study design, manuscript preperation, review of manuscript
I. K: Analysis of data, manuscrits preperation,review of manuscripts
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.
No conflicts of interest declared.
There was no financial support for the study. The expenditures were paid by the contributers of manuscripts.
The authors of manuscripts certify that they have no affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=2446http://ijcrr.com/article_html.php?did=2446
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Daroszewski M, Szpinda M, Flisi?ski P, Szpinda A, Wo?niak A, Kosi?ski A, Grzybiak M, Mila-Kierzenkowska. Tracheo-bronchial angles in the human fetus - an anatomical, digital, and statistical study. Med Sci Monit Basic Res. 2013;16(19):194-200.
Ceschinski H, Henkes H, Weinert HC, Weber W, Kühne D, Monstadt H. Torquability of microcatheter guidewires: the resulting torsional moment. Biomed Mater Eng.2000;10(1):31-42.
Scott AA, Sandham G, Rebuck AS. Selective tracheobronchial aspiration. Thorax. 1977;32(3):346-8.
Restrepo RD, Brown JM, Hughes JM. AARC Clinical Practice Guidelines. Endotracheal suctioning of mechanically ventilated patients with artificial airways 2010. Respir Care 2010;55(6):758-64.
Rubin BK. Physiology of airway mucus clearance. Respir Care. 2002;47(7):761-8.
Ficker JH. Physiology and pathophysiology of bronchial secretion. Pneumologie. 2008;62 (1):11-3.
Kolobow T, Li Bassi G, Curto F, Zanella A. The Mucus Slurper: A novel trachealtube that requires no tracheal tube suctioning. A preliminary report. Intensive Care Med. 2006;32(9):1414-8.
Berra L, Coppadoro A, Bittner EA, Kolobow T, Laquerriere P, Pohlmann JR, Bramati S, Moss J, Pesenti A. A clinical assessment of the Mucus Shaver: a device to keep the endotracheal tube free from secretions. Crit Care Med. 2012;40(1):119-24.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15HealthcareEvaluation of Scientific and Ethical Status of Drug Promotional Literatures (DPLs) for Ethical Medicinal Drug Promotion
English3035Pratit P. VyasEnglish Amol L. BhaveEnglishBackground: The study was aimed to evaluate the scientific and ethical status of Drug Promotional Literatures (DPLs) using World Health Organization (WHO) guidelines for ethical medicinal drug promotion. This would in turn create awareness amongst healthcare providers about DPLs and thus would promote rational use of drugs.
Methods: This cross sectional observational study was carried out at Department of Pharmacology, Medical College Baroda. DPLs were collected and evaluated for scientific and ethical status as per guidelines by WHO for ethical medical drug promotion.
Results: Out of total 616 DPLs collected, 371 satisfied the inclusion criteria. Out of them, 180 DPLs [48.5%] were of single drug whereas, 191 were of fixed dose combinations (FDCs) [51.5%] of which only [31.9%] FDCs were approved as per drug controller general of India (DCGI). Drugs acting on endocrine system [19.67%] were the most commonly promoted drugs.11.05% of DPLs were having catchy terms. Graphical presentations were present in [19.40%] of DPLs of which bar diagram [47.22%] was maximum, followed by line diagram [19.44%], tables [16.67%]. We observed that [11.61%] of DPLs were having irrelevant pictures while rest [88.39%] were with relevant pictures. In DPLs with relevant pictures, maximum pictures provided were of package of dosage form [41.36%] followed by photo/picture of woman [26.06%].35.04% of DPLs turned out to be promoting polypharmacy.
Statistical representation of data in the form of p-value related to drug under promotion was mentioned in [3.77%] of DPLs.
Conclusions: We hereby concluded that drug manufacturers didn’t follow the WHO guidelines for ethical medicinal drug promotion, thus failing to fulfil the rational promotion of drugs.
EnglishWHO guidelines, Drug promotional literatures, Ethical medicinal drug promotion, Drug marketingINTRODUCTION
According to World Health Organization (WHO), Medicinal Drug Promotion refers to “all informational and persuasive activities by manufacturers and distributors, the effect of which is to induce the prescription, supply, purchase, and/or use of medicinal drugs” (WHO 1988).[1]
For the purpose of drug promotion pharmaceutical companies usually use Direct-to-physician(DTP) technique as a major marketing strategy, the primary goal being to convince physicians to prescribe the manufacturer’s product through these advertisements.[2]Other than this, pharmaceutical companies also use visual aids, flip charts, leave-behinds , advertisements , audio-visuals and gifts as modes of drug promotion.[3][4]
In India, promotional activities standards are set by self-regulatory code of pharmaceutical marketing practices, January (2007) and governed by Organization of Pharmaceutical Producers of India (OPPI), and by National legislation.[5]However, it has been consistently shown by many studies that the information/data provided through drug advertisements is inconsistent with the code of ethics.[2][12-14]As it has been repeatedly shown by various studies that physician’s behaviour is influenced by pharmaceutical promotions[4],hence promotion in the form of financial or material benefits should not be offered to or sought by health care practitioner to influence them in prescribing drugs.[1]
Majority of the health professionals are dependent on commercial sources of drug information from medical representatives, drug advertisement brochures etc., and it has great impact on physician’s behaviour of drug prescribing pattern.[6]Furthermore, most of the of physicians were of the view that drug promotional activities has undoubtedly have an influence on their prescribing practices.[8][15]Even physicians who are using scientific literatures as commercial source of information to obtain knowledge could be influenced by the same without being aware of it.[16]
Often on many occasions, the materials provided through promotions are often misleading and confusing,[6][7] but on the contrary doctors get motivated by the intensive marketing made by pharmaceutical companies.
WHO has published criteria for ethical medicinal drug promotion in order to support and encourage the improvement in health care system through rational use of drugs.[1] These promotional activities highly influence the prescribing behaviour of health care providers. In this era of growing popularity of evidence based medicine, it becomes utmost essential for critical analysis of drug promotional literatures to promote rational drug prescribing. [8][9]
Hence this study is aimed for evaluating the scientific and ethical status of the drug promotional literatures using WHO criteria for ethical medicinal drug promotion in order to overcome their inaccuracies and inadequacies. Such studies would play a pivotal role in pursuing health care providers towards the ultimate goal of rational prescribing.
MATERIALS AND METHODS
STUDY DESIGN
Cross sectional observation study
DATA COLLECTION:
SAMPLE SIZE
Minimum 300 DPLs
INCLUSION CRITERIA
All DPLs were collected from following sectors:
Pharmaceuticals firms
Medical representative association
Private practitioners
Multispecialty hospitals.
EXCLUSION CRITERIA
DPL for medicinal devices and equipments (insulin pump, blood glucometer, etc)
DPL for Homeopathic and Ayurvedic medicines
Drug list
Drug monographs
Doubling of DPLs
METHODS OF SAMPLE COLLECTION
Following telephonic contact and conversation, details of our study were explained and appointment timings were fixed for collection of DPLs. As per inclusion and exclusion criteria, DPLs were collected and sorted.
The same protocol was followed for all sectors during the period of data collection.
DATA ANALYSIS
Data analysis was done under following headings :
Type of drugs:
Total DPL collection,
Classification of collected DPLs,
Product type (single/FDC)
Status of FDC as per DCGI.[18]
Pharmacological groups and DPL collection through various clinical disciplines
Catchy terms
Graphical Presentations :
Bar diagrams
Line diagrams
Tables
Cost comparison
Pseudographs, etc
Pictorial contents :
Statistical representation, data of Post marketing surveillance and Polypharmacy
Data were entered using Microsoft Office Excel 2007. Descriptive statistics were produced for each outcome.
RESULTS
TYPE OF DRUGS:
A total of 616 DPLs were collected, out of which 371 DPLs met the inclusion criteria and rest 245 DPLs were excluded. Out of total DPLs evaluated, 180 DPLs [48.5%] were of single drug whereas, 191 were of Fixed dose combinations [51.5%].In addition, we further evaluated the status of all 191 FDCs and found that out of total, only [61; 31.9%] FDCs were approved as per DCGI.[18][Figure no. 1]
PHARMACOLOGICAL GROUPS and DPL COLLECTION THROUGH VARIOUS CLINICAL DISCIPLINES :
Drugs acting on endocrine system [73; 19.67%] were the most commonly promoted drugs; followed by miscellaneous agents [70; 18.88%], agents affecting haematology system [59; 15.9%], antimicrobials [57; 15.36%], etc. In miscellaneous group, the most commonly promoted were dietary supplements [27; 38.57%].[Figure no. 2]
Maximum DPLs collected belonged to obstetrics and gynaecology [142; 38.27%] discipline followed by medicine [64; 17.25%], surgery [57; 15.36%], skin and v.d.[46; 12.4%], etc.
CATCHY TERM :
In our study we have observed that 41 [11.05%] DPLs having catchy terms.
GRAPHICAL PRESENTATION :
In our study some forms of graphical presentations [72; 19.40%] were present in DPLs. We observed that bar diagram [34; 47.22%] was the most commonly used graphical presentation, followed by line diagram[14; 19.44%], tables[12; 16.67%], cost comparison[6; 8.33%], etc.[Figure no. 3]
PICTORIAL CONTENT :
Of the total DPLs [371], different pictorial contents were observed amongst 353 DPLs and were evaluated. 41 [11.61%] DPLs were having irrelevant pictures while the rest [312; 88.39%] had relevant ones. In DPLs with relevant pictures, maximum pictures provided were of package of dosage form [146; 41.36%] followed by photo/picture of woman [92; 26.06%], picture of human organ [16; 4.53%], picture of adult male [10; 2.83%], etc.[Figure no. 4]
STATISTICAL REPRESENTATION :
We also evaluated that statistical representation of data in the form of p-value related to drug under promotion and found it to be mentioned in 14 [3.77%] DPLs.
DATA OF POST MARKETING SURVEILLANCE:
1 DPL [0.27%] was found to provide data/information regarding post marketing surveillance
POLYPHARMACY :
130 [35.04%] DPLs turned out to be promoting polypharmacy.
MISCELLANEOUS :
Paper quality, print and colour were excellent in almost all DPLs. Considerable difference/dissimilarity was found in brand name and generic/INN with respect to font size and colour. We found in our study that font size of brand name was 2-4 times the font size of generic/INN which does not meet the standard guidelines.
DISCUSSIONS
Drug Promotional Literature (DPL) is readily available, easily accessible and important source of drug information. Direct-to-physician (DTP) marketing is one of the important facet of the promotion of pharmaceuticals.[4][8][17] Every year, new drugs enter Indian market of which majority are “me-too” products. Very few of them are genuine innovations and rest are with some altered formulations. As a result, more number of FDCs are added to more than 20,000 drug formulations present already in the market. [6]
Promotional activities were concentrated not much on innovative medicines’ exposure, but on publicizing fixed dose combinations not recommended by WHO. Drug manufactures spend more than $ 11 billion each year in drug promotion and marketing. Around $ 8000 to $ 13000 per year is spent on each healthcare professionals for drug promotional activities. [7] Pharmaceutical industries do not follow WHO guidelines while promoting their drug products, thus accelerating their commercial motive rather than ethical educational aspect. As a result, little therapeutic information is provided to help physicians to reach any rational decision about promoted drug.
Each DPL was analysed keeping in mind the objectives of the evidence-based medicine with the help of available evidences in the medical literature for its concurrence with WHO guidelines for ethical medicinal drug promotion.
A total of 616 DPLs were collected in our study, out of which 371 satisfied the inclusion criteria and rest 245 were excluded. Out of 245 excluded DPLs, most common were drug list (68.17%) followed by doubling of DPLs (15.51%), ayurvedic products (7.76%) , protein supplements(4.49%),etc. It was observed from studies viz. Mali et.al. and Khakhkhar et.al. that DPLs with Fixed dose combinations (FDCs) mounted to 41% and 49% respectively. Our study findings also fall in line with above studies with total number of DPLs having FDCs amounting to 51.5% and rest (48.5%) are having single drugs. Similar findings were also supported by another study by Jadav et.al. in which DPLs promoting FDCs were 46%. In addition to that, we further evaluated the status of FDCs and observed that of total, only 31.9% FDCs were approved as per DCGI. Hence the efforts of pharmaceutical corporate in providing only the rational elements seem to be questionable.
Some studies viz. Khakhkhar et.al. and Jadav et.al. respectively have revealed that anti-microbial agents (19% , 18%) followed by drugs acting on Cardiovascular system(19% , 16%) are the most commonly promoted drugs in DPLs. In another study by Mali et. al., it was observed that chemotherapeutic agents (26%) were the maximally promoted groups. In contrast to the above studies we observed that drugs acting on endocrine system (19.67%) were the most commonly promoted drugs in DPLs; followed by miscellaneous group (18.88%), agents acting on blood (15.9%), anti-microbial (15.36%), etc. Amongst miscellaneous group, most common promoted were dietary supplements (38.57%). In contrast to our findings, in another study carried out in Nepal by Kadiralam et.al. revealed dietary supplements to be only in 3% of DPLs.
Studies like Khakhkhar et.al. and Jadav et.al. have observed catchy terms to be there in 72% and 95% of DPLs respectively. In contrast to the above study findings; in our study we have found that DPLs with catchy terms were only 11.05%.
Our study observation revealed some of the drug promotional literatures using graphical presentations to depict some literary information. A total of 72 graphical presentations were evaluated in 19.4% of DPLs. Similar findings have been also highlighted in other studies viz. Mali et.al. and Jadav et.al. in which graphical presentations were given in 16% and 12% of DPLs respectively.
Unlike some other studies[2][11] in which pseudographs (29%) and columns were being maximum respectively, our study observations state, bar diagrams (47.22%) to be most commonly used graphical presentation followed by line diagram (19.44%), tables(16.67%) , cost comparison(8.33%),etc, whereas pseudographs falling almost towards the end.
As a part of persuasive communication, these promotional brochures were made striking using various types of pictures and devoting majority of the literature area to non-specific and less accurate contents which represent the tendency of pharmaceutical companies of wasting money in printing eye catching glossy paper promotional literature deprived of important therapeutic information. Unlike other studies viz. Mali et al and Khakhkhar et. al., which showed the presence of irrelevant pictures in 90% and 69% of DPLs respectively, our study found that only 11.61% of DPLs were having irrelevant pictures. DPLs with relevant pictures (88.39%) observed package of dosage form (41.36%) to be maximum followed by photo portrait woman (26.06%), picture of human organ (4.53%), picture of adult male (2.83%), etc. Having maximum photo images of women indicates the urge to create attraction for particular product.
We also evaluated that statistical representation of data in the form of p-value related to drug under promotion and found it to be mentioned in only 3.77% of DPLs. Our findings are supported by another study of Khakhkhar et.al. showing only 7% of literature having data related to statistical representation. Data of post marketing surveillance were only given in 1 DPL. These important aspects related to long term safety of drugs were also grossly neglected. We have observed in our study that 35.04% DPLs were promoting polypharmacy. Of the various references we compared, none of them were having data regarding post marketing surveillance and polypharmacy.
Paper quality, print and colour were excellent in almost all DPLs. Considerable difference/dissimilarity was found in brand name and generic/INN with respect to font size and colour. We found in our study that font size of brand name was 2-4 times the font size of generic/INN which does not stand ideal.
Printed promotional material is an important source of information. Most health professionals are dependent on commercial sources of drug information from medical representatives, drug advertisement brochures etc., and it has great impact on prescribing behaviour [6].
In India, there are regional Ethics Committees for complaints against unethical drug promotion advertisements. Drug controller authority takes necessary legal steps in response to such complaints to against drug manufacturers and distributors[6]. Forwarding more complaints about irrational promotion to regulatory authority by cautious doctors might lead pharmaceutical industry to incline toward self-regulation. Government regulatory bodies must play a proactive role where code of ethics is failing. Wherever the hospitals are attached to the academic institutes, prior scrutiny of the promotional material for authenticity of the content could be done by respective department of pharmacology.
The strength of our study stands in the way of having critically evaluated drug promotional literatures which are the major source of establishing interaction between clinicians andmanufacturers which in turn promote rational usage of various agents in order to better the health status of community.
We do accept and feel that in this vast field of drug promotion strategies, we have evaluated only one type of promotional activity, i.e. Drug Promotional Literatures (DPLs). Hence the need always stands to assess other forms of drug promotional activities also i.e. visual aids, leave behinds, leaflets and audio visuals.
CONCLUSIONS:
We hereby concluded that drug manufacturers didn’t follow the WHO guidelines for ethical medicinal drug promotion, thus failing to fulfil the rational promotion of drugs. On the basis of the observations of our study, we have observed that many of the literatures were having non-scientific and unethical information based on which it is suggested that physicians need to be aware of the flaws in promotional literatures before accepting it as valid source of drug information.
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.
DECLARATIONS
Source of Funding: No
Conflict of interest: No
Ethical approval: Approval taken from Institutional Ethics Committee for Human Research (IECHR) Medical College and SSG Hospital, Baroda.
EC Reg No: ECR/85/Inst/GJ/2013
Englishhttp://ijcrr.com/abstract.php?article_id=2447http://ijcrr.com/article_html.php?did=2447
Ethical criteria for medicinal drug promotion. World Health Organization [Online]. 1988 May 13; Available from:
http://www.who.int/medicinedocs/collect/edmweb/pdf/whozip08e/ whozip08e.pdf.
Mali SN, Dudhgaonkar S, Bachewar NP. Evaluation of rationality of promotional drug literature using World Health Organization guidelines. Indian J Pharmacol 2010;42:267-72.
Cooper RJ, Schriger DL. The availability of references and the sponsorship of original research cited in pharmaceutical advertisements. CMAJ 2005;172:487-91.
Cardarelli R, Licciardone JC, Taylor LG. A cross-sectional evidence-based review of pharmaceutical promotional marketing brochures and their underling studies: Is what they tell us important and true? BMC Fam Pract 2006;7:13.
OPPI code of pharmaceutical marketing practices. Available:http://www.indiaoppi.com/OPPI%20Code%20of%20 Marketing%202007.pdf [Online]. 2007 Jan.
Gopalakrishnan S, Murali R. India: Campaign to tackle unethical promotion. World Health Organization. Essential drugs monitor [Online] 2002. p. 22. Available from: http://www.apps.who.int/medicinedocs/pdf/s4937e/s4937e.pdf
Rohra DK, Gilani AH, Memon IK, Perven G, Khan MT, Zafar H, et al.Critical evaluation of claims made by pharmaceutical companies in drug promotional material in Pakistan. J Pharm PharmSci 2006;9:50-9.
Villanueva P, Peiro S, Librero J, Pereiro I. Accuracy of pharmaceutical advertisements in medical journals. Lancet 2003;361:27-32.
Lexchin J. Enforcement of codes governing pharmaceutical promotion: What happens when companies breach advertising guidelines? CMAJ 1997;156:351-6
Khakhkhar T, Mehta M, Shah R, Sharma D. Evaluation of drug promotional literatures using WHO guidelines. J Pharm Negative Results 2013;4:33-8.
Jadav SS, Dumatar CB, Dikshit RK., Running title: Drug promotional literatures (DPLs) evaluation as per World Health Organization (WHO) criteria. J App Pharm Sci, 2014; 4 (06):084-088.
Stryer D, Bero LA. Characteristics of materials distributed by drug companies. An evaluation of appropriateness. J Gen Intern Med. 1996;11:575–83.
Smart S, Williams C. Evidence based advertising. Half of drug advertisements in BMJ over six months cited no supporting evidence? BMJ. 1997;315:1622–3.
Mindell J, Kemp T. Evidence based advertising. Only two fifth of advertisements cited published, peer reviewed references? BMJ. 1997;315:1622.
Drug Promotion what we know, what we yet to learn. Geneva: World Health Organization and Health Action International; 2005.
Gitanjali B, Shashindran CH, Tripathi KD, Sethuraman KR. Are drug advertisements in Indian edition of BMJ unethical? BMJ [serial online] 1997.
Medhi B, Prakash A. 2010. Ideal characteristics of promotional literature. In: Medhi B and Prakash A, ed. Practical Manual of Experimental and Clinical Pharmacology. 1st edition. India: JBPMP 342-45.
FIXED DOSE COMBINATIONS APPROVED BY DCG (I) SINCE 1961 TILL NOVEMBER, 2014. Available from:http://cdsco.nic.in/writereaddata/Aprroved%20FDC%20list%20till%20november%202014.pdf
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15HealthcareVisual Outcome and Complications of Resident Operated Phacoemulsification Cases Done by Third Year Residents in a Regional Institute of Ophthalmology
English3638Garima AgrawalEnglish Swati RavaniEnglish Shashank M. PatelEnglishIntroduction: Phacoemulsification is a state of the art surgery for cataract removal. Phacoemulsification involves removing the opacified crystalline lens via emulsification and aspiration followed by implantation of an intraocular lens. The surgery though simple has a learning curve. We designed a study to document the visual outcome and complications of resident operated phacoemulsification cases done by third year residents in a regional institute of ophthalmology.
Aim: We designed a study to document the visual outcome and complications of resident operated phacoemulsification cases done by third year residents in a regional institute of ophthalmology.
Material and Methods: Phacoemulsification was performed by Junior Resident under guidance of one Assistant Professor. The visual outcome and complications of the procedure were noted.
Results: We report good visual outcome with few complications in supervised resident performed phacoemulsification.
Discussion: Phacoemulsification can be performed by Junior Resident in a supervised manner with good postoperative results. This has also been documented by other studies.
Conclusion: Phacoemulsification can be performed by Junior Resident in a supervised manner with good post operative results.
EnglishPhacoemulsification, Resident casesIntroduction:
Phacoemulsification is a state of the art surgery for cataract removal. Phacoemulsification involves removing the opacified crystalline lens via emulsification and aspiration using an ultrasonic handpiece followed by implantation of an intraocular lens. 1The surgery though simple has a learning curve. Jaffe NS et al in their book on Cataract Surgery observe that phacoemulsification brings with it unprecedented demands on the surgeon. 2 They report that surgeons need good manual dexterity , expertise with the operating room microscope along with a thorough knowledge of intraocular anatomy and phacodynamics.2 The beginner surgeons at our teaching Institute who have no prior experience of cataract surgery are therefore started with extracapsular cataract extraction followed by manual small incision cataract surgery before making them perform phacoemulsification . We designed a study to document the visual outcome and complications of resident operated phacoemulsification cases done by third year residents in a supervised manner at a regional institute of ophthalmology.
Aim:
The study is designed to document the visual outcome and complications of phacoemulsification surgery done by third year residents in a supervised manner at a regional institute of Ophthalmology.
Material and Methods:
Third year residents who have completed six months of their residency as junior resident three with satisfactory post operative results in at least five extra capsular cataract surgery and 20 manual small incision cataract surgeries were considered eligible for phacoemulsification . Mastery over capsulorrhexis was essential. Every case was supervised by one Assistant Professor with an experience of at least 1500 phacoemulsification surgeries with satisfactory post operative results. We documented twenty phacoemulsification surgeries performed by third year residents from July 2017 to December 2017.
Patient selection was done for beginner resident phacoemulsification cases .Patients with well dilated pupil, clear cornea, nuclear sclerosis grade two or three with normal ocular surface were included in the study. Exclusion criteria included nuclear sclerosis grade one, nuclear sclerosis grade four or five, semi-dilated pupil, corneal opacities, other ocular co-morbidities as glaucoma, ocular surface disorder, retinal disorders. Uniocular patients were excluded from the study.
All patients were subjected to a thorough pre-operative work- up including visual acuity, intraocular pressure, slit lamp examination and indirect ophthalmoscopy . Blood pressure was measured and complete systemic work up including cardio-respiratory status was done. Blood and urine investigations were ordered including complete blood count and random blood sugar. History of drugs including Tamsulosine was documented.
The pre operative preparation was done as per protocol .The surgery was carried out in the operation theatre .The student must have assisted at least 1000 phacoemulsification surgeries and performed few steps of phacoemulsification under guidance in at least 10 surgeries in conjugation with one Assistant Professor. A thorough knowledge of pharmacodynamics was essential for the student.
We use a standard phacoemulsification technique . A temporal clear corneal incision is made. Two side ports are constructed. Capsulorrhexis and hydroprocedures are performed. Koch’s stop and chop technique is employed at our institute. 3 Nuclear emulsification is followed by cortical removal. Foldable intraocular lens is then inserted followed by viscoelastic wash and closure. Every step of the surgery was closely supervised by one Assistant Professor. All intraoperative complications and their management were documented. Postoperative visual acuity was documented at first day post operative, one week and six weeks. Best corrected visual acuity was documented at six weeks. Postoperative complications were documented .
All patients were given topical antibiotics, steroids and lubricating drops postoperatively for six weeks as per protocol.
Results:
Residents were able to perform phacoemulsification under guidance. They were able to perform incision, capsulorrhexis, hydroprocedures, trench making. Initially help was needed in the first cracking of the nucleus. Later they were able to chop and emulsify the nucleus pieces. Irrigation aspiration was supervised though complications were common if resident was not careful. Intraocular lens insertion went successfully. The coordinated management of resident and assistant professor were able to give good postoperative results. We concentrated on teaching the residents one step in every surgery ,taking over the other steps as per the case to achieve good post operative results.
Twenty resident phacoemulsification cases were documented. Posterior capsular rent was noted in one case while emulsifying the last nuclear segment. It was managed with anterior vitrectomy, followed by intraocular lens implantation. Subsequently cortical and viscoelastic removal was done in a supervised manner. There were no major intraoperative complications in nineteen cases.
The postoperative best corrected visual acuity as documented at six weeks was 6/6 in seventeen cases. Three cases had best corrected visual acuity of 6/18, 6/24, 6/18 due to dry age related macular degeneration.
There were no major post operative complications. Mild corneal edema was noted in eight cases which resolved at one week postoperative with topical steroids.
Discussion:
We report good visual outcome with very few complications of resident performed phacoemulsification cases under close supervision.
Randleman JB reported quality visual outcomes of resident performed phacoemulsification cases. They reported intraoperative complications in 5% cases with significant reduction in vitreous loss rates after the first eighty resident cases. Surgical competency improves significantly with increasing surgical experience.4
Thomas R et al reported an acceptably low rate of surgical complications and good visual outcomes by residents learning phacoemulsification in a supervised manner.5
Conclusion:
Resident performed phacoemulsification cases had good visual outcome with few intraoperative and postoperative complications. We conclude that phacoemulsification can be performed safely by third year residents in a supervised manner with good visual outcomes and few complications.
Acknowledgement
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles journals and books from where the literature for this article has been reviewed and discussed.
Ethical Clearance: Taken
Informed Consent: Taken
Source of funding : None
Conflict of Interest: None
Englishhttp://ijcrr.com/abstract.php?article_id=2448http://ijcrr.com/article_html.php?did=2448
David Allen. Phacoemulsification. In: Yanoff M, Duker JS, editors. Ophthalmology.4th Ed. China: Elsevier Saunders;2009. p 361-365.
Jaffe NS, Jaffe MS, Jaffe GF. Machine Parameters. In: Jaffe NS, Jaffe MS, Jaffe GF. Cataract Surgery and its Complications. 6th Ed.Mosby;1997.p 57-64.
Jaffe NS, Jaffe MS, Jaffe GF. Surgical Technique. In: Jaffe NS, Jaffe MS, Jaffe GF. Cataract Surgery and its Complications.6th Ed.Mosby;1997.p 65-131.
Randleman JB, Wolfe JD et al. The resident surgeon phacoemulsification learning curve. Arch Ophthalmol 2007;125(9):1215-1219.
Thomas R, Naveen S, Jacob A, Braganza A. Visual outcome and complications of residents learning phacoemulsification. Indian J Ophthalmol 1997;45(4):215-219.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15HealthcareProfile of Poisoning at a Tertiary Care Hospital in Haryana
English3945Navtej SinghEnglish Tarun AroraEnglish Jyotsna SinghEnglishIntroduction: Poisonings continues to be a frequent reason for admission to hospitals and intensive care units in the developing countries. The fatal issue is often related to delay in diagnosis and improper management.
Aim: The purpose of the study is to report the morbidity, mortality and survival pattern of poisoning cases received at a tertiary care centre at Haryana. The focus was also in depicting the signs and symptoms of various poisoning for early diagnosis.
Methods: This was a retrospective study consisting of patients admitted with poisoning during the period January 2017 to December 2017, in a tertiary care centre in Haryana. Total of 200 patients admitted with poisoning were analyzed. Diagnosis was made on basis of history of exposure and characteristic clinical picture, with emphasis given to age, sex, month of year, motive of poisoning, type of compound, clinical presentation and final outcome of poisoning
Results: Among the 200 cases, 127 (63.5%) cases of aluminium phosphide and 58 (29%) cases of organophosphate poisoning were observed. Few cases of tricyclic antidepressents poisoning (2%), zinc phosphide poisoning (2%) herbicide (2.5%), phenol and transfluthrin (all out) ingestion(0.5%) each were reported. The most common motive of poisoning (95.5%) was with a suicidal intent. Out of the 200 poisoning cases 146(73%) cases admitted survived on treatment and a mortality rate of 27% was reported. 90.7% of the deaths were due to aluminium poisoning ingestion, while mortality due to organophosphate poisoning was just 7.4%. Maximum cases were observed in the age-group of 21-30 years which holds 72 (36%) cases followed by 49 (26%) cases in 31-40 years. Males outnumbered females in every age group. 92.5% of the cases were from rural background, while only 7.5% of the urban inhabitants were affected by poisoning.
Conclusion: Aluminium phosphide ingestion is the leading cause of deaths due to poisonings observed in Haryana, predominantly seen in youths residing in rural areas with male preponderance. Low cost of these compounds, easy availability at peak moments of frustration; due to marital discord, poor economic growth has pushed up the incidence of self poisoning. Hence up gradation of primary health care facilities to render immediate management of these poisoning cases could go a long way in helping to reduce mortality and morbidity.
EnglishPoisoning, Aluminium phosphide, Organophosphate, SuicidalIntroduction
Poisoning among all age groups and both sexes is known worldwide. Poisoning accidental or intentional is significant contributor to mortality and morbidity all over the world. According to WHO pesticide self poisoning or accidental exposure is responsible for afflicting 300.000 people every year with 22000 deaths in developing countries especially those from rural background. 1 India being an agriculture based country use of pesticides, rodenticides and herbicides remain the main agent of pest control and crop protection. Low cost, easy availability, efficacy of action and rapid death have made these compounds the agent of choice for self poisoning. 2 It has been estimated that 5-6 persons per lakh of population die due to poisoning every year in India. This figure could just be the tip of the iceberg since most cases of poisoning actually go unreported. High mortality could be due to lack of hospital services in the vicinity, delayed transport ,non availability of specific antidote, and increased patient to care givers ratio or an improper management.3
Aluminium Phosphide (AIP) commonly known as celphos or wheat pill is used to preserve grains all over the world, is one of the dreaded poisons encountered in toxicology. AIP when ingested releases phosphine gas on contact with moist surfaces or HCL that causes cell hypoxia due to inhibition of oxidative phosphorylation leading to circulatory failure.4 Patients can present clinically with gastrointestinal hemorrhage, arrhythmias, shock, renal, and hepatic failure and CNS disturbances. Patients remain mentally clear till cerebral anoxia due to shock supervenes resulting in coma. ECG changes ranging from ST segment elevation or depression, PR and QRS interval prolongation, complete heart block and fibrillation has been observed. Toxic chemical myocardial inflammation manifests as depressed left ventricular ejection fraction. Treatment of AIP poisoning is mainly supportive and there is no specific antidote. Mortality with AIP poisoning is very high, almost100%.5
Organophosphate compound (OPC) a common pesticide used in agriculture for crop protection is implicated in accidental and suicidal poisoning with 4-30% mortality in Indian studies.1 Acetylcholine is a neurotransmitter present at the neuromuscular junction in peripheral and central nervous systems. Acetylcholineesterase (AChE) is an enzyme that hydrolyses and breaks down acetylcholine. Organophosphate compounds cause phosphorylation and inactivation of this enzyme leading to accumulation of acetylcholine. The inhibition of AChE with subsequent accumulation of acetylcholine at synapses results in overstimulation and disruption of neuronal endings in both central and peripheral nervous system. Complications of OPC poisoning include aspiration of gastrointestinal contents, excessive secretions, neuromuscular involvement, intermediate syndrome, septicemia and adult respiratory distress syndrome. 6,7 The fatal issue is often related to delay in diagnosis and improper management. Management is severe poisoning is difficult requires intensive care management with atropine and oxime cholinesterase reactivators. Key to survival lies in early diagnosis followed by rapid decontamination and definitive therapy.
Zinc phosphide a rodenticide, dark grey crystalline compound used to kill field mice and rat. It reacts with water and gets converted to phosphine gas in the body on ingestion in the stomach. Zinc phosphide is used widely by young members of society for suicidal attempts.8 The clinical symptoms arise due to metabolic and non metabolic effects of phosphine gas and manifest as hypotension, shock, pericarditis, pulmonary edema and congestive heart failure.9 The mortality rate varies from 37%-100% as no antidote is currently available nor a specific treatment protocol has been provided. Gastric flushing and charcoal treatment only is recommended. Apart from gastrointestinal symptoms, Chug et al.199810 reported in their studies that oliguria, coma, convulsions, hepatotoxicity and thrombocytopenia could be seen in zinc phosphide poisoning. Due to extent of damage to lungs and heart patients are lost at early stages.
Phenol (carbolic acid) is an oldest antiseptic agent used in households for cleansing floors. Phenol is a protoplasmic poison with corrosive local effects. Phenol when ingested causes extensive local corrosions. Excruciating pain, nausea vomiting, sweating and diarrhea are the presenting symptoms. Severe GIT burns and strictures are its long term complications. Systemic manifestations develop after 5-30 minutes post ingestion producing hypotension, tachycardia/ bradycardia, dysarrythmias , seizures acidosis hemolysis, meth-haemoglobinemia and shock. Dose is between3-30gram is lethal.11 Early medical intervention following immediate medical evaluation helps in survival. Gastric lavage is not recommended if phenol is ingested. Immediate administration of olive oil and activated charcoal by nasogastric tube is necessary. Decontamination of skin and eyes with copius amount of water followed by undiluted polyethylene glycol is recommended. Intravenous fluid administration and dopamine infusions can be lifesaving. Arrhythmias are corrected with lidocaine infusion, convulsions with diazepam.12
Deaths due to tricyclic antidepressant (TCA) poisoning is due to arrhythmias or hypotension mainly due to quinidine like actions on heart tissues.13 TCA are extensively used for management of depression and other psychiatric diseases.TCA poisoning caused by excessive medication accounts for 270 deaths per year in the United Kingdom. Symptoms include elevated body temperature, blurred vision, dilated pupils, sleepiness, confusion seizures and rapid heart rate even cardiac arrest. Seizures and coma are common complications. Fatality is a result of cardiovascular toxicity. Prompt transport of patient to the nearest emergency department is implicit. Sodium bicarbonate is still considered the treatment of choice apart from supportive management.14
Since there is paucity of literature regarding poisoning in Haryana, this particular observational study was undertaken. Aim to predict morbidity, mortality and survival pattern of poisoning. An attempt has been made to provide recommendations for treatment and prevention of death by poisons on rampage in Haryana.
Materials and methods
The study constituted patients with poisoning admitted to intensive care unit between January 2017 to December 2017 at BPS Government Medical College for Women, Sonepat, Haryana a referral tertiary care center. Ethical clearance was obtained from hospital administration for disclosure of record details only for academic purpose. However, confidentiality was maintained as neither name or CR number of the patient was documented. A total of 200 poisoning cases were analyzed during this period. Diagnosis was made on basis of history of exposure and characteristic clinical picture. Plasma cholinesterase levels could not be analyzed because of non-availability in the hospital. Data was collected from all poisoning cases in a detailed performa as per history given by the patient or relatives, with emphasis given to age, sex, month of year, motive of poisoning, type of compound, clinical presentation and final outcome.
Treatment was started as per the hospital protocol for managing patients of poisoning. The body was washed with soap and water after removal of clothes. Nasogastric tube was passed to decompress the stomach and gastric lavage was done in all the patients. Patients of OPC poisoning were treated with atropine, pralidoxime and respiratory support if required. A loading dose of 3 mg of atropine was given immediately followed by a maintenance dose of 8 mg hourly until target end point of atropination was achieved documented by (1) a clear chest on auscultation with no wheeze (2) heart rate of >72 /min and (3) Dilated pupils. PAM was administered with a bolus of 2gm over a period of 4 hours. Patient with Glasgow coma scale of less than 8 with hypoxia were intubated and mechanically ventilated.
Patients with aluminium phosphide poisonings were confirmed by history and typical odour of the compound. Airway protection was given before gastric lavage. Gastric lavage with diluted potassium permanganate, coconut oil, sodium bicarbonate and activated charcoal was performed. Supportive treatment with IV fluids, magnesium sulfate infusion was given. Vasopressors and ionotropic drugs were administered in patients with hypotension. Patients with unstable hemodynamic were mechanically ventilated. Monitoring of hemodynamic parameters, urine output , arterial blood gases and blood pressure was regularly done in all patients of poisoning . All patients were dealt up to recovery or death from poisoning.
Results
A total of 200 cases of poisoning due to various compounds were registered during the study period from January 2017 to December 2017 in the emergency department.
The socio-demographic profile of the patients is as follows. The age of the patients varied from 11 to 75 years. Maximum cases were observed in the age-group of 21-30 years which holds 72 (36%) cases followed by 49 (26%) cases in 31-40 years and 18.5% of poisoning cases in 11-20 years age group. Males outnumbered females in every age group except above 71 years and above. Male to female ratio is 2.33:1. The most striking feature was observed in 51-60 years age group male to female ratio afflicted by poisoning was highest10:1 as given in the Table 1.
The above table shows that meiosis and blurred vision was the most common manifestation found in 101(79.5%) of the total 127 cases of OPC poisoning. The peripheral muscarinic (SLUDGE) symptoms occurred acutely within minutes. Salivation however was observed in only 5.5% of the cases. Lacrimation, Diarrhea, diaphoresis was seen in 15.7% of the cases on presentation. Urination was not found as a presenting symptom in either of the cases. Nausea and vomiting was the next common presenting symptom found among 57 out of the 127 OPC cases. Respiratory symptoms followed next in the table with 40% presentation as wheezing. Nicotinic effects of OPC poison resulted in hypertension in 45(35.4%) and paralysis in 7(5%) cases. 12 cases were received in an unconscious state. Seizures were reported in 5 cases only.
Intermediate Syndrome (IMS) develops 24-96 hours after exposure and reflects a prolonged action of acetylcholine on the nicotine receptors. The clinical features are muscular weakness in the ocular, neck, bulbar, proximal limb and respiratory muscles. The risk of mortality is due to the associated respiratory depression. Most patients with intermediate syndrome develop respiratory failure, which requires mechanical ventilation.10% cases required ventilatory support. OPC poisoning resulted in a mortality rate of 7%. Following atropinization 20% cases reported toxic psychosis after treatment.
Out of the 5 cases of herbicide poisoning received, isopropyl salt of glycophosphate was ingested by 3 cases and 2-D aminosalt 58,52 24-D poisoning was seen in the rest. Herbicides present OPC and carbamate like poisoning. All cases presented with nausea and repeated vomiting. Seizures was observed in one patient who failed to survive on ventilatory support.
Gastrointestinal symptoms are usually first to appear after exposure to celphos or AIP poison. Nausea and vomiting occurred in all the cases however abdominal pain and diarrhea was not reported among any . 76.2% of the cases had hypotension on arrival in emergency along with GI symptoms. 19(32.7%) cases were received in an unconscious state.6 cases presented with respiratory difficulty and had lung crepts. 33(57%) cases had multiorgan dysfunction on hospital presentation. 9 cases were put on ventilator support.
Discussion
Poisoning is a health hazard and the preferred means of committing suicide in males and females in India. The common causative factors which led to self poisoning were marital disharmony, poor economic conditions and disagreement with family members.15
Interesting change in trend and nature of poisoning has been observed. Among the 200 cases of poisoning,127(63.5%) cases of AIP poisoning and 58(29%) cases of OPC poisoning have been observed. New chemicals such as tricyclic antidepressents (2%) and zinc phosphide (2%) herbicide(2.5%), phenol and transfluthrin (0.5%) being consumed with a suicidal intent has been observed in the present study. In contrast other studies1,2,3,7 have reported organophosphates form the largest bulk of pesticide poisoning. Gargi et al 200316, at Amritsar found the poisonings with organophosphate among 17.64% and aluminium phosphide in 38.23% cases. A similar study done in the Haryana-Rohtak belt by Siwach SB et al17 in 1995 observed aluminium phosphide as the most commonly abused substance followed by OPC and zinc phosphide in 67.8,13.9 and 4.3% cases respectively.
In the present study the victims involved were maximum seen in the 3rd decade, 72 cases(36%) followed by 49(24.5%) cases in the 4th , 37 cases in the 1st (18.5%)and 23 cases (11.5%)in the 5th decade. Poisoning cases have been observed in the elderly individuals also 5.5% incidence in the 51-60 and 3.5% incidence in 61-70 year age group. 79% victims are the young population less than 40 years and 21% above 40 years of age in the present study similar to Syed MA et al. 2014,3 who observed 80.2% of the patients less than 40 years and 19.8% above 40 years. Gargi et al 2003,16 reported the incidence of poisoning of 45.5% in the 21-30 years age group and poisoning in younger population of 11-20 years at 18.5% in accordance with the present study.
Most of the poisoning cases were from rural areas of Haryana 92.5%, predominantly in the young population with male preponderance. Mean male female ratio being 2.33:1 a pattern similar to that reported elsewhere in India.1,2,7,15,16.
Villages are more affected by the menace and failure in the life and tolerance to life is better understood by the urban population in the present study in accordance with other studies.1,2,7 In contrast incidence of poisoning was observed higher in urban areas51.4%and lower in rural areas 45.59% by Gargi et al 2003.16
A season wise variation is seen in the present study, distribution is highest during the rainy , followed by summer season and least in winter season. In summer (March-May) 53 cases, Rainy season (June –August) 60 cases, Spring (Sept- Nov) 49 cases and 37 cases in the winter (Jan- Feb) were observed in the present study. Syed et al, 20143 recorded the highest incidence during summer , followed by rainy and least in spring season.
The present study is in unison with other recent studies that suicidal poisoning is the highest among the population.5,17 In the present study 95.5% cases with suicidal motive and 4.5% of accidental exposure to pesticides, have been observed similar to Syed et al 20143. In contrast a study by Gargi et al 200316, maximum cases were of accidental poisoining 44.4%, followed by 40.60% cases of suicidal poisoning and 3% homicidal poisonings were reported.
The overall mortality rate for OPC poisoning varies from 4%- 30%.18 In the present study mortality due to OPC poisoning was 6.8% similar to Safdar et al;200319. These patients had reported late to the tertiary care centre or developed lung complications on ventilator.
Deaths due to aluminium phosphide poisoning is under reported in Indian subcontinent with mortality varying from 37-100%, because of its easy availability since 1992.Mortality due to aluminium phosphide poisoning in the present study is 38.6% consistent with the literature. Out of the 127 cases of aluminium phosphide poisoning 49 cases who consumed fresh tablets of celphos died while remaining 78 cases consumed denatured tablets survived.
Most symptoms and signs in OP poisoning resulted due to excessive muscarinic stimulation in the present study consistent with previous studies. 10% of the patients developed intermediate syndrome in the present study. Reported frequency of intermediate syndrome varies from 8% to 49%. 2
Conclusion: Aluminium phosphide is the leading cause of deaths due to poisonings observed in Haryana, predominantly seen in youths residing in rural areas with male preponderance. Lack of education, poverty, stressful life, cheap and easy availability of these compounds were the reasons behind the poisoning. Hence upgradation of primary health care facilities to render immediate management of these poisoning cases could go a long way in helping to reduce mortality and morbidity. Strict implementation of pesticide act and new laws and legislations can be made by the government regarding the free sales of the chemical compounds. Social awareness regarding handling of these compounds and their lethal consequences is required at grass root level especially the rural population. Psychological counseling and educating the youth about the dangerous effects of poisoning should be undertaken by the government on priority basis. Alternatives to AIP or celphos and OPC which are less toxic should be developed by the horticulture department. The use of bio- pesticides, known for their purity, effectiveness and nontoxic nature should be promoted. Organic pesticides like salt spray, neem enriched sprays, mixture of chrysanthemum flower tea extract, mineral oil and citrus oils with cayenne pepper should be marketed by the government to reduce the health hazards Lab research should be taken to find specific antidote for aluminium phosphide poisoning.
Conflict of interest
The authors declare that they have no conflict of interest concerning this article. . No funding was required for data collection, data analysis and data interpretation of the stud
Acknowledgement
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are 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=2449http://ijcrr.com/article_html.php?did=2449
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15Life SciencesComparative Evaluation of Bioproductivity Studies of Simarouba, Pongamia and Jatropha for Biodiesel Parameters
English4651Gayatri VaidyaEnglish G. R. NaikEnglishThe vegetable oils (non-edible) have proved to be promising feedstock for the biodiesel production. The present study deals with the evaluation of Simarouba , Jatropha and Pongamia for their growth performance from the seed germination to the first bearing, production and characterization of oil and biodiesel as they are considered as biofuel crops capable to grow on waste lands. Variations in bioproductivity of the plants were compared every six months for four years of investigation and biodiesel parameters were also studied and analyzed statistically. Identification of better genotype or superior phenotype having better yield and oil content is the important step in the tree improvement strategies involved in the biofuel program. The results obtained from the studies on the bioproductivity traits, their correlation and satisfying biodiesel quality has proved a Simarouba species as a potential candidate to provide sustainable feed stock for biodiesel industries.
EnglishBioproductivity, Biodiesel, Feedstock, Crop improvementIntroduction
The gradual depletion of petroleum reserves and the increasing environmental concerns have created great demand for alternative source of petroleum based fuel. Energy consumption, economic growth and industrialization have lead to higher energy demand. Vegetable oils (triglycerides) are promising feedstock for biodiesel production, since they are renewable in nature and can be produced on the large scale and are environmental friendly (18). Numbers of studies have shown that triglycerides hold promise as alternative diesel engine. In the countries like India usage of edible oil for biodiesel production causes problems such as the competition with edible oil market which increase cost of oil and biodiesel (9). Based on global crop production statistics, the country will require tenfold increase in agricultural production if its total energy demands are to be met using biofuel crops (17). This will cause deforestation in some countries and slowdown food production. The waste land areas are considered as potential niches for promotion of perennial non-edible crops for biofuel, that aid in restoring afforestation, conservation and environmental friendly energy production. Approximately 68.35 million hectares area of the land is lying as wastelands in India as reported by Government of India Ministry of Rural Development Department of Land Resources New Delhi, India. It is estimated that, India has the potential to produce about three million tons of vegetable oil from nontraditional oil seeds, minor oil seeds and oil seeds of tree origin. It is estimated that potential of biodiesel production from non traditional sources is 1.38 million tons and about 75 percent of domestic production is consumed for industrial purpose (16).
More than 300 trees borne oil seeds that include edible and non-edible oil have been identified as a suitable raw material for biodiesel industry. In India more than 100 plant species found in the wild or in cultivated conditions have been identified to bear oil seeds in commercially extractable proportion (5 )Several potential tree borne oil seeds (TBOs) and non-edible crop source have been identi?ed as suitable feedstock for biodiesel (19, 20). The National Oilseeds and Vegetable Oils Development (NOVOD) Board, Gurgaon, India, has initiated a tree improvement programme for tree borne oil-yielding species (TBOs) in different states with mandate for population identification, selection of superior genotypes and establishment of seed orchards to produce high-quality fruits / seeds for oil extraction.
It is recorded that non-edible crops can be grown in waste land and cost of cultivation is much lower because these crops can still sustain reasonably high yield without intensive care (8,12). Several plant species like Jatropha curcas, Pongamia pinnata, Simarouba glauca, Calophyllum inophyllum, Maduca indica, Hevea brasilinsis, Azardirachta indica, Ricinus communis, Shorea robusta, Mesua ferra, Mallotus phillippinensis, Salvador, Garcinia indica are considered as fuel crops for biodiesel production. These species are resistant to drought, non-grazing, high seed yield, and sustain their growth in arid and semiarid agro climatic conditions. Preliminary evaluation of several oil seed crops for their growth, and utilization under agroforestry system has been recorded (14) most of these plants have multiple uses such has commercial, pharmaceutical, pesticidal properties and have capability to grow in the arid and semiarid regions. There is need to introduce the area under waste land with oil yielding tree species. Research and development on germplasm resources and identification of elite cultivars becomes necessary. Preliminary evaluation of several non-edible oilseed crops for their growth, feedstock and adaptability show that these feed- stocks should have the following advantages (1,17,20).
Aim
The aim of the present investigation is to compare bioproductivity parameters of three important biofuel plants Simarouba gluaca, Pongamia pinnata and Jatropha curcas from the phase of their seed germination to seed maturity and select a candidate clone that will serve as a potential and sustainable feedstock for biofuel industries. The characterization, evaluation and selection of desirable genotype for economic value will been done by considering few important bioproductivity characteristics, which will help in selection of high yielding cultivar that are capable to grow on waste land areas and aid in the rural development programs.
Methodology
The candidate plus trees were identified after a detail survey and inspection. The selection process for high nutlet yield for oil production was considered based on their superiority with respect to fruit yield, seed quality. The seedlings of J. curcas and P. pinnata and S. glauca were raised in beds (Black soil: sand: farm yard manure in 2:1:1 ratio) in three replicates. At 8- 9 months the seedlings were transferred to field trials in 2×2ft pits with 4feets spacing between the plants of J. curcas, 5ft spacing between P. pinnata and S. glauca. The study was conducted in the biodiesel technology park, Gulbarga University Gulbarga India, located on the latitude 17o 12 ' to 17o 46' N, longitude 76o 04' to 77o 42' E and altitude 391 to 472 meters. The area have mainly black soil with annual rain fall measured is less than 750mm, while the mean area temperature is 38 to 42oC with 35 to 62% humidity.
Bio productivity analysis
Simarouba glauca, Jatropha curcas and Pongamia pinnata were evaluated for their growth performance from seedling stage to first bearing in field. Some of the bioproductivity parameters like germination count, plant height, canopy growth, collar diameter, number of branches per plant, number of leaves per branch, number of flowers per bunch, number of pods per branch and number of seeds per branch were recorded following (6, 13, 14). 100 seed weight and 100 pod weight was recorded by the using electronic balance. Total oil content (OC) of seeds was estimated by the soxhlet extraction method using n-hexane as the solvent (10). The biomass assessments of the plants were carried out till the end of experimental period. The biodiesel was produced from the process of alkaline catalyzed transesterification. Important fuel properties like viscosity, flashpoint and copper strip corrosion of biodiesel were performed as per ASTM standards ASTM D130, ASTM D445 and ASTM D93, respectively to test the quality of the biodiesel.
Data analysis
The comparative analysis of Bioproducivity assessment of Simarouba glauca, Jatropha Curcas, and Pongamia pinnata was done by subjecting the recorded data to the statistical analysis using statistical software Origin 6 following appropriate methods.
Result
The mean value calculated on data collected for every six months by field studies on bioproductivity were subjected to the origin 6 software for graphical representation. The gradual increase in plant height, canopy growth, collar diameter, number of branches per plant and number of leaves per branch in Simarouba glauca, Jatropha curcas and Pongamia pinnata was observed. Simarouba glauca produced tall trees with the mean height of 34.63±1.567 cms (6 months), to 295.482±2.517cms (48 months). Pongamia pinnata produced progeny with plant height of 30.889±2.057cms at 6 months to 241.908±4.353cms at 48 months and lowest plant height that is 18.128±1.300cms to169.845±4.285 cms of mean values was seen in plants produced by Jatropha curcas(Fig 1.). While considering the canopy growth, Simaroba glauca had larger canopy growth that is 33.347±1.795cms to 244.549±2.135 cms of mean value, Pongamia pinnata had canopy growth of 20.899±0.9828 cms to 211.333±5.585 cms of mean value, where as smaller canopy growth was observed in Jatropha that is15.403±0.6729 cms to181.724±3.466 cms of mean value (Fig 2.).Collar diameter parameter showed highest growth in Simarouba 1.97±0.1252 cms to 17.545±0.3957 cms followed by Pongamia and Jatroph that is of 0.788±0.1136 cms to 13.857±0.4083 cms and 1.115±0.1080 cms to 16.144±0.4868 cms respectively (Fig 3.). Considering number of branches (Fig 4.) Simarouba glauca bares low number of branches from 2.5±0.2236 to 24.7±0.7895 where as Pongamia pinnata bears 3.6±0.3055 to 32.2±0.7272of branches and Jatropha Curcas showed highest number of branching patterns that is about 3.9±0.3145 cms to 42.2±0.8138 cms. Figure 5 shows enormous high growth in number of leaves per branches Simaroba glauca that is 45.6±2.845 to 1142.4±30.254 mean value compared to Pongamia piñatas (10.6±1.147 to 309.6±11.259) and Jatropha curcas (6.0±0.6142 to 212.7±8.046) which showed lower number of leaves. Jatropha curcas plants have shown early flowering during their growth. Simarouba glauca plants showed higher flower count 105.8±4.95 of its mean value where as Pongamia and Jatropha has flower count of 24.8±2.439 and 13.8±74.24 respectively (Fig 6.). Jatropha excelled in count of number of seeds per bunch that is 239.1±9.930 of mean value followed by Simarouba 42.8±1.162 where as Pongamia showed least number of seed count that is of 38.8±3.116 (Fig 7.). Maximum 100 seed weight is seen is Pongamia 164.56±0.72 gm, Simaroba showed 94.67±0.97 gms of seed weight and minimum seed weight was observed in Jatropha 63.82±0.61gm.(Fig 8.). Bar graph has shown highest oil content in Simarouba (67.06±0.54) compared to Jatropha (34.24±0.91) and Pongamia (31.16±0.86) (Fig 9.).
Seed traits
High germination rate (84.48%) was observed in Simarouba glauca, compared to Pongamia pinnata (71.54%) and Jatropha curcas (43.31%). 100 pod weight (304.14gm) and 100 seed weight (164.56gm) of Pongamia pinnata is high compared to Simarouba glauca which showed 100 pod weight (113.27gm) and 100 seed weight (94.67gm) . Jatropha curcas has 100 pod weight (108.39gm) and 100 seed weight (63.82gm). It is observed that the percentage of oil content (67.6%) in Simarouba glauca is almost double compared to percentage of oil content in Jatropha curcas (34.34%) and in Pongamia pinnata (31.16%). In Simarouba the amount of seed cake observed per kg of seed is 552.34gm, where as 624.08gm in Jatropha and 697.82 gm in Pongamia pinnata. The mean values of the seed traits are shown in Table.1.
Biodiesel quantity and quality
It is observed that 4.32kg of seeds are required to produce one liter of crude oil which yields 865.43ml of biodiesel in Simarouba, where as 6.23kg of seeds are required to procure one liter of crude oil which yield 677.54ml of biodiesel in Jatropha curcas. In case of Pongamia pinnata 6.74kg of seeds are required for per liter of crude oil which yields 639.52ml of biodiesel. The amount of glycerin per liter of biodiesel is observed is 194.52ml in Simarouba where as it is 317.03ml in Jatropha and 221.48ml in Pongamia respectively. Biodiesel quality tests as per ASTM standard showed, viscosity (4.16 cSt) of Simarouba which is less compared to the viscosity (5.22 cSt) of Jatropha and viscosity (5.81 cSt) of Pongamia. Flash point (162.17 cSt) of Simarouba is less as compared to flash point (161.41) of Jatropha and flash point (163.55) of Pongamia when tested as per ASTM standard methods ASTM D130, ASTM D445 and ASTM D93 respectively and the biodiesel quality meets the ASTM D6751 standards for biodiesel. The values of biodiesel parameters are shown in Table 1.
Discussion and Conclusion
The results of the present study shows that Simarouba Species performed better with respect to seedling growth and biodiesel parameters compared to Jatropha and Pongamia. The seed oil content is very high in Simarouba glauca as compared to Jatropha curcas and Pongamia pinnata, it is observed that the percentage of oil content (67.6%) is almost double compared to percentage of oil content in Jatropha curcas (34.34%) and in Pongamia pinnata (31.16%). Identification of better genotypes or superior phenotypes having better yield and oil content is the initial step in any tree improvement strategies (20)involved in the biofuel program. Compared to Jatropha sp and pongamia sp only 4.32kg of seeds are required to produce one litre of crude oil which had produced 865.43ml of biodiesel in Simarouba sp. The biodiesel properties were found to be within the ASTM D6751 standard. Simarouba biodiesel should less viscous property that is about 4.16 cSt .It is one of the important fuel property that is responsible for the free flow of the fuel. The flash point observed is 162.17 which will help in the safe handling of the fuel. Thus, according to the results obtained from the studies on bioproductivity traits, and satisfying biodiesel quality has made Simarouba glauca a potential candidate to provide sustainable feed stock for biodiesel industries.
Acknowledgments
Authors are thankful to the Gulbarga University for by providing work facility, University of Agricultural sciences Dharwad, Bangalore and Raichur for providing seeds for the research. Authors acknowledge the immense help received from the scholars whose articles are cited and included in reference 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 articles has been reviewed and discussed.
Conflict of Interest
The authors declare that there is no conflict of interest regarding the publication of this paper.
Englishhttp://ijcrr.com/abstract.php?article_id=2450http://ijcrr.com/article_html.php?did=2450
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ASTM Standard D93, 2008, “Standard Test Methods for Flash Point by Pensky-Martens Closed Cup Tester,” ASTM International, West Conshohocken, PA, 2008.
ASTM D445, 2006, “Standard Test Method for Kinematic Viscosity of Transparent and Opaque Liquids (and Calculation of Dynamic Viscosity),” ASTM International, West Conshohocken, PA, 2006.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15Life SciencesEstimation of Height of a Neonate in Relation to Foot Length in Different Zones of Himachal Pradesh
English5255Soni PankajEnglish Kapoor KanchanEnglishIntroduction: Stature is one of the most important and useful anthropometric parameter that determine physical identity of an individual and hold a special place in the field of Forensic anthropometry. Estimation of stature is significant in the personal identification in case of murders, natural disasters and accidents. Besides determination of race, sex and age of the unknown individual, estimation of stature enhances the reliability of identification.
Methods: The present study is based on the measurements of crown heel length and foot length of total 409 full term normal newborns (216 male, 193 female) delivered in labor ward of civil hospitals in Himachal Pradesh, measurements of the parameters were taken in 12-24 hours after birth, measured by using digital vernier caliper.
Results: The mean, standard deviation and correlation was calculated between foot length and height of newborn. High significant value was found in foot length (p=0.001) for both male and female. Middle Himalayas shows high correlation between male and female (r=0.44)
Conclusion: Crown heel length and foot length were significantly correlated with each other in all the three zones of Himachal Pradesh and high correlation was found in females
EnglishHimachal, Anthropometry, Newborn, Crown heel length, Foot length, HimalayasINTRODUCTION
India is a secular country where people of different ethnic groups, religions, education and sociological status live together. So one cannot expect the same type of growth pattern in all the places and the normal standard of anthropometric measurements varies from places to places.
Newborn anthropometry is the most important as there is no such measurement for universal use because it is dependent on racial, ethnic, environmental, age factors, biological, ecological and geographic factors1.
Measurement of human individuals for the purpose of understanding human physical variation has been a long time practice. Today this practice is called anthropometry. Anthropometry is series of systematized measuring techniques that expresses quantitatively the dimensions of the human body and skeleton. Anthropometry is the single most portable, universally applicable, inexpensive and noninvasive method available to assess the proportion size and composition of the human body. It provides a simple and objective method of assessment of fetal growth at the time of birth2.
Growth the vital process is measured by measuring the height of a person, which is a sum of the length of certain relationship with form of proportions to the total stature. This relationship is very useful anthropologically to find racial differences and medico-legally, when only parts of the deceased body are available. Height estimation by measurement of various long bones has been attempted by several workers with variable degree of success. Each worker has derived his own formula for calculating the stature from long bones. However, foot measurement has not frequently been used for this. It was Rutishauser (1968) who for the first time showed that reliability of prediction of height from foot length was as high as that from long bones3.
The geographical location, racial and environmental factors are responsible for the differences in growth and body composition in individuals. In view of this, we selected to undertake an anthropometric study of normal newborns in hills of Himachal Pradesh, which is known for its unique and uncanny socio-political and cultural tradition. Its unique composition, location, and character all makes it the bounder land4.
The aim of the present study is to measure crown heel length and foot length of full term newborns from different zones of Himachal Pradesh and to calculate mean value, standard deviation and correlation coefficient of each zone and compare the present findings with the available literature on the same.
AIM AND OBJECTIVE
To calculate and compare mean value and standard deviation of anthropometric measurements of all three zones of Himachal Pradesh. Determine the correlation between crown heel length and foot length and compare the present findings with the available literature.
MATERIALS AND METHODS
The study was undertaken on 409 normal full term newborns comprising of 216 males (52.81%) and 193 females (47.19%) delivered in the labor ward of civil hospitals of Himachal Pradesh. All the parameters were measured in 12-24 hours after birth by using infantometer and stiff transparent metric ruler (cm scale).
Ethical clearance was taken from Geetanjali University, Udaipur, Rajasthan, (India). Informed consent of mother /father /guardians and permission from Director of Health Services, Shimla, Himachal Pradesh government was taken before the study.
The exclusion criteria included neonates of high risk or complicated pregnancies having medical illness such as hypertension, diabetes mellitus, infection, autoimmune disease, heart disease etc. Neonate who had caput succedaneum and cephalheamatoma and who were delivered by caesarean section showing any craniofacial deformity were also not included in the study.
The crown heel length was measured in supine position with full extension of knee and distance between top of head and heel when press against a vertical surface and role on a stabilizing board. Foot length was measured from the heel to tip of the toe. Heel was fixed against the vertical end of the gauge and the sliding end was adjusted against the tip of the big toe after straightening the foot and the foot length was recorded.(Fig1).
The data for each newborn was recorded in a form and analyzed. For comparison of the means of the anthropometric measurements unpaired t- test was used.
OBSERVATION AND RESULTS
The present study was conducted to obtain a baseline standard criterion (Mean ±SD) of normal full term newborn’s parameters and their correlation with each other. Foot length (p=0.001) in Himachal Pradesh showed statistically significant sex difference (pEnglishhttp://ijcrr.com/abstract.php?article_id=2451http://ijcrr.com/article_html.php?did=2451
Shastry CKR and Bhat BPR. Anthropometric measurements of newborns. Int J Contemp Pediatr. 2015; 2(2): 85-89.
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Patel SM, Shah GV and Patel SV. Estimation of height from measurements of foot length in Gujarat region. J Anat Soc India. 2007; 56(1): 25-27.
Balokhara JM. The Wonderland Himachal Pradesh. 1st Ed. India. H.G publication. 2011.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241105EnglishN2018March15Life SciencesEvaluation of Methyl Blue Sabouraud Dextrose Agar Medium for Differentiation of Candida dubliniensis from Candida albicans
English5659Abiroo JanEnglish Gulnaz BashirEnglish Asiya Yaqoob BeighEnglish Bashir A. FomdaEnglish Nazir Ahmad VarEnglish Nadeem AhmedEnglish Junaid AhmedEnglishBackground: Candida dubliniensis that was first identified as a new species by Sullivan et al. (1995) in Dublin, Ireland (and was subsequently named after its place of origin) while performing an epidemiological investigation of oral candidiasis in HIV-infected and AIDS patients in the early 1990s. This pathogenic Candida species shares many phenotypic features with Candida albicans which cause problems its identification. Several phenotypic based tests have been developed to distinguish C. albicans from C. dubliniensis but none has been demonstrated being sufficient alone for accurate differentiation of the two species.
Aim: To facilitate the differentiation of these species, we evaluated methyl blue Sabouraud dextrose agar medium.
Method: Two hundred Candida spp. were tested including 186 stock strains of C. albicans and 14 strains of C. dubliniensis. Identification of all these strains was confirmed by polymerase chain reaction-restriction fragment length polymorphism (PCRRFLP) using BlnI (AvrII) enzyme. All isolate were inoculated on the medium, incubated at 37 °C in ambient air for 24 to 96h. Examination was done in Fluorescent chamber with illumination at 365 nm.
Result: On this medium, 156 C. albicans isolates showed fluorescence at 48h of incubation while none of the 14 C. dubliniensis isolates did so even on extending the incubation period. Also after 96h of incubation colonies of all 14 test strains and the two reference strains of C. dubliniensis showed yellow colour when viewed against light while others did not.
Conclusion: In conclusion, based the results of our study, methyl blue SDA test offers an additional simple means for identification of C. dubliniensis.
EnglishCandida dubliniensis, Candida albicans, Methyl blue Sabouraud dextrose agar medium, Phenotypic identification, FluorescenceINTRODUCTION
The augmentation of mycoses has been favored by the increased numbers of immunocompromised individuals and species previously not associated with human disease and novel species have been identified as potential pathogens. 1,2,3A clear paradigm of this phenomenon is Candida dubliniensis that was first identified as a new species by Sullivan et al. (1995) in Dublin, Ireland (and was subsequently named after its place of origin) while performing an epidemiological investigation of oral candidiasis in HIV-infected and AIDS patients in the early 1990s.4,5 The earliest known isolates of C. dubliniensis precede the AIDS pandemics with one isolate deposited in the Central Bureau voor Schimmel cultures in Holland as C. albicans in 19526 and another in the British National Collection for Pathogenic Fungi as C. stellatoidea in 1957.4
Although the first isolate of C. dubliniensis, had been recovered way back in 1950s, it was not until the late 1980s or early 1990s that the next isolates of C. dubliniensis were identified.5 This clearly highlights the fact that due to phenotypic similarity with C. albicans, C. dubliniensis is generally misidentified. Afterwards, C. dubliniensis isolates were identified in a wide range of clinical settings.7,8,9,10,11,12,13 C. dubliniensis is most frequently isolated from the oral cavity because of greater adherence to human buccal epithelial cells, mucin, and the oral bacterium Fusobacterium nucleatum. 14
Although primarily associated with recurrent episodes of oral candidiasis in AIDS and HIV-infected patients, C. dubliniensis has also been implicated in cases of superficial and disseminated candidiasis in patients without HIV infection.4 The incidence of this yeast species is increasing whereas its epidemiology still remains to be elucidated. To gain a more complete understanding of the precise epidemiological role played by C. dubliniensis in human disease, it is essential that rapid and reliable tests for its identification be available in routine clinical microbiology laboratory. However, the introduction of such tests has been complicated by the fact that C. dubliniensis shares many phenotypic characteristics with C. albicans.
A variety of methods have been developed for phenotypic discrimination of isolates of C. dubliniensis from C. albicans. Variable results have been reported by different authors for each phenotypic method and none has been found sufficient alone for differentiation of the two species.15,A potentially more stable identification would be one based on the analysis of genetic variability5 but the tests based on genotypic analysis are not readily applicable for the identification of this species in most average mycology laboratories. So an easy-to-perform phenotypic test, if reliable, would be a valuable tool for differentiation of Candida dubliniensis from Candida albicans. Therefore, this study was designed to evaluate methyl blue Sabouraud dextrose agar medium for differentiation of the two species.
MATERIALS
This study was conducted in the Mycology Division of Department of Microbiology of a tertiary care hospital in Kashmir, India. The study was approved by the Institute’s Ethics Committee.
Test strains
A total of 200 Candida spp. were tested in this study. These included 186 stock strains of C. albicans tentatively identified by phenotypic methods such as germ tube formation, colony colour on HiCrome Candida differential agar (HiMedia) and characteristic morphology on corn meal agar. These were isolated from cancer patients with oral candidiasis/colonization and held in stock collection of Mycology Laboratory, Department of Microbiology. Remaining 14 isolates were strains of C. dubliniensis which were kindly provided by Dr. Ziauddin Khan (Professor and Chairman Department of Microbiology, Kuwait University). Identification of all these strains was confirmed by Polymerase Chain Reaction-restriction fragment length polymorphism (PCR-RFLP) using BlnI (AvrII) enzyme which produced two strong bands of 200 bp and 340 bp in C. dubliniensis and only one band of 540 bp in C. albicans.8
Reference strains
C. albicans 90028 obtained from National Culture Collection of Pathogenic Fungi, Department of Medical Microbiology, PGIMER, Chandigarh and C. dubliniensis (type strain CD36) and C. dubliniensis (CBS 7987) which were kindly provided by Dr. Ziauddin Khan (Professor and Chairman Department of Microbiology, Kuwait University) were included in the study.
METHODS
Methyl blue SDA was prepared as per manufacturers guidelines. The media was surface inoculated by overnight growth of test as well as reference isolates. Each plate was inoculated with 6 isolates. Incubation was done at 37 °C in ambient air for 24 to 96h. Examination was done in Fluorescent chamber with illumination at 365 nm. 4
RESULTS
Out of 186 test strains of C. albicans 156 strains fluoresced on methyl blue SDA when exposure to long-wave UV light while 30 (16.13%) strains did not. All the test strains of C. dubliniensis failed to fluoresce under these conditions at 48h of incubation and even on extending the incubation period further (Figure 1). Also after 96h of incubation colonies of all the test strains of C. dubliniensis showed yellow color when viewed against light while none of the test strains of Candida albicans formed such colored colonies. (Figure 2) The reference strain of C. albicans fluoresced on methyl blue SDA while those of C. dubliniensis did not but they showed yellow color when viewed against light while.
DISCUSSION
The aniline dye and the cell wall specific polysaccharides of C. albicans react to produces the fluorescent metabolite. No other species of Candida, when grown on SDA with aniline blue medium produces fluorescence when exposed to long-wave ultraviolet light.16 This property of C. albicans has been exploited to differentiate it from C. dubliniensis.
In our study we found that fluorescence on methyl blue SDA was 83,87% accurate in identifying C. albicans and 100% in identifying C. dubliniensis. We also found that 16.1% of C. albicans failed to produce fluorescence. Our findings are in agreement with Kirkpatrick WR. et al. (1998) 17 Kantarc?oglu AS et al. (2002)15 and Akgu¨l O et al. (2009)18 who found that fluorescence was not visible in all C. albicans isolates. Sullivan et al. (1998) reported that fluorescence may not be reproducible in isolates subjected to storage and repeated subculture.5
We also found that after prolonged incubation of 96h yellow colouration was produced by the two reference strains of C. dubliniensis and not by any of the reference or test strain of C. albicans. This feature of C. dubliniensis which could be observed by examining the growth against light can also help in the differentiation of C. dubliniensis from C. albicans. To the best of our knowledge, production of yellow colour by C. dubliniensis on methyl blue SDA has not been reported previously. Combining the above two features, methyl blue SDA appears to be a medium well-suited for medical mycological use. It can serve as a primary isolation and differentiation medium for C. dubliniensis.
Conclusion
In conclusion, methyl blue SDA test offers an additional simple means for identification of C. dubliniensis. Our study was first to report production of yellow coloration by colonies C. dubliniensis on methyl blue SDA. This feature also differentiates C. dubliniensis from C. albicans with 100% accuracy. So this medium can be used as a screening medium for identification of C. dubliniensis. Further studies over a large number of isolates in multiple laboratories are suggested to evaluate the reproducibility of this simple method.
Acknowledgements
The authors thank Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar for funding the project. Authors thank National Culture Collection of Pathogenic Fungi (NCCPF), Department of Medical Microbiology, PGIMER Chandigarh and Dr. Ziauddin Khan; Professor and Chairman Department of Microbiology, Kuwait University for providing control strains for the project. 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.
COMPLIANCE WITH ETHICAL STANDARDS
Funding: This work was supported by research grant from our parent institute, Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar
Conflict of Interest: The authors declare that they have no conflict of interest.
Informed consent: Informed consent was obtained from all individual participants included in the study.
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