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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June16HealthcareMarked Lasers in the World of Paediatric Dentistry – A Short Review
English0105Sumit RajewarEnglish Mayur BhattadEnglish Runal BansodEnglishLasers are one fine classic technology ever invented. The implementation of lasers in the world of Paediatric dentistry implies a very child-friendly approach. Lasers used in dentistry surely win the race as they offer wide and various advantages over the other procedures, instruments and technologies which make the experience of the child to the dental clinic less traumatic and also help in the proper behavioral management of the child. Lasers also provide a stress-free environment and offer optimal and protective care to the patient. This article aims to briefly review the commonly used lasers and their applications in Paediatric dentistry.
EnglishLasers, Paediatric dentistry, Application of laser in dental fieldINTRODUCTION
Paediatric dentistry is a unique specialty which not only encompasses a particular skill but also introspects various aspects of child growth and development1. Handling and working with a Paediatric patient requires appropriate and efficient skill, functioning & development. Since many years there has been a wave of advancement in the technology in the field of Paediatric dentistry. To such changing trends, it is very essential to adapt and involve some child-friendly approaches into dental care, thus raising the standards1.
Laser is one of the finest technologies ever invented and is an acronym that stands for amplification of light by stimulated emission of radiation. Gordan Gould in 1959, first introduced lasers2,6. The concept and principle of lasers was first unfolded when physicist Albert Einstein described the theory of stimulated emission2,7. Theodore Maiman at Hughes Research Laboratories in 1960 first developed a working laser2,8. Lasers have become a household name. Dr. A.L. Schawlow in the early 1960s described laser as an "invention in search of an application” 3. Nowadays, the laser has found myriad applications and uses in the field of medicine and surgery, thus replacing the scalpel and whine of handpiece in the field of dental surgery3,9.
Mainly three types of lasers are being used as instruments for surgical intervention: Neodymium-doped Yttrium Aluminum Garnet (Nd:YAG), Argon (Ar), Carbon dioxide (CO2).3 Contemporary dentistry indulges the use of minimally invasive procedures, hence lasers can serve as a great alternative to drilling as they cause less pain, sound and vibration4,10.
A dry environment inside the mouth provides a good field of working and view to the clinician which further results in better outcome4. The use of lasers in place of sharp instruments definitely adds a spark to the dentist's clinic and grabs the attention of the patients. However, with great efficiency comes the great cost, so are the lasers. Moreover, laser may be difficult to access and may not be applicable in all fields of dentistry. The laser is inefficient to remove the metal restorations and thermal damage to the soft tissues4.
Paediatric dentists use different types of new lasers which provide them a minimally invasive environment for hard and soft tissue procedures with minimal patient discomfort and a painless pre and post treatment protocol1. Lasers have also minimized the use of injections, the smell of different materials in conventional dentistry. This was greatly appreciated by the parents and the children. Due to this marked advantage of lasers, the dental visits become stress-free and radiate a positive and healthy dental attitude inside a child, thus adding a smile on their face1.
Lasers can undoubtedly and successfully be used for diagnosis of oral and dental conditions and diseases, in treating the hard and soft tissues and also in preventing some rapidly progressing oral and dental conditions in children4.
The latest advances in laser technology and research have set a base of revolution in Paediatric dentistry to provide optimal, preventive, interceptive and restorative dental care along with a stress-free environment. This paper briefly reviews and throws light on some laser applications in Paediatric dentistry1.
HISTORY OF LASER
Laser was first developed by Theodore Maiman using a synthetic ruby crystal on May 16, 19604. The laser was firstly applied for the diagnosis and treatment of skin diseases. Later it was used for various endoscopic surgeries and in ophthalmology. In dentistry, it was first applied and used for oral soft tissue surgeries4. Stimulation of a synthetic material inside a light chamber generates an intensified light and the energy is emitted uniformly and continuously towards the target organ without directly contacting it4.
The Nd-YAG laser was produced in 1961 with a combination of 1%-3% neodymium along with yttrium –aluminium2. A year later; an argon laser was developed after the development of Nd-YAG laser. In 1963, the ruby laser was firstly used for the coagulation of retinal lesion2. A year later in 1964, CO2 was built up by Patel at the Bell laboratories2. After the invention of diode laser, the application of laser became diverse and widespread in dentistry4. Lasers used in dentistry possess variable wavelengths and they run in a continuous wave, as well as run in a pulsed or running pulsed mode4. A range of 193-10600 nm of wavelength is applicable in medicine and dentistry. There are mainly 4 main groups of lasers based on their specific applications: solid state lasers, liquid lasers, gas lasers, semi-conductor lasers4. Gas lasers possess a simpler design as compared to the other types. Liquid lasers have a marked ability to change their frequency4. Human dental tissues are composed of a combination of apatite crystal, water, blood and tissue pigment; hence the dental practitioners must use the best laser for each treatment3. For soft tissue treatments, the dentist or the clinician can use any type of dental laser irrespective of its wavelength as all dental lasers are absorbed now and then by one or more of the soft tissue components3. But for hard tissues, the only lasers to be used are from the Er (Erbium) family as they use extremely short durations of pulse and easily ablate the layers of calcified tissue with minimum thermal effects3. Different laser wavelengths have different absorption coefficients when they come in contact with dental tissues due to monochromaticity of laser energy3. All biologic tissues contain water which finally absorbs the two Er wavelengths, including the CO2 wavelength. The lasers with shorter wavelength like Ar (Argon), diode, and Nd: YAG are transmitted through water3. The structure of teeth and bone are formed by apatite crystals, which readily absorb CO2 wavelength and to a lesser degree, those of the Er family3.
Four types of interaction i.e, laser light absorption, transmission, reflection and scattering take place when a laser light hits the target tissue. These interactions are dependent on the optical properties of the target tissue and the wavelength of the laser light2.
LASERS IN PAEDIATRIC DENTISTRY
Motivating a child for dental visit is very important in order to prevent oral and dental diseases or conditions4. The American Academy of Paediatric Dentistry has advised that parents must visit a dentist no later than 6 months after the eruption of first teeth or around their child’s first birthday3. The biggest merit of the use of lasers in paediatric dentistry is due to its scrupulous and meticulous interaction with damaged tissues5.
Lasers are a helping hand in achieving haemostasis during soft tissue procedures without the need for suture in numerous cases5. Due to this property, wound healing takes place more rapidly along with less patient discomfort both pre and post-operatively with a reduced need for analgesics5.
Another fascinating advantage of lasers is the reduced operator chair time during soft tissue procedures with little or no local aesthesia in conjunction to it5. The technology of lasers gifts the dentist to easily perform micro dentistry thus removing only the diseased part and preserving the other healthy tissues or structures3. Lasers are proven and efficient in removing caries very effectively with minimal involvement of the surrounding tooth structure. The mechanism being the high H2O content in caries affected tissue than a healthy sound tissue5. Lasers are soft gadgets and thus cause minimum noise and vibration as compared to the conventional high- speed dental handpiece, thus eventually reducing the pain and discomfort of patient and relaxing him. These conventional high – speed dental handpiece causes noise and vibration and to overcome this, the non-contact of Erbium Lasers with hard tissue totally removes or eliminates the vibratory effects of conventional handpieces, thus allowing comfortable teeth preparations and reduced anxiety of children5. The Erbium and Nd: YAG lasers have proven to have an analgesic effect on the hard tissues, thus totally prohibiting the use of local anaesthetics and injections during tooth preparations5.
DISCUSSION
Lasers for soft tissue treatments
1) Treating ankyloglossia
Children are subjected to the usual manner by using a local anaesthetic of operator’s choice. The tongue is stabilized with the help of a haemostat and the frenum is revised. Great care should be taken to avoid the glands present on the floor of the mouth3. Laser settings of Er:YAG , 30 Hz, 50 mJ, no water is used for the treatment of tongue-tie with the use of safety goggles1.
2) Frenectomy
A tight maxillary frenum may be a hindrance to proper latching during breastfeeding in a newborn. While in older children, high frenum attachment can cause midline diastema1. Laser setting for frenectomy are Er:YAG 30 Hz, 50mJ and laser energy is headed at the insertion of frenum and area between the two central incisors1. Sutures are usually not required and the postoperative period is uneventful1.
3) Tooth exposure, an aid in eruption of tooth
Lasers expose the teeth without any damage to the tooth enamel thus, allowing better eruption of teeth1. Lasers with no absorption into the enamel are useful in exposure of teeth with a retarded eruption requiring operculectomy. Laser setting for such laser are Er:YAG 30h , 45mJ both in contact and non-contact mode can be used. The behaviour management of Paediatric patients becomes very easier with the help of the above technique1.
4) Crown lengthening and gingival recontouring
Gingivectomy is done using CO2 lasers. Secondly, it can also be used in surgical removal of soft tissue tumours in the oral cavity. Lasers provide a bloodless field and also reduce the microbial load exposed to laser radiation thus sterilizing the wound.
5) Laser in pulpotomy of deciduous teeth
Different wavelength lasers are used with a power of 0.5-1W for the preservation of pulp vitality1. For pulpotomy of deciduous tooth, a CO2 laser can be used at a power of 1-4W in a non-continuous manner to avoid excessive exposure of laser energy to pulp tissue1. There may be formation of a carbonized layer on the root canal surface, this being the disadvantage, hence irrigation using 3% H2O2 and 5.25% NaOCl must be used to remove this layer2. Use of diode laser for pulpotomy of deciduous teeth showed a 100% success rate and was proven to be a better alternative than ferric sulphate and electrosurgery from the clinical as well as radiographical aspects2.
6) Laser for direct and indirect pulp capping in deciduous teeth of Paediatric patients
Laser energy can cause closure of the dentinal tubule and also has a sedative effect on the inflamed pulpal tissue2. Laser used for indirect pulp capping has the same sedative effect as the effect of laser-produced in pulpitis2. For direct pulp capping a CO2 laser is used as it controls the haemorrhage and facilitates proper and better placement of calcium hydroxide paste at the site of exposure by sterilizing it2.
7) Laser for diagnosing the vitality of pulp
The key to diagnose the vitality or non-vitality of the pulp is based on the changes in red blood cell flux in the pulpal tissue. This is done by a non-invasive method called Laser Doppler Flowmetry2. Stimulation of the normal pulp by a pulsed laser at 2W and 20 pulses per second at a 10mm distance from the tooth surface produces pain within a time range of 20-30 seconds and then pain disappears after a couple of seconds once the laser stimulation is stopped1. Laser Doppler Flowmetry uses helium, neon and gallium aluminium as a semiconductor diode laser to measure the changes in red blood cell flux in the pulp tissue2.
Hard tissue interactions
1) Lasers for caries removal
The most effective laser for caries removal is Er:YAG. It is very effective in removing caries from both enamel and dentin without causing any thermal injury to the pulp tissue underneath2. The first use of this laser for removal of caries was done by Hibst & Keller in the 1980's in their study1. The affected layer is decontaminated using the antibacterial property of Er:YAG laser and the layer retains its remineralizing potential.
2) Pit fissure sealants
Sealing of enamel lesions with low viscous light-curing resins is a promising approach to non-operative dentistry. One such resin is the pit and fissure sealants1. In procedures like fissurotomy or cleaning and smoothening of the pits and fissures, a laser can be used before the sealant application2. For fissurotomy an erbium laser is used2. Although the need for acid etching is persistent and essential even after the application of a laser2. It’s of utmost importance that the pit and fissure sealant is able to prevent the microleakage at its periphery failing which there is continuation of the carious process beneath the sealants1. The use of Er-Cr:YSGG laser for surface conditioning does not have any effect in the reduction of microleakage or the enamel sealant interface in deciduous teeth2.
3) Combined laser and fluoride activated therapy for caries prevention
The tooth structures can be protected from the acid challenges by reducing critical pH1. This can be done by laser irradiation for the dissolution of enamel from 5.5 to 4.81. The critical pH can further be reduced or decreased in the presence of fluoride in concentrations as low as 0.1ppm. Once the enamel is lased, it will not undergo any dissolution until the critical pH reaches a pH of 4.31.
4) Lasers for detection of caries and efficacy of diagnodent
Sometimes conventional methods may be too tricky and unapproachable to the diagnostic tool. Manual probing and radiographic evaluation may be two such methods as these methods may be inefficient in the detection of some enamel defects1. In cases of complex anatomy of fissure areas, radiographs may fail to detect early carious lesions although they are effective in detecting the early carious lesions1. For the detection of occlusal caries or any occult lesion in the deciduous or permanent teeth, a laser fluorescence at a wavelength of 625nm is very effective. One such device which uses laser fluorescence technology is the Diagnodent2. For the detection of demineralization, particularly in the interproximal surfaces, an argon laser at a wavelength of 488nm can be used as it is more effective in detecting caries in deciduous teeth2.
5) Lasers for bleaching of tooth
The main content of a bleaching gel is the peroxide which when oxidised produces bleaching action. When laser light hits this bleaching gel, heat is generated thus accelerating the oxidation process2.
6) Laser for preparation of Paediatric crown
The laser used is Biolase. The specifications are set at 5.5 W with 55% of water and 65% of air. The method used for the preparation of Paediatric crowns is the same as conventional method. The merit of these techniques is the increase in the micromechanical bonding with resin cement by producing roughness on the prepared tooth surfaces2.
CONTRAINDICATIONS OF LASERS
Lasers should not be used in epileptic patients.
In patients having severe chest pain or arrhythmias.
In patients on pacemakers.
In pregnant women, lasers should not be used in and around the uterus area.
They should not be used on tissues showing some malignant potential or benign tumours having malignant tendencies.
THE SAFETY OF LASERS
Ocular hazards are very common, hence it is very mandatory to use a protective eyewear2. The operator or the clinician must be aware of the hazards caused by the use of lasers and about the accidental exposure to non-target tissue2. Several hazards such as tissue damage, fire and explosion, ocular hazards, combustion hazards, equipment hazards, respiratory hazards may be encountered by the clinician during his dental practice. Hence awareness about the potential risks and hazards of lasers is very important for dental practioners3.
CONCLUSION
Lasers are proof that fine technologies do exist. Despite some cost-related factors, lasers are one of the most adapted and accepted therapies both by the patients and the parents in Paediatric dental practice. The biggest merit of lasers being their minimal invasiveness, as a result of which Paediatric patients show great cooperation to the dentists. This being the sparkle factor, lasers are surely useful adjunct to regular Paediatric dental practice.
ACKNOWLEDGEMENT:
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references to 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.
CONFLICT OF INTEREST:
Authors declare there is no conflict of interest.
SOURCE OF FUNDING:
There is no source of funding.
Englishhttp://ijcrr.com/abstract.php?article_id=2686http://ijcrr.com/article_html.php?did=2686
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June16HealthcareA REVIEW OF THE CONCEPT OF ANGIOLOGY IN AYURVEDA
English0610B. M. N. KumarEnglishThe Sushruta Samhita (classical text) is one of the three great treatises (Brihattrayi) of Ayurveda representing mainly the school of surgery. Sushruta Samhita (classical text) is the best one in Sharira (Anatomy). The term sira (blood vessel) is as old as Vedas. In Ayurveda, the term sira (blood vessel) has been used for blood vessels. Angiology is the division of modern anatomy and it deals with different types of blood vessels of the body. The ancient texts of Ayurveda have mentioned sira (blood vessel), dhamani (artery) and srotas (capillary) are interchangeable words and these terms are equal to blood vessels in modern anatomy. According to Ayurveda, the term sira (blood vessel) reflects different modern anatomical terms like blood vessel, vein, and nerve. Therefore, it requires great research work to get a clear concept. The main aim of this work is to understand the concepts of sira (blood vessel) in Ayurveda and its correlation with modern angiology.
EnglishSira, Dhamani, Artery, Vein, Sushruta, Blood vesselIntroduction
Sushruta was the first scholar scientist who described the method of the dissection of a human cadaver and emphasized the importance of dissection in the study of anatomy 1. That’s why he is regarded as the father of anatomy and the Sushurut Samhita as the best one in sharira2. In Ayurveda the structure sira (blood vessel) is of vital importance, we can see an elaborate description of the siras (blood vessel) in various classical texts3. Sushruta has explained the anatomy of sira (blood vessel) in sharira sthana (part of Sushurut Samhita) 7th chapter “Sira varna vibhakta nama shariram”4. According to Ayurveda, the term sira (blood vessel) reflects different modern anatomical terms like blood vessel, vein, and nerve5. So, the main aim of this work is to understand the concepts of sira (blood vessel) in Ayurveda and its correlation with modern angiology.
Materials and Methods: The literary material related to sira (blood vessel) has been collected from different sthanas (parts) of Ayurvedic text books and modern anatomy books like Chaurasia general anatomy, Gray’s anatomy etc. critically reviewed and correlated with modern terms.
Review of literature
It is said that the word sira (blood vessel) derived from the Vedic term hira. The term hira is described as blood carrying channel towards the hrudaya (heart) 6. Ayurvedic acharyas have used anatomical term sira (blood vessel), which is one of the controversial term (structure). It is used to represents tubular structure, to carry material such as rasa (plasma) & rakta (blood) and it is one of the synonyms of srotas (channels) 7.
A. Origination of sira
Sushruta has stated that sira (blood vessel) originates in the embryonic life from nabhi (umbilicus) and they spread upward, downward and in oblique fashion from nabhi (umbilicus). Pranas (life) of living beings stay in nabhi (umbilicus). Nabhi (umbilicus) is surrounded by siras (blood vessel) in the same way as the nave of the wheel is surrounded by spokes8.
B. Development of sira
Sushruta described that vayu by taking sneha (oiliness) of the meda (fat) converts them into sira (blood vessel) and snayu (ligament). When the paka is mild, it is sira (blood vessel)9. It is Pitruja bhava (paternal origin). The hard structures like hair, nail, teeth, bones, blood vessels, ligaments, etc. are derived from father10.
C. Structure of Sira
Siras are like the fine fibers in the leaf of a tree, thick at their roots and becoming finer towards the end, the branches of the sira (blood vessel) resemble the tendrils, the first branch gives out a branch and this again gives out another branch and so on. The blood streams in all the sira (blood vessel) which are “like water channels going out to the diverse ranges of a garden or agricultural field11.
D. General functions of Sira
Sira (blood vessel) has special properties to perform akunchana (contraction) and prasarana (dilatation) karma. The continuous uninterrupted nourishment of the body takes place due to the pumping of the heart and contraction and dilatation of the main blood vessels related to the heart. This nourishment takes place under the principle of “kedari kulya nyayaa”(theory of transmission). The rakta dhatu (blood) thus circulates the entire body and nourishes through the process of upasneha karma (diffusion). As a garden or a grain field is made wet by the water carrying big and small channels, similarly the sira (blood vessel) by their contractility and dilatory property, supply nutrition to the body14. Dalhana commented this arama (garden) or kedari (a small piece of land) is irrigated by jalharani of kulya (small channels), in the same fashion body is nourished by sira (blood vessel). Through this process, the entire body gets nourished constantly15.
E. Number and types of sira
The total numbers of the siras (blood vessel) are 700. The Mula siras (root vessels) are 40. These classified into 4 types based on carrying vata, pitta, kapha and rakta.
1. Vatavaha siras are 10, when they reach the organs of the body where vata predominant, divide into 175 branches.
2. Pittavaha siras are 10, when they reach the organs of the body where pitta predominant, divide into 175 branches.
3. Kaphavaha siras are 10, when they reach the organs of the body where kapha predominant, divide into 175 branches.
4. Raktavaha siras are 10, when they reach the yakrut (liver) and pliha (spleen), divide into 175 branches.
By this Sushruta meant that vatavaha siras are those which are found in vata predominating areas, similarly pitta and kaphavaha siras are found in pitta and kapha predominating areas respectively 16.
F. Colour, characters and functions of four types of siras
1. Vatavaha sira – Aruna varna (crimson red) and filled with vayu. These siras (blood vessel) perform physical functions without hindering the specific of buddhi (intellect) and sense organs. Acharya Dalhana has explained the term kriyanam in this he includes both voluntary action and involuntary action. The word buddhi karma (intellect function) is related to the five sense organs and manas (mind). The intellect plays its role in deciding the normal state. When there is a hindrance in the normal functioning of sense organs; it is supposed that there is something wrong with the buddhi (intellect) or it has gone under moha (confusion) 17.
2. Pittavaha sira– Neela varna (blue) and have a warm touch. These siras (blood vessel) create lusture in the body and develop a good appetite. Maintain normal health and normal functions of the body.
3. Kaphavaha sira– Gaura varna (white) and cold to touch and steady. These siras (blood vessel) give lubrication to the various body parts and produce firmness in the joints. It also improves strength and maintains normal functions of the body.
4. Raktavaha sira (blood vessel) – Red and they are neither too hot nor too cold. These siras (blood vessel) nourish the dhatus (tissues), improves the complexion, cause a definite perception of sparsha (touch) and maintain normal functions of the body.
G. Sarvavaha sira (blood vessel)
According to Sushruta no sira (blood vessel) in the body carries either the vayu or the pitta or the kapha alone. Therefore siras (blood vessel) should be considered as sarvavaha sira (blood vessel). The particular sira (blood vessel) is to circulate a particular dosha (body humor) in its specific area. But all the three doshas (body humor) circulate in the whole of the body. Therefore doshas (body humor) are not apt for circulation only in their specific areas but they circulate in the whole of the body. This proves that the siras (blood vessel) are sarvavaha19.
Discussion
In Ayurveda the term sira (blood vessel) used in two purposes-in general sira has been used to denote the vessels otherwise in specific sense sira means veins. He described the angiology under the term of sira (blood vessel) and he includes artery, vein, capillary and lymphatics in four types of siras (blood vessel) 20. The following points suggest that similarities in between the Ayurvedic term of sira and the blood vessels in modern science-
Sira (blood vessel) originates in the embryonic life from nabhi (umbilicus) and they spread upward, downward and in oblique fashion from nabhi (umbilicus)8. This statement of Sushruta is accepted only during embryonic life. In foetus it can be seen also, that number of blood vessels are attached to the umbilicus21. In fetal life, the siras (blood vessel) are concerned with the nutrition of the foetus through the umbilical cord, but after birth, these siras (blood vessel) no more exist. Sushruta has labelled them “Nabhiprabhava” because either they start or end in nabhi (umbilicus) in uterine life. Thus Sushruta’s description regarding the origin of sira (blood vessel) seems to be correct. Here the term sira (blood vessel) is used for umbilical vessels22.
Sushruta’s description regarding the structure, the sira is very similar to the structure of blood vessels in modern anatomy. After leaving the heart, large arteries are branch into smaller ones that reach out to different parts of the body. These smaller vessels despite everything further into minute vessels considered arterioles that enter the body tissues. Inside the tissues, the arterioles branch into a network of microscopic vessels called capillaries. Substances move all through the capillary walls as the blood exchange materials with the cells. Before leaving the tissues, capillaries join and form venules, which are little veins. The venules converge to shape larger veins that in the long run return blood to the heart. The walls of arteries, veins, and capillaries differ in structure. In all three, the vessel wall surrounds a hollow center through which the blood flows23.
As a garden or a grain field is made wet by the water carrying big and small channels, similarly the sira (blood vessel) by their contractility and dilatory property, supply nutrition to the body24. The blood vessels of the body (supply arteries, capillaries, and veins) make up a closed framework of tubes that carry blood from the heart to tissues all over the body and after that back to the heart. Arteries carry blood away from the heart, whereas veins carry blood toward the heart. Here dilation and contraction are the functions of arteries. Because of pulsation, the blood circulates all over the body. In the nutrition process of the body, all the three blood vessels take part. Lymphatics also take part in nutrition and they circulate lymph25.
The four types of siras (blood vessel) are correlated with blood vessels by the following way26:
The colour and character of vatavaha siras like aruna varna (crimson red) and filled with vayu (pulsation) are very similar to the characters of an artery.
The colour neela varna (blue) of pittavaha siras are very similar to veins. These are blue because these carry deoxygenated blood.
The gowra varna (white) of kaphavaha siras are very similar to lymphatics. These are white because these carrying clear fluid lymph.
The colour and function of rakthavaha siras like rohini (red) and nourishes the dhatus (tissues) are very similar to capillaries. These are red and exchange the nutrients in tissue level.
Conclusion
According to Ayurveda sira (blood vessel) is a tubular structure, which carries the materials such as rasa (plasma) & rakta (blood). In common, this term sira (blood vessel) implies for blood vessels. In modern anatomy the vatavaha siras can be compared with the arteries, the pittavaha siras can be accepted as veins, kaphavaha siras can be considered as lymphatic channels and raktavaha siras are correlated with capillaries of the body. So it seems that Sushruta includes the vascular system (angiology) under the term of sira. So the word Sira is correlated with the blood vessels and lymphatics is not farfetched and fanciful.
Acknowledgement: Author acknowledges the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Conflict of interest-nil
Financial support-nil
Englishhttp://ijcrr.com/abstract.php?article_id=2687http://ijcrr.com/article_html.php?did=2687
Srikantha Murti KR, English translation of Sushruta Sharira Sthana, Volume-I, Chaukhambha Orientalia Publishers, Varanasi, 3rd edition, 2007, p-102.
Sharma PV, Sushruta Samhita Sharira Sthana English translation and Nibandha sangraha commentary of Dalhana, Volume-II, Chaukhambha Orientalia Publishers, Varanasi, 2007, p-315
Patawardhan Kishor, Human Physiology in Ayurveda, Chukhambha Orientale, Varanasi, 1st edition, 2005, p-112.
Rama Sundara Rao M. , Sharira Rachana Vignanam , Vijayawada – 520002, 1st edition, 2005, p-236
Tarachand sharma, Ayurvediya Sharira Rachana Vijnana. Natha Pustaka Bhandara, Rohataka (Hariyana), 1983, p-143.
6. Sen Gananath, Sanjna panchaka vimarsha, , Krishnadas Academy Publishers, Varanasi, reprint edition, 1993, p-53.
7. Agnivesha, Charaka Samhita Sutra Sthana, Jadavaji Trikanji Acharya with the Ayurveda Dipika commentary of Chakrapanidatta, Chaukhambha Orientalia Publishers, Varanasi, reprint edition, 2009, p-285.
8. Srikantha Murti KR, English translation of Sushruta Sharira Sthana, Volume-I, Chaukhambha Orientalia Publishers, Varanasi, 3rd edition, 2007, p-122.
9. Vagbhatta, Ashtanga Hruday, sarvanga Sundri commentary by Lalcandra Vaidya, Motlala Banarasidasa Publishers, 1990, p-122
10. Ghanekar, Sushrut Samhita Sharira Sthana, Meharchand Lachmandas Publication, New Delhi, 2015, p-241
11. Srikantha Murti KR, English translation of Sushruta Samhita Sharira Sthana, Volume-I, Chaukhambha Orientalia Publishers, Varanasi, 3rd edition, 2007, p-122.
12.Vagbhatta, Astanga Sangraha, Hindi Commentary by Atrideva Gupta, Krishnadasa Academy, Varanasi, 1993, p-113
13. Bhela, Bhela Samhita, Edited by Shastri V.S.V. and Sharma C.R.R., C.C.R.I.M.H. Pub., New Delhi, 1997, p-412
14. Thatte DG, English translation of Sushruta Sharira Sthana, Chaukhambha Orientalia Publishers, Varanasi, 2007, p-140
15. Sharma PV, Sushruta Samhita Sharira Sthana English translation and Nibandha sangraha commentary of Dalhana, Volume-II, Chaukhambha Orientalia Publishers, Varanasi, 2007, p-200
16. Thatte DG, English translation of Sushruta Sharira Sthana, Chaukhambha Orientalia Publishers, Varanasi, 2007, p-140
17. Tiwari Rashmi, Vatvah Sira (blood vessel) – A Critical & Conceptual Correlation with Modern Science, Int J Ayu Pharm Chem, 2019, 10 (2):124-131
18. Vagbhatta, Ashtanga Hruday, sarvanga Sundri commentary by Lalcandra Vaidya, Motlala Banarasidasa Publishers, 1990, p-124
19. Sharma Anantram, Sushrut Samhita Sharira Sthana, Chaukhamba Surbharti Prakaashan, Vaaranasi, reprint edition, 2008, p-102
20. Ashok Kumar. B., Thomas A, Chaudhary S. A review on sira vyadhana: an important para-surgical procedure of ayurveda. Int J Health Sci Res. 2019; 9(11):62-68.
21. Shiba Datta .P., Thesis on A critical study on Avedhya Sira of head and neck in Àyurveda and modern literature, Govt. Àyurvedic college, Ujjain, April-2008.
22. Dr. Kulkarni BG, Nabhi Marma- An embryological and Anatomical focus, Journal of Indian system of Medicine, 2014, 2(4): 68-73
23. Chaurasia BD, Handbook of General Anatomy, CBS publishers, New Delhi, IIIrd edition, 2000, p-81
24. Blood vessels in Ayurveda, https://www.planetayurveda.com/shira-blood-vessels/,21 march 2020, DOI: https://doi.org/10.31838/pa/2020.21.03.022
25.Tortora and Angasontakos, Principles of Anatomy and Physiology, Harper and Row publishers, Newyork, IVth edition, 1984. P-482
26. Khan Rohee, Khan Wadood, A Literature Review of Sira and Vein, International Ayurvedic Medical Journal, 2017, p-1557-1563
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June16HealthcareComparative Investigation of Physico-Chemical Properties of Two Varieties of Palm Kernel Oil in Use in Ethno Medicine
English1114Edwin N. OguegbuluEnglish Henry NwadibiaEnglishAim: There are two common varieties of palm kernel oil in Nigeria namely; Elaeis guineensis (virenscens ‘Ojukwu’ and nigrescens) (family: Arecaceae). However, the former has been more popular in traditional medicine. This study aimed to extract the palm kernel oil from the two varieties using n-hexane as organic solvent; subject the extracts to various physico-chemical analysis and by using the data so generated, attempt to rationalize or otherwise justify the extremes in disparity between their potency and efficacy.
Methodology: Equal weights of the two varieties of palm kernel: E. guneensis( virescens ‘Ojukwu’ - with brilliant colour and nigrescens) were granulated separately. The oil was extracted by cold maceration in n-hexane and the oil - extract thereafter recovered by the use of a rotary evaporator. The samples were subjected to GC-MS, refractometry, polarimetry, saponification and iodine values as well as relative densities.
Results: The percentage yields were 38.21 for Virescens and 41.79 for Nigrescens. GC-MS shows that e.g. Virescens kernel oil exhibited 18 components against E.g. Nigerensis with 16. Some of the components are same for both in the peak area. Relative densities were 0.875 and 0.872 for which saponification and iodine values were 70.64mg/KOH/g oil and 160.53 for Virescens as against 62.00/KOH/g oil and 117.06 for nigrescens. The refractive index and angle of rotation for Virescens were 1.4550 and 159.50o whereas those for Nigrescens were 1.4550 and 160.50o.
Conclusion: Though some of the differences from the data between the two varieties were not statistically significant at p ≤ 0.05, nevertheless, the wider peak areas depicting; higher concentrations for virescens and also the degree of unsaturation associated with higher iodine values could all be linked to the extreme versatility of the virescens.The unsaturated fatty acids are easily metabolized in human body to physiologically important prostaglandins.
EnglishElaeis guineensis-virenscens ‘Ojukwu’ and nigrescens, PKO, Physicochemical parameters, Greater degree of unsaturation for virescensINTRODUCTION
Elaeis guineensis – Jacq (family: Arecacae) – Palm tree, has two varieties that are prominently used in traditional medicine. Those varieties are the Virescens and nigrescens. The two, shown in figure 1, are distributed in equatorial tropical rain forest regions of West Africa1,2. Traditional remedies were derived from palm to heal many diseases throughout these regions.
The fixed oil-bearing plants include; palm, coconut, olive, castor, linseed and more. The three distinct groups of oil crops are3;
Those that are annual or biannual such as soybeans, sunflowers, groundnuts
The perennial tree crops such as cocoanuts
Crops such as cotton and corn germ.
It was found that Traditional African religion has a tremendous influence on the practice of Traditional medicine4. It is further generally acknowledged that negative spiritual influences had an impact on human health5. Those negative spiritual effects are often associated with witchcraft, sorcery, broken taboos, displeased ancestors, spirits or deities 6. Consequently, remedies were found in the application of tangible objects such as palm fruit and kernel oil or recourse to intangible behaviors as in incantation 7,8.
Apart from the medicinal applications, palm has immense economic values in tropical West Africa; industrial, food and nutrition, fuel, fuel additives, plastic, surfactants and good energy source.
The ethnomedicinal uses, especially for the Virescens include; antidote for certain types of toxic and allergic conditions, several skin ailment, control of convulsion in children, stabilization of certain adverse influences. Most of these ethno uses may not be eventually proven empirically with an experimental model despite the level of advances in analytical tools. The elusive experimental nature may also be attributable to the concept of three-dimensional mind and limitations of time and space9.
Currently, Palm Kernel oil (PKO) is used as a liniment for indolent tumours10. It exhibits some level of anti-microbial activity11. Other medicinal uses include treatment of gastrointestinal disorders, antioxidant properties, anticancer, cardiovascular and hepatoprotective properties12.
Triglycerides make up to 95 % of edible fatty acids. Fats and oils belong to the group of lipids; and are found in both plants and animals. Fatty acids are the major components of fats and oils. They are very important sources of energy for the humans, component of the membrane surrounding the sub-cellular organelles and carrier tool for lipid-soluble vitamins.13
Essential fatty acids (Linoleic and alpha-linolenic acids) are largely polyunsaturated. Most of the naturally important fatty acids occur in cis - transfiguration but with the presence of double bonds. The trans-configuration is equally possible.l4
The unsaturated fatty acids due to the presence of double bonds show remarkable difference from the saturated counterparts in shapes, biological, physicochemical properties such as Melting Point(M.P)., Relative Density(R.D)., refractive index, optical rotation, the iodine values saponification
(-SH) group or photolysis15.
Generally, unsaturated fatty acids are more unstable, exhibit higher degree of liquidity and therefore are chemically more susceptible to undergo chemical addition reactions than the saturated molecules which are relatively inert. Further, these polyunsaturated fatty acids have been identified as precursors of prostaglandins hence the essential fatty acids are enzymatically easily metabolized (lipoxidation) in humans to produce physiologically important prostaglandins.16
For fatty acids that occur in humans, double bonds are rarely inserted in carbon atoms less than 16 due to lack of desaturases enzymes capable of influencing double bonds between carbons 1-717. This is unlike plants, where double bonds can be found in carbon 3 and 6 from the methyl terminal group. By this, there could be a possibility of 1-6 double bonds in a single fatty chain.18
The aims and objectives of this study, therefore, were to extract the palm kernel oil from the two varieties using n-hexane as organic solvent, subjected the extracts to various physic-chemical analysis and by using the data so generated, attempted to rationalize or otherwise justify the extremes in disparity between the potency and efficacy of their biological activities.
MATERIALS AND METHODS
The ripped fresh fruit bunches of the two palm varieties; Elaeis guineensis (virescens and nigrescens) were collected from plantations in Obiakpo Local Government Area of Rivers State, Nigeria, The authentication was at the Herbarium of Department of Plant Science and Biotechnology, University of Port Harcourt. The samples were processed by following a modification of methods earlier reorted19. They were then subjected to manual threshing to release the palm fruit lets from the bunches; sterilized (heat was applied to partially cook the fruits and may serve in terminating certain undesired enzymatic actions.); digested to assist in separation of the nuts from the pulp and the nuts were eventually cracked to obtain the palm kernel seeds. Thereafter, equal weights of the two varieties of samples (390 g each) were milled using Delmar machine to get the desired particle sizes.
The extraction of the palm kernel oil was achieved by the adoption of solvent extraction method as reported16. The milled palm kernel samples were macerated with
n-hexane (500 ml each) for 24 h at room temperature with agitation at regular intervals. The samples were filtered to obtain the palm-kernel oil extract and n-hexane mixture. The respective pure palm kernel oil (PKO) samples were recovered en vacuo in a rotary evaporator. The two PKO samples (A for virescens and B for nigrescens) were further subjected to; saponification and iodine value tests, refractive index, polarimetry, relative density and GC –MS.
RESULTS
Result of the percentage yield of Elaeis guineensis varieties (virenscens ‘Ojukwu’-A and nigrescnes –B):
A = 38.21 % (mean weight of nut= 1.336 g)
B = 41.79 % (mean weight of nut= 1.113 g)
GC-MS result showed that virescens kernel oil exhibited 18 components against nigerensis with 16. Some of the components presented as same for both samples A and B in the Retention Time; Area: Height ratio and in peak areas. The rest of the peaks where areas were larger for sample A than B reflected higher concentrations of components present in same sample.
Some of the fatty acids and esters components identified in the mass spectroscopic fragments included; Octanoic acid, 2-Undecanone, Dodecanoic acid, Tetradecanoic acid, Chloromethyl octyl ether, Acetic acid, chloro-, decyl ester, n-Hexadecanoic acid, 9-Octadecenoic acid, and 9-Decenoic acid.
DISCUSSION:
Though the brilliant colour of sample A is more prominent than sample B, however the mean weights of their nuts and percentage yields did not show any significant differences at 1.336 g;38.21 % for A and 1.113 g;41.79 % for B respectively.
As shown in Table 1, the Iodine values of 160.50(A) and 117.10(B) indicates a remarkable difference. This means degree of unsaturation was higher in sample A than B. Thr respective values of Refractive Indices, Optical Rotation and Relative Densities as shown in Table 2 did not on the other hand exhibit any statistically significant difference at p ≤ 0.05, however, the wider peak areas depicting higher concentrations for virescens(A)and also the degree of unsaturation associated with higher iodine values could all be linked to the extreme versatility of the virescens. Further still, like other Essential fatty acids with unsaturation, this virescens(A) could be metabolizable to prostaglandins in the human body with vital cell functions.
CONCLUSION:
There is a need to characterize and elucidate the exact structures of the polyunsaturated fatty acids of virescens PKO. Additionally, there must be a meaningful effort for the conservation of this valuable plant to avoid extinction. A good pharmaceutical formulation of this product would, therefore, offer yet another potent health remedy to the world.
ACKNOWLEDGEMENT
Staff members and Laboratory facilities of Pharmacognosy & Phytotherapy and Pharmaceutical & Medicinal Chemistry Departments both of Faculty of Pharmaceutical Sciences, University of Port Harcourt. Rivers State, Nigeria.
I also wish to thank all the Authors, Editors and Publishers of the numerous articles consulted in the course of this research paper.
CONFLICT OF INTEREST
There was no conflict of interest involved in this research work.
Englishhttp://ijcrr.com/abstract.php?article_id=2688http://ijcrr.com/article_html.php?did=2688Naher, J.L., Yusuf, U.K., Ismail, A., Tan, J.G., Mondal, M.M.A. (2013). Ecological Status of Ganodsna and basal stem rot disease of oil palm (Eaelis guinensis – Jacq). AJCS. 7; 1723 – 1727.
2. Burkill, H.M. (1997). Useful plants of West Tropical Africa. 2 volumes. 4th edition. Kew. London. Families M – R. Royal Botanic Gardens Pages 340-390.
3. Robbelen, G., Downey, K.R., Astri, A. (1989). Oil Crops of the World. McGrac-Hall. Inc. Page 2.
4. Ezeanya, S.N., (1976). Healing in Traditional African Society in West African Region. Department of Religion. U.N.N. Page, 24.
5. Sofoworg, A. (1993). Medicinal plants and Traditional Medicine in Africa. Spectrum Books Ibadan. Nigeria.
6. Cocks, M, Moller, V. (2002). Use of Indigenous and Indigenized medicines to enhance personal well-being; a South African case study. Soc.Sci. Med. 54(3); 381 – 397.
7. Stekelenburg, J. Jager, B.E., Kolk, P.R., Western, E.H, Ven der Kwaak, A., Wolffers, I.N., (2005), Health care-seeking behavior and utilization of traditional healers in Kalaboo, Zambia. Health Policy. 71: 67 – 81.
8. Gruca, M, Andel, T.R., Balsley, H. (2014). Ritual use of Palms in Traditional Medicine in Sub-saharan Africa; a review. Journal of Ethno-biology and Ethnomedicine. 10(60); 1 -24.
9. Adodo, A. (2007). New frontiers in African Medicine. Guide book for PAX Health Care providers. Metropolitan Pren Ltd. Lagos. Page 12.
10. Graham,J.G, Quinn,M,L, Fabricant,D.S, Farnsworth,N.R(2000). PlantsUsed against Cancer –an extension of the work of Jonathan Hartwell. Journal of Ethnopharmacology.73(3);347 -377.
11. Ekpa, O.D,Ebena,R.(1996).Comparative Studies of Mmanyanga, Palm andCocoanut Oils; Anti- Microbial Effects of the Oils and their MetallicSoaps on some Bacteria and Fungi. Global Journal of Pure and Applied Sciences. 2:155-163.
12. Owoyele, B.V, Owolabi, G.O. (2014). Traditional oil palm (Eaelis guineensis-Jacq) and its medicinal uses; A review, TANG./www.e-tang.org.vol. 4.issue 3.
13. Templetor, W. (1978). Basic organismic chemistry. M and B Handbooks. Richard Clery (The Chaucer Press). Ltd. Great Britain. Page 224.
14. Udo, E. (1986). Fats and oils: The complete guide to fats and oils in health and nutrition. AGVE Books, Canada. Pages 3-49.
15. Tvrzicka,E, Kremmyda,L-S, Stancova,B, Zak,A (2011).Fatty Acids as Biocompounds: Their Role In Human Metabolism, Health and Disease;- A Review Part 1:Classification, Dietary Sources and Biological Functions. Biomed. Pap. Med. Fac. Univ. Palackv. Olomouc.Czech. Repub.155(2):117 -130.
16. Crawford, M.A,(1980). The role of essential fatty acids and prostaglandins. Postgraduate Medical Journal.56:557 -562.
17. Nelson, D.L,Cox,M.M.(2005). Lipid Biosynthesis In: Principles of Biochemistry. New York: W.H.Freeman and Company.Pp.787 -815.
18. Sheehy, T, Sharma, S.(2010). The nutrition transition in Barbados; trends in macronutrient supply, from 1961 to 2003. B.J.Nutri.104:1222 -1229.
19. Adeniyi,O.R,Ogunsola, G,O,Oluwusi,D.(2014). Methods of Palm Oil Processing in Ogun, State, Nigeria: A Resource Use Efficiency Assessment, American International Journal of Contemporary Research. Vol.4.No.8:173.
20. Islam,M.N,Sabur,A,Ahmmed,R,Hogue,M.E.(2015).Oil Extraction from Pine seed(Polyalthia longifolia) by Solvent Extraction Method andIts property. Analysis. Procedia Engineering.Volume 105; pages 613-618.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June16HealthcareA Raising Alarm on Clinical Recommendations in the Diagnosis and Management of Novel Corona Virus in Pregnancy and Newborn
English1519G. Prema PriyaEnglish Praveena DayaEnglish Nithya S.EnglishWorld Health Organization has declared corona virus as pandemic as it has spread worldwide after its first outbreak in Wuhan, China in 2019. However, there is a lack of literature on corona virus disease in pregnancy. Hence this article focuses on the clinical manifestations, effects of COVID-19 in pregnancy, neonate, preventive measures, treatment options, plan of delivery and breastfeeding in infected mothers. COVID-19 is also known as SARS-CoV2. The symptoms may vary from mild to severe. Mild symptoms include cough, cold, sore throat, fever, myalgia, etc., Severe symptoms such as pneumonia, shortness of breath and even death can occur. At present, there is no recommended drug or vaccine for the virus approved by FDA. However, early isolation, oxygen therapy, antibiotics, antipyretics, avoidance of fluid overload, aggressive infection control measures, testing for other co-infections and involvement of multidisciplinary team remains the mainstay of treatment for outbreak control. Corona virus itself is not an indication for delivery or caesarean. Individualized decision should be made based on the history, clinical findings and laboratory results. Instrumental birth can be preferred if the mother is exhausted or hypoxic in the second stage of labour. Routine precautionary separation of newborn is not recommended as this may affect breastfeeding and bonding between mother and baby. As the knowledge evolves, much new information regarding COVID-19 keeps updating and all existing guidelines subjected to change. All corona virus positive cases should be notified as per Government guidelines in order to trace the contacts, isolate and break the chain of transmission.
EnglishCorona virus, Delivery, Newborn, PregnancyIntroduction:
Corona virus (CoV) belongs to the family of viruses that cause mild to severe symptoms such as common cold, pneumonia, severe respiratory illness and death. Its pathogenic potential is similar to severe acute respiratory syndrome (SARS-CoV) and Middle-East respiratory syndrome (MERS-CoV). The virus is also known as severe acute respiratory syndrome corona virus-2 (SARS-CoV-2). In 2019, corona virus outbreak was first reported in Wuhan, China.1
The novel corona virus 2019 (COVID-19) is considered as public health emergency as the virus has spread worldwide to more than 180 countries with 41, 77,504 infected cases and 2, 86,330 deaths globally. Men are more affected than women in this outbreak. In India, there were 70,756 infected cases and 2,293 deaths due to corona virus. Hence WHO has declared corona virus disease 2019 (COVID-19) as pandemic.2
Epidemiology:
Corona virus was initially considered to be zoonotic which spreads from animals to human. But later it was noticed to spread from human to human through respiratory droplets. It may also spread by touching a surface or object with virus on it and keeping it on eyes, nose or mouth without hand wash. Currently, there is no evidence of transmission of the virus through genital fluids.
The primary epidemiological risk factor for the novel corona virus (COVID-19) includes history of travel from mainland China or history of close contact with the infected individuals. The incubation period of the disease range from 1 to 14 days. The clinical manifestations may vary from common cold, cough, fever, sore throat, myalgia, shortness of breath or difficult breathing. In severe cases, it can cause pneumonia, acute respiratory disease syndrome and even death. People with older age or with pre-existing medical conditions such as heart disease, diabetes, cancer are at high risk of serious illness.3
Discussion:
A literature review shows that 12 pregnant women were infected with SARS-CoV during 2002-2003 pandemic. In the first trimester, out of seven women, four (57%) had miscarriage. In the second and third trimester, out of five women, two (40%) had fetal growth restriction and four (80%) had a preterm birth.4,5 The maternal mortality was 25% with SARS-CoV. In 2012-2015, MERS-CoV pandemic, 11 pregnant women were infected. Out of these two (20%) had preterm delivery. Ten (91%) had adverse outcomes. Six (55%) neonates required admission to neonatal intensive care unit and three (27%) died.5-7
Corona viruses are single stranded RNA, non-segmented enveloped virus. SARS CoV-2 is a beta corona virus similar to SARS-CoV and MERS-CoV. It has 79% nucleotide identity to SARS-CoV and 50% to MERS-CoV.4-6 Considering these, the novel corona virus 2019 seems to have adverse effects on pregnant women and neonates.
Maternal and perinatal effects of corona virus:
With limited data available, it was found that the pregnant woman is not susceptible to severe corona virus infection. The pregnant women can be asymptomatic or symptomatic. If symptomatic their symptoms are similar to that of non-pregnant such as cough, fever, sore throat, myalgia and shortness of breath. The severe symptoms such as pneumonia, marked hypoxia are common in older women and those with pre-existing medical conditions.8-10 In a case series by Chen et al,11 nine women were diagnosed with COVID-19 in third trimester. The clinical manifestations of these nine women were similar to that of non-pregnant. Of these five had lymphopenia. Pneumonia was diagnosed in all, but none required mechanical ventilation. No deaths reported. The mode of delivery was caesarean in all. Apgar scores of these neonates were good. There are also case reports of preterm birth, prelabour rupture of membrane and fetal compromise with COVID-19. There is no evidence that steroids for fetal lung maturity can cause harm in COVID-19. Hence it can be given if indicated.
In Zhu et al study,12 of the nine pregnancies, six had intrauterine fetal distress and preterm delivery. The mode of delivery was caesarean in seven patients. Wang et al reported one case of COVID-19 mother who required mechanical ventilation at 30 weeks. She had an emergency caesarean with good recovery.8
Vertical transmission of COVID-19 is rare. Chen et al study found there is no evidence of COVID-19 in amniotic fluid, cord blood, placenta or breast milk of infected mothers.13There is inadequate data on COVID-19 and risk of miscarriage and congenital anomalies. In studies from SARS and MERS infection, it was reassuring that there was no convincing relationship between the infection and risk of miscarriage. However, in general the risk of congenital malformations with high-grade fever during pregnancy should be considered.
Diagnosis and Testing:
Currently Centre for Disease Control recommends nasopharyngeal polymerase chain reaction (PCR) swab testing for an individual with symptoms of corona virus, those with close contact with confirmed COVID-19 within 14 days of symptom onset or those with history of travel from geographically affected areas within 14 days of symptom onset.14, 15 Person under investigation (PUI) should be notified to local or state health authority. If PCR availability is limited, then the presence of ground-glass opacities in chest CT with abdomen shielding is considered as pathognomonic finding for COVID-19.16
The diagnosis of COVID-19 pneumonia is based on the combination of patient history, epidemiological exposure, clinical findings, laboratory results, chest CT findings and positive COVID-19 positive result as qRT-PCR test alone has a false-negative of at least 30%.8
The government of India has made mandatory to notify all corona virus cases. The affected patients along with their contacts are traced, isolated and treated in order to break the chain of transmission.17
Prevention:
World Health Organization and centre for Disease control has recommended preventive measures against the new corona virus which includes frequent hand washing with alcohol-based hand rub or soap and water, maintaining social distance of at least 1 meter from those who cough or sneeze, avoid touching eyes, nose and mouth, practicing respiratory hygiene, staying home if unwell and seeking medical attention if fever, cough or difficult breathing. 2, 15 Avoidance of Ibuprofen and Angiotensin converting enzyme inhibitor drugs appear to prevent virus amplification as COVID-19 acts through ACE2.
Treatment:
Currently, there is no specific antiviral drug or vaccine approved by US Food and Drug Administration (FDA) for corona virus infection. However, the first human trial of vaccine was started in US. Hydroxychloroquine is currently in use for both prophylactic and treatment for covid19 as recommended by the Federation of Obstetrics and Gynaecology of India (FOGSI).18 Hydroxychloroquine is considered to be safe in pregnancy and breastfeeding. Azithromycin can be used if there is suspicion of bacterial infection.
The principles of management include early isolation, oxygen therapy, antibiotics, antipyretics, avoidance of fluid overload, aggressive infection control measures, testing for other co-infections and involvement of multidisciplinary team. Early mechanical ventilation should be initiated for progressive respiratory failure. Maternal uterine contractions and fetal heart rate monitoring should be done.
Royal College of Obstetrician and Gynaecologists (RCOG) recommends that pregnant women with confirmed COVID-19 infection but asymptomatic is advised to be self-monitored at home for 14 days.19,20 Those recovered from mild illness in first trimester should undergo a detailed mid trimester anatomy ultrasound. Those in third trimester should be monitored with fetal growth scan and doppler because of the risk of fetal growth restriction. Pregnant women with COVID-19 pneumonia should be managed in a tertiary care center. When sepsis or organ failure criteria set in, the patient should be transferred to intensive care unit.
Intrapartum care and mode of delivery:
International Society of Infectious Disease in Obstetrics and Gynaecology (ISIDOG) recommends that an individualized assessment should be made to delay the scheduled induction of labour and elective caesarean birth if there is no urgency in order to minimize the risk of infection transmission.21 However, in case of medical or obstetric indications, induction should not be postponed. Foley catheters and prostaglandins can be used. Oxytocin has to be used with care because of the risk of fluid overload.
When woman with suspected or confirmed COVID-19 present in labour, she should be kept in an isolation room with multi-disciplinary team approach involving the consultant obstetrician, consultant anaesthetist, consultant neonatologist, consultant physician, midwife and neonatal nurse in charge. Efforts should be made to minimize the number of staff members entering the room.22 Efforts should be made to follow the infection control guidelines strictly. Full maternal and fetal assessment should be done. Maternal observations include pulse rate, blood pressure, temperature, respiratory rate and oxygen saturation. Electronic fetal heart rate monitoring with cardiotocograph is recommended for all women with COVID-19 in labour.18 The onset of labour should be confirmed according to the standard care. Oxygen saturation should be aimed to maintain more than 94%.
Corona virus infection itself is not an indication for caesarean delivery. Hence the mode of delivery should be discussed with the woman. If the symptoms deteriorate during labour, then an individual assessment should be made regarding the risk and benefit of continuing the labour versus emergency caesarean in view of maternal resuscitation. An individualized decision should be made regarding shortening the duration of second stage of labour with instrumental birth if the woman becomes exhausted or hypoxic.19
Currently, there is no evidence to suggest that epidural or spinal anaesthesia is contraindicated in a woman with corona virus infection. Use of entonox in general anaesthesia may be done with filter.19 Effective implementation of negative-pressure delivery room may prevent the infant from acquiring the virus.
Tranexamic acid and prostaglandins are safe, oxytocin can be used with care in third stage of labour and postpartum. However, methyl ergometrine should not be used because of its risk of acute respiratory failure reported after its administration.21
Deep venous thromboembolism prophylaxis with low molecular weight heparin can be given if indicated.19,21
Neonatal care and breastfeeding:
At present, there is limited data available in this context. Studies from China have advised isolation of the infected mother and baby for 14 days.12 However, routine precautionary separation should not be done because of the detrimental effects on breastfeeding and bonding. Chen et al found no evidence of COVID-19 in breast milk of the infected mothers.13 Hence breastfeeding can be encouraged with use of face mask and infection control measures by the mother.
Recently COVID-19 positive case was found in a neonate 36 hours after birth. Hence FOGSI recommends COVID testing for all neonates born to mothers with confirmed corona virus infection within 14 days of delivery or up to 28 days of birth and symptomatic neonates exposed to close contacts with corona virus infection.18 An individualized decision should be made by the neonatologists after discussing the risk and benefits with the mother and family members. Women wishing to breastfeed should be advised regarding the use of facemask and hand wash before touching the baby, breast pump or bottles to limit the viral spread to the baby. For neonates who are isolated, formula or expressed milk can be given. Babies born to COVID-19 positive mothers may need close monitoring, early neonatal care and follow-up even after discharge.19
Implications:
Currently, there are limited studies on the exact management of corona virus disease in pregnancy. Hence the present article has been written combining various recommendations published and peer-reviewed so far in recent studies. This is based on the recommendations by Centre for Disease Control and Prevention (CDC), World Health Organization (WHO), Royal College of Obstetrics and Gynaecology (RCOG), Federation of Obstetrics and Gynaecology of India (FOGSI) and International Society of Infectious Disease in Obstetrics and Gynaecology (ISIDOG). This article aims to provide a holistic approach for both readers and healthcare professionals to provide the best care for pregnant women in this panic era of corona virus pandemic.
Conclusion:
As COVID-19 outbreak is marching towards its peak we recommend many prospective studies in the upcoming future regarding COVID-19 in pregnancy for better understanding and outbreak control. However increased awareness, following preventive measures, vigilant knowledge about infection control measures is essential for reducing the disease burden. There is on-going research by multiple organizations on developing safe and effective vaccine for COVID-19. However, it is not known how quickly it may be available. As the knowledge evolves, much new information regarding COVID-19 keeps updating and the existing guidelines so far are subjected to change. Further, we recommend researchers to collect complete data on corona virus disease in pregnancy to gain more knowledge about the disease course, outcome and to throw light on the dark areas.
Acknowledgement:
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references to 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.
Conflict of interest: Nil
Source of Funding: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=2689http://ijcrr.com/article_html.php?did=2689
World Health Organization. WHO Timeline - COVID-19. https://www.who.int/news-room/detail/27-04-2020-who-timeline---covid-19
World Health Organization. Novel corona virus - China. Disease outbreak news: Update. 12 January 2020. https://www.who.int/ csr/don/12-january-2020-novel-corona virus-china/en/ [Accessed 7 March 2020].
Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, Zhang L, Fan G, Xu J, Gu X, Cheng Z, Yu T, Xia J, Wei Y, Wu W, et al. Clinical features of patients infected with 2019 novel corona virus in Wuhan, China. Lancet 2020; 395: 497–506.
Wong SF, Chow KM, Leung TN, Ng WF, Ng TK, Shek CC, Ng PC, Lam PW, Ho LC, To WW, Lai ST, Yan WW, Tan PY. Pregnancy and perinatal outcomes of women with severe acute respiratory syndrome. Am J Obstet Gynecol 2004; 191: 292–297.
Swartz D, Graham A. Potential Maternal and Infant Outcomes from Corona virus 2019-nCoV (SARSCoV-2) Infecting Pregnant Women: Lessons from SARS, MERS, and Other Human Corona virus Infections. Viruses 2020:1-16.
Alfaraj SH, Al-Tawfiq JA, Memish ZA. Middle East respiratory syndrome corona virus (MERS-CoV) infection during pregnancy: report of two cases and review of the literature. J Microbiol Immunol Infect 2019; 52: 501–503.
Alserehi H, Wali G, Alshukairi A, et al. Impact of Middle East Respiratory Syndrome corona virus ( MERS - CoV ) on pregnancy and perinatal outcome. BMC Infect Dis 2016:1-4. doi: http://dx.doi.org/10.1186/ s12879-016-1437-y
Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, Wang B, Xiang H, Cheng Z, Xiong Y, Zhao Y, Li Y, Wang X, Peng Z. Clinical characteristics of 138 hospitalized patients with 2019 novel corona virus infected pneumonia in Wuhan, China. JAMA 2020. DOI: 10.1001/jama.2020.1585.
Guan W, Ni Z, Hu Y, Liang W, Ou C, He J, Liu L, Shan H, Lei C, Hui DSC, Du B, Li L, Zeng G, Yuen K, Chen R, et al., for the China Medical Treatment Expert Group for Covid-19. Clinical Characteristics of Corona virus Disease 2019 in China. N Engl J Med 2020. DOI: 10.1056/NEJMoa2002032.
Lei D, Wang C, Li C, Fang C, Yang W, Cheng B, Wei M, Xu X, Yang H, Wang S, Fan C. Clinical characteristics of pregnancy with the 2019 novel corona virus disease (COVID-19) infection. Chin J Perinat Med 2020; 23 (3).
Chen H, Guo J, Wang C, Luo F, Yu X, Zhang W, Li J, Zhao D, Xu D, Gong Q, Liao J, Yang H, Hou W, Zhang Y. Clinical characteristics and intrauterine vertical transmission potential of COVID-19 infection in nine pregnant women: a retrospective review of medical records. Lancet 2020. https://doi.org/10.1016/ S0140-6736(20)30360-3.
Zhu H, Wang L, Fang C, et al. Clinical analysis of 10 neonates born to mothers with 2019-nCoV pneumonia. Transl Pediatr 2020;9(1):51-60. doi: http://dx.doi.org/10.21037/tp.2020.02.06
Chen S, Huang B, Luo DJ, et al. Pregnant women with new corona virus infection: a clinical characteristics and placental pathological analysis of three cases. Zhonghua Bing Li Xue Za Zhi 2020;49(0):E005-E05. doi: 10.3760/cma.j.cn112151-20200225-00138
New corona virus pneumonia prevention and control program (5th edn.) (in Chinese). 2020. http://www.nhc.gov.cn/yzygj/s7653p/202002/d4b895337e19445f8d728fcaf 1e3e13a/files/ab6bec7f93e64e7f998d802991203cd6.pdf
Centers for Disease Control and Prevention. Corona virus Disease 2019 (COVID-19). Pregnant Women. https://www.cdc.gov/corona virus/2019-ncov/specific-groups/pregnancy-faq.html.
Kalafat E, Yaprak E, Cinar G, Varli B, et al. Lung ultrasound and computed tomographic findings in pregnant woman with COVID-19. Ultrasound Obstet Gynecol 2020. doi: 10.1002/UOG.22034
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FOGSI. Pregnancy with COVID-19 infection. New Delhi: 2020.
Royal College of Obstetricians & Gynaecologists. Corona virus (COVID-19) Infection in Pregnancy. 2020. https://www.rcog. org.uk/globalassets/documents/guidelines/2020-03-26covid19- pregnancy-guidance.pdf. [Cited: May 1, 2020]
Self-isolation advice-Corona virus (COVID-19) 2020 [Available from: https://www.nhs.uk/conditions/ corona virus-covid-19/self-isolation-advice/ accessed 05 March 2020.
Donders F, Lonnée-Hoffmann R, Tsiakalos A, Mendling W, Olieveira J, Fengxia X, et al. ISIDOG Recommendations concerning COVID-19 and Pregnancy. Diagnostics. 2020; 10:243.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June16HealthcareEvaluation and Correlation of Abnormal Cell Flagging of Automated Haematology Analyzer with Peripheral Blood Film at a Hematology Laboratory in Tertiary Care Oncology Centre
English2025Hemangi JoshiEnglish Biren ParikhEnglish Akash ThakkarEnglish Manasvi PatelEnglishObjectives: Automated hematology analyzer generates flags for white blood cells abnormalities, indicating associated manual peripheral blood film examination. This study was aimed at evaluation and correlation of abnormal cell flagging with manual blood film reviews to improve performance in a hematology laboratory. In this study, an automated slide maker SC-120 was used to study the performance of fully automated haematology analyzer Mindray BC-6800.
Methods: Total 500 routine samples were obtained over a period of seven consecutive days, and run through analyzer which displayed flags for white blood cells. Thereby, results from flags were evaluated and correlated with smear findings through careful statistical analysis of the observed parameters.
Results: Flags for white blood cells and Nucleated Red Blood Cells (NRBC) were generated by BC-6800 for 211 samples out of total 500 run samples, from which 46.45% patients were diagnosed with haematological disorder and 53.55% with solid neoplasms. Sensitivity, specificity and Youden’s Index observed against total 500 samples were 100%, 99.31% and 0.99 respectively. Efficiencies for blasts, abnormal lymphocytes and atypical lymphocytes were 95.64%, 95.20% and 97.60% respectively, whereas sensitivity for blasts was 75.81%. Further, sensitivity and specificity of NRBC were 86.76% and 100% respectively. Youden’s index observed for various flags was close to 1, indicating near to satisfactory performance of analyzer.
Conclusion: The present study confirms that performance of an automated analyzer aligns with standard manual methodology. However, to avoid false-negative results by analyzer, peripheral smears should be examined manually.
EnglishAutomated haematology analyzer, Flagging, Peripheral blood film, Evaluation and CorrelationIntroduction
The complete blood count and differential cell count performed in hematology laboratories play a vital role in the diagnosis of blood disorders. Enhancement in technologie3s of laboratory equipment and advancement in the automation of cell counters not only helps in generating precise and accurate results but also reduce the test time enormously [1].
On other contrast, manual peripheral blood film examination has its own importance since morphological abnormalities of cells determined by flags are largely dependent on the validation, verification and calibration of analyzer which may differ from individual laboratory’s criteria and standards.
However, after sufficient evaluation and correlation, the reliability on flags reduces the extra burden in the form of laboratory cost, labour cost and turnaround time as it avoids the need of manual peripheral blood film examination. This way, pathologists can focus more on reviewing smears against flags displayed by analyzing critical in the diagnosis of patients.
In this study, evaluation and correlation of abnormal cell flagging performance of Mindray BC-6800 automated hematology analyzer was done with peripheral blood films prepared and stained by the SC- 120. The Mindray SC- 120 is an automatic slide maker that is a standalone or integrated into the CAL 8000 cellular analysis line. The BC-6800 is a fully automated hematology analyzer works on two methodologies to perform complete blood count and differential counts: Light scattering at two angles and fluorescence signals of flow cytometry and thus generates flags of abnormal cells [2].
The aim and objective of this study are following:
To correlate the abnormal cell flagging performance of Mindray BC-6800 automated hematology analyzer with peripheral blood film findings.
To evaluate the reliability of flags generated by Mindray BC-6800 automated hematology analyzer by comparing them with the results of peripheral smear examinations.
Materials and Methods
This study presents prospective evaluation and correlation of results generated by BC- 6800 with peripheral blood films at a hematology laboratory in a tertiary care oncology centre which is National Accreditation Board for Testing and Calibration Laboratories accredited by ISO 15189 since year 2010.
The data used in this study have been compiled over a period of seven consecutive days from blood samples of patients who needed a peripheral blood film examination by physician’s recommendation and from patients who had routine check-ups. A total five-hundred samples were obtained in order to evaluate flagging performance for this study.
Peripheral blood samples were collected in K2EDTA vacutainers and analysed within the span of two hours of collection.
Various flags of different parameters were obtained by Mindray BC- 6800 automated hematology analyzer on which quality controls are performed on daily basis and abnormal parameters were shown by various flags. The base value of flags was optimized in the laboratory by altering the cut-off provided by the manufacturer as default settings and matching with peripheral blood films. The results produced by Mindray BC- 6800 were analysed with microscopic examination of peripheral blood films prepared and Wright stained by an automatic slide maker SC- 120 without carry over, integrated into CAL 8000 cellular analysis line. Two qualified examiners verified morphology of cells and 200 cells differential count on peripheral blood films.
During the smear findings for blasts, immature granulocytes and nucleated red blood cells(NRBCs), the positive result for abnormality is considered when at least one or more than one cell shows abnormality out of 100 white blood cells. For immature granulocytes, presence of promyelocyte/myelocyte (≥1%) or metamyelocyte (≥2%) is considered as positive smear findings. Similarly, for atypical lymphocytes, positive smear findings are to be considered when more than five abnormal cells found out of 100 white blood cells following the consensus guidelines provided by International consensus group of hematology review [3].
Further, in order to the evaluation of flags generated by BC- 6800 Microsoft excel was used to compare the findings of flags with the results produced from peripheral blood film examination.
Sensitivity, Specificity, Efficiency, Positive predictive value, negative predictive value and Youden's index of flag performance by BC- 6800 were determined based on peripheral blood film examination. To determine all these parameters of flag performance, cases were classified as ‘true and false positives and negatives’.
Results
Total 500 blood samples were obtained. Among them, 56% samples were of male and 44% were of females. Considering age factor, a total 29% samples were from people less than 18 years of age and 71% were from age greater than 18 years. Among total 500 samples, 61% of patients were clinically diagnosed with the hematological disorder and 39% were diagnosed with solid tumors or neoplasms.
All samples were run through Mindray BC-6800 automated hematology analyzer, out of which analyzer displayed flags for white blood cells and NRBC against 211 samples and no flags against 289 samples. Thereafter results obtained from peripheral blood films for all those 500 samples were evaluated and correlated with that of automated analyzer. The values of important parameters evolved through this study is shown in Table 1.
The age and sex-wise distribution of 211 flagged samples between hematological disorder and solid neoplasms depicts results as shown in Table 2. Among rest of the 289 samples for which analyzer did not display white blood cell and/or NRBC flag, 80 samples were from patients diagnosed with solid neoplasms and 209 were of hematological disorder.
Specificity and efficiency observed for blasts flag was 98.4% and 95.6% with relatively low sensitivity of 78.81%. Sensitivity, specificity and efficiency of Mindray BC-6800 was found to be 100%, 94.5% and 95.2% for abnormal lymphocyte flags and 100%, 97.5% and 97.6% for atypical lymphocytes respectively.
Out of 500 samples, analyzer displayed true flags for NRBCs in 59 samples while false negative flags were 9 out of total 500 samples. Sensitivity, specificity and efficiency was found to be 90.35%, 99.48% and 97.40% for immature granulocytes and 87.50%, 99.57% and 98.60% for shift to left respectively. Table 3 depicts the above result.
Table 4 shows a satisfactory good correlation between differential white blood cell flags obtained from the automated analyzer and manual examination of peripheral blood film.
Discussion
Currently, results generated for complete blood count by automated analyzer has been satisfactorily enough to replace the manual standard methods for haematological abnormalities [4]. Over the period of time they are proved to be a reliable source and hence immensely helped to reduce laboratory manual errors and time taken to accomplish the test. However, despite sophisticated results given by the analyzer, inevitable errors were observed for various flags displayed. The automated analyzer is standardized to display the values for interfacing parameters as flags, it eventually needs an expert manual review to confirm its authenticity.
Flags indeed are helpful to warn against abnormalities but sometimes either they misidentify other cellular types displaying as false positive or they lack sufficient identification and displaying false-negative results [5]. Hence, there is a definite need for manual evaluation against all the displayed parameters of flags by automated analyzer in order to confirm abnormal findings and to maintain a high level of quality control.
In this study, analyzer displayed flag for blast against 54 samples, out of which 7 samples were found negative for blast on observation through peripheral blood film findings. Further out of those 7 samples, 6 were diagnosed with hematological disorder and they were on chemotherapy treatment while 1 was diagnosed with non-Hodgkin’s lymphoma.
Apart from this, the analyzer displayed a flag for abnormal lymphocytes for 88 samples, among which 24 samples were found negative on manual review. Out of those 24 samples, 17 were diagnosed with hematological disorder and 7 with solid neoplasms. All patients were on chemotherapy.
The analyzer also displayed flag for atypical lymphocytes against 32 samples, among them 12 samples found to be negative on manual review. Out of those 12 samples, 11 were found with haematological disorder and 1 found with solid neoplasms. Hence, there is false positive results for blast, abnormal lymphocytes and atypical lymphocytes in post chemotherapy patients.
In order to determine the sensitivity and specificity of flags generated by hematology analyzer, the cut-off values are tuned to generate more false-positive results, since the end result of errors due to deep analysis of peripheral findings are less dramatic than missing of particular information related to patient's diagnosis and follow-ups [6].
Analyzer was unable to display flags for immature granulocytes for 11 samples. Identification of immature granulocytes plays a critical role in case of neonatal septicemia in order to differentiate neutrophils and band cells. This is in lines with studies which proved that although time taking, manual checking of granulocytes differential count is the gold standard in giving band cell count and total to immature granulocyte cell ratio [7].
Comparison of this study with the results of another study done elsewhere, according to Mostafa et al., wherein they took 75 cases and observed sensitivity for blast, atypical lymphocytes, immature granulocytes and NRBC detection on NS-hema21t as 0%. Similarly, specificity observed for blast, atypical lymphocytes, immature granulocytes and NRBC was 1%, 33.3%, 90% and 1%. Efficiency of the same flags was 60%, 28.5%, 66.6%, 66.6% [8]. According to a study done by AviNahar et al., out of total 500 samples, specificity, sensitivity and efficiency of five-part differential automated hematology analyser - Beckman Coulter Ac. T was found to be 77.83%, 94.83 % and 70.60 % respectively for white blood cells [4].In present study sensitivity, specificity and efficiency is comparatively high than observed values by Mostafa et al. The difference can be due to specific profile of patients and particular haematology analyzer used in the study.
Hence it is proposed by few studies that in order to maximize the flag’s efficiency, the cut off values could be set in automated analyzer through the development of a probability rate, which may help in minimal occurrence of false negative and false positive results [9,10].
The following limitations of the present study should be considered: (i) The study was not blinded; the observers could access the findings of analyzer which might have led to over-reporting of suspected flags. (ii) The data accumulated is collected consecutively in seven days from a single population having a specific profile in a tertiary care hospital that uses particular type of hematology analyzer. According to these factors, the results that we have shown in this study may not be as accurate in other laboratories.
Conclusion
In a conclusion, this study provides sufficient evidence against the performance of automated analyzer’s alignment with that of standard manual methods. However, manual peripheral blood film review plays a critical role to avoid false-negative results and thus ensuring the final results. Hence necessary to prosper appropriate, timely and high-quality outputs.
Acknowledgment
Authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature of this article has been reviewed and discussed.
Funding: Not applicable
Conflicts of interest/Competing interests: All authors declare that they have no conflicts of interest
Englishhttp://ijcrr.com/abstract.php?article_id=2690http://ijcrr.com/article_html.php?did=2690
Sandhaus LM, Meyer P. How useful are CBC and reticulocyte reports to clinicians?. Am J Clin Pathol.. 2002;118(5):787-93.
Lee HT, Park PW, Seo YH, Kim KH, Seo JY, Jeong JH, Kim MJ, Ahn JY. Performance evaluation of Mindray CAL 8000 (BC-6800 and SC-120) hematology analyzer and slide maker/stainer. J Clin Lab Anal.. 2017;31(4):e22065.
http://www.islh.org/web/consensus_rules.php Last checked October 201, Accessed on 5 May 2020
Nahar A, Sudhamani S, Sirmukaddam S, Kiri V. Coulter Flags & Peripheral Smear Examination: Man v/s Machine. BAOJ Pathol. 2017;1(002).
Hedley BD, Keeney M, Chin?Yee I, Brown W. Initial performance evaluation of the UniCel® DxH 800 Coulter® cellular analysis system. Int J Lab Hematol. 2011;33(1):45-56.
Barnes PW, McFadden SL, Machin SJ, Simson E. The international consensus group for hematology review: suggested criteria for action following automated CBC and WBC differential analysis. Laboratory hematology: official publication of the Int J Lab Hematol. 2005;11(2):83-90.
Ike SO, Nubila T, Ukaejiofo EO, Nubila IN, Shu EN, Ezema I. Comparison of hematological parameters determined by the Sysmex KX-2IN automated hematology analyzer and the manual counts. BMC Clin Pathol. 2010;10(1):3.
Mostafa NB, Youssef AZ, Kassab MA. Performance Evaluation of NS-hema21t Automated Hematology Analyzer and Comparison of the Hematological Parameters with Sysmex XT1800i. International Journal of Science and Research. 2017;3(8): 2395-6011.
Lacombe F, Cazaux N, Briais A, Labroille G, Puntous M, Reiffers J, Belloc F, Boisseau MR, Bernard P. Evaluation of the leukocyte differential flags on a hematologic analyzer: The Cobas Argos 5 Diff. Am J Clin Pathol. 1995;104(5):495-502.
Sireci A, Schlaberg R, Kratz A. A method for optimizing and validating institution-specific flagging criteria for automated cell counters. Arch Pathol Lab Med. 2010;134(10):1528-33.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June16HealthcareMusic Therapy for Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease [COPD] Patients- An Interventional Trial
English2629R. SobanaEnglish Sumathy SundarEnglish K. JaiganeshEnglishBackground: Complementary therapies such as musical interventions are used as adjuncts in the rehabilitation of chronic illnesses.
Methodology: Patients who attended the Pulmonology OPD of a south Indian medical university and diagnosed as moderate asthmatics as per American Thoracic Society classification wererecruited. They were given music therapy in the form of vocal exercise and monotone OM chanting,by qualified music therapist 20 minutes a day for 21 days.The pulmonary functions- FVC (Forced Vital Capacity) and FEV1/FVC (Forced Expiratory Volume 1 second), dyspnoealevel by Visual Dyspnoea Assessment Scale (VDAS) and stress level by Cohen’s perceived stress scale were recorded during the recruitment and after completion of the entire music therapy sessions.
Results: Statistical analysis of pre and post music therapy data by paired t-test (p≤0.01) showed there was a significant improvement of pulmonary functions, reduction of dyspnoea and perceived stress levels of our study population after undergoing music therapy.
Conclusion: Our study had shown that Music therapy can act as a holistic approach in pulmonary rehabilitation as there was a beneficial effect in the pulmonary functions, reduced breathlessness and stress level.
EnglishActive music therapy, COPD, Pulmonary rehabilitationINTRODUCTION
Chronic Obstructive Pulmonary Diseases are a group of chronic inflammatory diseases leading to compromised lung functions and diminished gaseous exchange.1 The mortality and morbidity of the disorder is alarming when we look at the evidence-based literature reports.
BOLD-Burden of Obstructive Lung Diseases reported global prevalence of COPD as 11.5% in general population by the survey in 29 countries among subjects aged 40 and above by spirometric evaluation.2 WHO reported COPD as the second leading cause of DALYS Disability Adjusted Life Years –years of life lived with disability, next to Ischemic Heart Diseases.3 Due to compromised pulmonary functions apart from respiratory symptoms psychological comorbidities such as anxiety and depression are reported high in subjects with COPD.4
To evolve at the strategies for diagnosis, management and prevention of COPD, GOLD -“Global Initiative for Obstructive Lung Disease” GOLD was initiated. It was a network of professionals of multiple divisions collaborating together to improve quality of life of COPD patients.5 GOLD guidelines recommend that, apart from improving the pulmonary functions the subjective component of COPD must also be taken care when the management is planned.6 Complementary Alternate Medicine CAM plays a significant role as supportive measures along with pharmacological interventions in the restoration of health and wellness. Yoga, mindfulness, music therapyare few modes of CAM widely practiced due to their potential benefits.7 The effects of music therapy in various clinical settings were studied by researchers.8 Listening to music was a common type of intervention in these studies. Research shows active musical intervention in form of participatory musical activity would yield better results.9 This form of music therapy process has to be researched and validated so that it could be recommended as supportive care for pulmonary rehabilitation.
OBJECTIVES
To deliver music therapy sessions to COPD patientsin the form of vocal exercise and monotone OM chanting 20 minutes a day for 21 days.To observe and record the impact of the music therapy session on the pulmonary functions, dyspnoea and perceived stress levels.
METHODOLOGY
It was an interventional trial conducted by the Centre for Music Therapy in collaboration with the Department of Pulmonology and Physiology of a south Indian medical university. The study was permitted by the Institutional Human Ethical Committee. (IHEC clearance: FACULTY /2015/12, ECR/415/ Inst /PY/2013)
Subjects fulfilling the inclusion criteria were recruited after explaining the music therapy intervention and informed consent was obtained for undergoing music therapy and utilising their clinical data for research.
Inclusion criteria: Patients aged 20 - 60 years of both sexes, diagnosed as moderate asthmaticas per American Thoracic Society classification.10 Asthmatics were chosen for music therapy since it was the most common type of COPD presented in the above mentioned research setting and as per the recommendation of the pulmonologist of the institution.
Exclusion criteria: Critically ill patients, patients with hard of hearing and those unwilling to experience musical intervention.
Baseline assessment of pulmonary functions, dysphonic index and perceived stress level were performed during recruitment. Pulmonary functions - FVC (Forced Vital Capacity) and FEV1/FVC (Ratio of Forced Expiratory Volume in the first second by the Forced Vital Capacity) were estimated by digital spirometer and subjects categorised as per the American Thoracic Society guidelinesgiven below.
Dyspnoea level was assessed by Visual Dyspnoea Assessment Scale (VDAS). It is a numerical scale rated from 1 to 10, the severity of symptoms indicated by increase in the numerical rating. The validity was tested and documented by AG. Gift, in his study on the assessment of the level of shortness of breath.11 The stress level was estimated by the Perceived Stress Scale, which is a self-rating questioner documented by Sheldon Cohen.12 It consist of self-rated questions with 10 items rated from 0 to 4 relating to the stressors the person is exposed currently. This tool is tested and validated and is widely used by researchers to estimate stress levels.
Music therapy intervention: Patients were given a briefing on the method of musical process and the benefits of active participation. The music therapy session was delivered by a qualified music therapist 20 minutes once a day for three weeks. It was a vocal exercise in the form of "monotone OM chanting”. Subjects were guided by music therapist to chant rhythmically in the note "S" with the background of the Tampura which was used as the drone. OM is the primordial cosmic sound and a syllable used in the Vedas and Upanishads and many mantras to denote the self-knowledge, the Universe and a tool for meditation. The recital of this syllable in the monotone "S” induces deep abdominal breathing. After 21 days of sessions, all the study parameters were recorded.The pulmonary functions, psychometric parameters (dyspnoea level and perceived stress) recorded pre and post music sessions were analysed by paired t-test for significance.
RESULTS:
Pulmonary functions show an increase of the mean FEV1/FVC from 61.03% to 72.11% (p≤0.001) and mean Forced Vital Capacity from 3.89 litres to 5.03 litres (p≤0.021), after interventions which were approximately 17% improvement in the lung functions.
The dyspnoea level had reduced from 7.06 to 5.21 (p≤0.001) which is a shift from severe to mild breathless level according to AG. GIFT’s rating. According to the visual dyspnoea scale of 1-10, a score of less than 6indicates mild breathlessness. The stress level (PSS) had come down from 36 to 23 indicative of reduced stress.
DISCUSSION:
There was a significantimprovement ofpulmonary functions, reduction ofdyspnoea and perceived stress levels of our study population after undergoing music therapy for the specified period of 21 days. This outcome could be explained by exploring the mechanisms by which music therapy acts.Evidence-based research documents state that music therapy acts by both physiological and psychological modulations.13
The active musical activity of practicing OM chanting leads to the enhancement of deep breathing by physiological modulation. Deep breathing reduces the dead spacethereby the minute ventilator volume was increased leading to enhanced vital capacity and gaseous exchange.Hence due to the physiological impact, the pulmonary functions of our subjects had improved.14 Another mechanism is by the action on the neuroendocrine pathway leading to psychological modulations.The auditory pathway is the most densely interconnected tract, with collaterals to the nuclei of Hypothalamus, Limbic system, Amygdala and Hippocampus which are the seat of emotions.15 By virtue of these neural networks, music acts on theHypothalamoPituitary axis. There is a shiftto parasympathetic dominance leading to a reduction of cortisol level which is responsible for stress. Sobana et al documented that music listening produces Heart Rate Variability of parasympathetic pattern.16 Music activates the limbic system stimulating the reward-punishment center and promotes a feeling of wellbeing. There is evidence-based functional MRI report of increased vascularity to limbic and Para limbic structures upon music experiences.17
Most of the earlier researches were done on the influence of passive music listeningin COPD patients.VP Singh et al studied the effect of a single session of hearing self-selected music versus progressive relaxation after acute exacerbation of pulmonary symptoms. There was a reduction in the anxiety score and dyspnoea level of the music group. Report on the beneficial effect of as little as a single musical session showed the magnitude of musical influence.18 Another researcher MacBride observed reduction in the dyspnoea whereas the levelof anxiety was unaltered by music listening.19 Brooke C and Sidani document a contrary result of unaltered anxiety and dyspnoea level after musical exposure.20 Panigrahi et al performed a systematic review on the benefits of musical intervention on COPD patients. Improvement in Quality of life, anxiety and dyspnoea were reported by him.21 Wai SF reported engagement in musical activity reduced anxiety and depression in elderly assessed by the HAD-Hospital Anxiety Depression Scale.22
Compared to the earlier studies, our intervention was an active involvement, hence both improvements in pulmonary functions and subjective impact were produced.We can infer that subjective impact of diminished dyspnoea and stress levels were possible by both improved pulmonary functions and the anxiolytic impact of music.
CONCLUSION: Hence we could conclude that, even though music listening helps pulmonary rehabilitation, active involvement is more beneficial. Our study had shown that Music therapy can act as a holistic approach in pulmonary rehabilitation as there was a beneficial effect in the pulmonary functions, reduced breathlessness and stress level. It has to be taken up as an adjunct therapy to pharmacological drugs and patients have to be motivated to practice for a long term to obtain a relatively permanent change.
Acknowledgement: Centre for Music Therapy Research and Education, Sri Balaji Vidyapeeth, Pondicherry, India.
Conflict of interest and Financial support: NIL
Englishhttp://ijcrr.com/abstract.php?article_id=2691http://ijcrr.com/article_html.php?did=2691
Respiratory tract diseases and conditions; institute of public health describes findings in chronic obstructive pulmonary disease role of music in the management of chronic obstructive pulmonary disease (COPD): A literature review. (2014). Respiratory Therapeutics Week, 541.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June16Life SciencesBacteriological and Antimicrobial Sensitivity Profile of Burn Wound Infections in a Tertiary Care Hospital of Uttarakhand
English3036Shalabh JauhariEnglish Shekhar PalEnglish Mohit GoyalEnglish Rajat PrakashEnglish Deepak JuyalEnglishIntroduction: Burn wound injuries are one of the most common, invasive and devastating forms of trauma. Despite the recent advances in burn wound management, bacterial infections persist as an important complication and leading cause of morbidity and mortality among burnt patients. Identification and antimicrobial susceptibility pattern of bacterial pathogens associated with burn wounds can help clinicians to plan patient management effectively and efficiently.
Materials & Methods: This prospective study was conducted for a period of one year (July 2016- June 2017). A total of 160 specimens (wound swabs and pus exudates) from burn wound patients received at microbiology department for culture and sensitivity were included in the study. Once received the samples were processed immediately as per the standard operating procedures of our laboratory. Identification and antimicrobial sensitivity testing of the bacterial isolates was performed on VITEK®2 COMPACTautomated identification and antimicrobial susceptibility testing (ID/AST) system (bioMerieux, France) and interpreted as per Clinical Laboratory Standards Institute guidelines. The use of automated VITEK®2 COMPACT system for ID/AST ensures accurate results for most of the clinical isolates and eliminates the requirement of human analysis and error of results.
Results: A total of 160 samples were received from burn wound patients, out of which 113 (70.6%) were culture positive. P.aeruginosa, A.baumannii and Proteus mirabilis were the most predominant gram-negative isolates whereas S.aureus, Coagulase-negative staphylococcus and Str.pyogenes were the most commonly isolated gram-positive organisms.
Antimicrobial sensitivity profile of bacterial isolates revealedPiperacillin-tazobactam, imipenem, cefoperazone-sulbactam and colistin to be the most effective antimicrobials against gram-negative isolates, whereas linezolid, teicoplanin, vancomycin and amikacin were the most effective drugs against gram-positive isolates.
Conclusion: Due to the increased morbidity and mortality associated with the burn wound infections, early detection of the causative agents and the intervention are a prerequisite for better clinical outcomes of burnt patients. Data extrapolated from our study can be helpful for primary care physicians to optimize the treatment modalities, articulating policies for empiric antimicrobial therapy and to minimize the rate of infection among burn wound patients.
EnglishMulti drug resistant, Pseudomonas aeruginosa, Staphylococcus aureus, Total body surface area, VITEKIntroduction
Burns injury, one of the most common, invasive and devastating forms of trauma is a global public health concern. It causes damage to the largest organ in the human body, the skin, which functions to provide homeostasis, thermoregulation, sensation, immunological defense and acts as a formidable barrier against various infections.1 World Health Organization (WHO) has estimated that burn injury results in 265,000 deaths annually, with nearly half of these occurring in the WHO Southeast Asia Region, 2more so in low and middle-income countries, which are least equipped to provide timely and comprehensive care. 3 Millions of those who survive are left with lifelong disabilities and disfigurements, often with resulting social stigma and rejection. In India, over 1,00,000 people are affected by burns annually and over 20,000 of them die.4
Different cultural and social factors and the availability of healthcare facilities result in diverse epidemiology of the burn wound injury.5 The most common cause of the burns are due to chemicals, hot liquids followed by electricity and molten or hot metals.6 The severity of a burn depends on the degree of heat, duration of exposure, and thickness of the involved skin. The treatment of burns requires a multidisciplinary approach and it is often cost-intensive. Of note, majority of burn injuries in India occur in rural areas where the unavailability of quality healthcare facilities and financial constraints can further complicate the effective and efficient management of such cases.
Despite the recent advances in burn wound management, microbial infections persist as an important complication and leading cause of morbidity and mortality among burn patients.1,7 Most of the times such infections are the reason for a prolonged hospital stay which eventually account for overwhelming pharmacotherapeutic and pharmacoeconomic implications not only on patients but on healthcare facility as well. Predominant risk factors for burn wound infection are the size of burn wound, i.e., the percentage of total body surface area (TBSA) burnt and the duration of hospitalization.8 Burn wound itself provides a conducive environment for the microorganisms to colonize, which eventually leads to infection. The primary insult from a burn is the wound itself with three characteristic areas of involvement, a) Zone of coagulation: first associated area of the wound, nearest to the heat source and includes dead tissue forming the burn eschar; b) Zone of stasis: is the area adjacent to the zone of coagulation and is viable but at risk of ischemia due to perfusion defects; c) Zone of hyperemia: it is the third area, which consists of relatively normal skin, with increased blood flow and vasodilatation and minimal cellular injury.8Primarily the burn wound injuries have the moist, protein-rich eschar, which is an ideal environment for microbial colonization and infection. The avascular zone of coagulation diminishes the immunological defenses, particularly neutrophils, from attacking pathogens via their respiratory burst mechanisms, which requires oxygen.9The inflammation also impairs wound healing due to the release of proteases from macrophages.
Typically the burn surface is sterile immediately after the thermal injury and after a period of about 48-72 hrs (relative sterility), the wound is initially colonized by the surrounding microbes from the skin, hair follicles and sebaceous glands (endogenous flora),10 which are usually gram-positive bacteria. After around fifth to sixth day the gram-positive organisms are often replaced by gram-negative organisms 11 which are either present in hospital environment or are transmitted from the hands of healthcare workers and fomites (exogenous flora). Moreover, the gastrointestinal tract is also one of the predominant potential reservoirs for endogenous gram-negative organisms that colonize the burn wound surface.8Among the gram-positive organisms, Staphylococcus aureus and Streptococcus pyogenes, and among the gram negativeorganismsPseudomonas aeruginosa, Acinetobacter baumannii, Escherichia coli, Klebsiella pneumoniae, Proteus spp. and Citrobacter spp. are the most predominant organisms involved in burn wound infection. These pathogens, particularly the gram-negative organisms are known for their increasing resistance to a variety of broad-spectrum antibiotics and can further complicate the clinical outcome of the patients. Moreover, infection with multi drug-resistant organisms or polymicrobial infections are associated with worse clinical outcomes. Nearly 73% of post-burn deaths occurring within five days have been reported to be sepsis-related.12
The use of prophylactic antibiotics is common practice with burnt patients.13 Drug resistant bacteria with intrinsic resistance towards antibiotics, the ability to survive longer in the hospital environment and hand-to-hand transmission of bacteria reflect their easy spread and the possible causes of outbreak.14,15 The bacterial infections in burnt patients vary both with time and place.16,17Thus, continuous surveillance and update of antibiotic resistance pattern of microorganisms is imperative for infection control programs and accurate antibiotic treatment in the burnt patients. With the above background, the present study was undertaken to identify the bacteriological profile of infected burn wounds and their antimicrobial sensitivity pattern among the patients admitted in a tertiary care hospital of Uttarakhand. This study will be helpful to determine the predominant bacterial agents causing burn wound infection in our healthcare setup and their antimicrobial profile will be helpful to tailor the existing guidelines for better patient management and care.
Materials and Methods
This prospective study was conducted in Dept. of Microbiology of Shri Mahant Indiresh Hospital Dehradun for a period of one year (July 2016- June 2017). A total of 160 specimens (wound swabs and pus exudates) from burn wound patients received at microbiology department for culture and sensitivity were included in the study.
Following aseptic conditions, all the samples were collected and transported to the microbiology laboratory without delay. Once received the samples were processed immediately as per the standard operating procedures of our laboratory. Samples were plated on 5% sheep blood agar (BA) and Mac Conkey’s agar (MA), and were incubated at 37°C for 48 hours before being reported as sterile. Plates were examined for the growth and the preliminary identification was made based on colony morphology, gram staining, and the battery of biochemical tests (catalase, coagulase and oxidase tests). Based on the aforesaid tests the organisms were broadly classified as gram-positive cocci (in clusters or chains) and gram-negative bacilli (oxidase positive or oxidase negative). Further identification (ID) and antimicrobial sensitivity testing (AST) was done using VITEK®2 COMPACTautomated ID/AST system (bioMerieux, France). The use of automated VITEK®2 COMPACT system for ID/AST ensures accurate results for most of the clinical isolates and eliminates the requirement of human analysis and error of results.
For gram-negative bacteria, ID-GNB, AST-N280 and AST-N281 cards (bioMerieux, France)and for gram-positive bacteria ID-GPB, AST-P628 (bioMerieux, France) were used following the manufacturer's instructions. Briefly, a single bacterial colony (pure growth) was taken and the suspension was made in normal saline. The optical density of the bacterial suspensions was adjusted to 0.5 McFarland. Finally, the Vitek Tubes were shaken well before putting into the Vitek machine to maintain homogenous suspension. The AST card contained following antibiotics: ampicillin, amoxicillin/clavulanic acid, amikacin, ceftriaxone, ciprofloxacin, clindamycin, co-trimoxazole, cefoperazone/sulbactam, colistin, cefuroxime, erythromycin, gentamicin, imipenem, linezolid, piperacillin/tazobactam, teicoplanin, tigecycline, and vancomycin. E.coli ATCC 25922, S. aureus ATCC 25923 and P. aeruginosa ATCC 27853 were used as controls. Results were interpreted as recommended by the Clinical and Laboratory Standards Institute (CLSI) guidelines (M100-S24 and M100S, 26th Ed.). The MIC breakpoint used to identify bacteria susceptible for colistin was 2 mg/l and tigecycline was 1 or 2 mg/l.18
Results
Out of total 160 patients, the majority of the cases were seen in age group between 31 years to 40 years (27.5%). Males (60.7%) were more commonly affected than females (39.3%) and the male: female ratio was 1.5:1. Table 1 depicts the gender and age-wise distribution of burn wound patients. Among the causes of burn, thermal burns (36.2%) were found to be the most predominant followed by electric burns (26.9%) and scald burns (16.2%). Table 2 shows the distribution of the type of burns.
Out of total 160 samples, processed bacterial growth was seen in 113 (70.6%) samples while 47 (29.4%) samples showed no growth. Among the 113 samples with bacterial growth, gram-negative organisms (68; 60.2%) outnumbered the gram-positive organisms (45; 39.8%). P. aeruginosa, A. baumannii and Proteus mirabilis were the most predominant gram-negative isolates whereas S.aureus, Coagulase-negative staphylococcus (CONS) and Str. pyogenes were the most commonly isolated gram-positive organisms. Table 3 shows the distribution of various bacterial isolates grown from burn wounds of the patients.
Antimicrobial sensitivity testing was carried out for all 113 bacterial isolates. Piperacillin-tazobactam, imipenem, cefoperazone-sulbactam and colistin showed maximum activity for gram-negative isolates, whereas linezolid, teicoplanin, vancomycin and amikacin were the most effective drugs against gram-positive isolates. Table 4 depicts the antimicrobial sensitivity profile of all the bacterial isolates.
Discussion
In the present study a total of 160 samples were collected, out of which, 113 samples showed growth with an isolation rate of 70.6%, a finding which was in tandem with the previous studies by Srinivasan et al., Dutta et al., and Richcane et al. who reported the isolation rate to be as high as 86.28%, 88.23% and 90.7% respectively.8, 19, 20
Regarding the sex distribution of the patients in the present study, males (60.7%) outnumbered the females (39.3%) with male: female ratio of 1.5: 1. The possible reasons for this male preponderance can be related to socio-economic and cultural habits of earning the livelihood primarily by males and also to their adventurous nature and the greater desire to be active in comparison to their female counterparts.21,22 Our findings were in concordance with previous studies by Aali et al., Ghaffaret al. and Richcane et al. 20,23,24 but were in contrast to the studies by Khurram et al. and Latikasharmaet al.25,26
Among the causes of burn, thermal burns (36.2%) were found to be the most predominant followed by electric burns (26.9%) and scald burns (16.2%). A study by Shahzadet al. also reported thermal burns to be the most common cause of burn injuries.27Various other studies by Richcane et al., Agbenorku et al., and Mahalakshmyet al., have reported scald burns as the most common cause of burn injuries.20,28,29The most affected age group in our study was between 31 to 40 years (27.5%) of age, a finding that is in parallel to the various other studies.8,25,26,30,31 The probable reasons for this are, the active involvement of this age group in outdoor work and more common exposure to fire-related work (household and occupational). In contrast to our findings, various other studies reported age group of 0-5 years as the most common age group suffering from burns.20,28,32,33Underdevelopment of the cognitive function, tendency of being more active during early developmental stages and to pull or push objects containing hot liquids have been reported to be the common reasons for the same.28
Nosocomial infection in burnt patients is a major challenge for clinicians. A previous study reported that 75% of all deaths among burnt patients were associated with infection.19 Our study results revealed a high isolation rate of about 70.6% with gram-negative isolates comprising the predominant bacterial etiology. The presence of gram-negative organisms in the majority of the cases suggests that most of such wounds may either have resulted due to prolonged hospital stay or due to prolonged time between the injury and the hospital admission. The predominance of gram-negative bacteria in burns has been documented in several studies where they have been shown to be an independent predictor of mortality among burnt patients.34,35 Studies by Bessa et al. and Hwee et al. also support our view by stating that the long hospital stay is directly proportional to high incidence of burn wound infections particularly of gram-negative etiology and is inversely proportional to the positive clinical outcome of the patients.36, 37 One of the major factors adding to the complication of burn wound patients is a multi drug resistant (MDR) organism. Any MDR strain if sets in the hospital environment, can persist for months. Robust microbiological surveillance as well as restrictive antibiotic policy can be helpful in prevention and treatment of such MDR isolates. Moreover, overcrowding in burn ward is an important cause of cross-infection and must be avoided to prevent any nosocomial infection among patients.
In the present study, P.aeruginosa was the most commonly isolated gram-negative bacteria followed by A.baumannii and Pr.mirabilis. Similar findings, with P.aeruginosa being the predominant isolate among burn wound patients have been reported previously. 25,38,39 High prevalence of these pathogens is associated with their ability to flourish well in a moist environment and their prolonged persistence in hospital environment,40 which eventually can result in a high level of antibiotic resistance among such pathogens, particularly in Pseudomonas spp.41 Moreover, the local practices like application of cow dung, toothpaste, fountain pen ink and mud paste over the burn wound can also be the possible reason for isolation of these organisms from the burn wound patients.25
Among the gram-positive organisms, S.aureus was the most predominant followed by CONS and Str.pyogenes. Although various other studies have shown S.aureus to be the most predominant etiological agent in burn wound patients,42 but in the present study it was found to be the second most common isolate after P.aeruginosa. Similar observations have been reported by previous studies as well.38, 39, 43 CONS accounted for 8.9% of the total organisms isolated from the burn wounds, a finding which is in tandem with previous studies by Mama et al. and Richcane et al. who reported CONS in 14.5% and 2.3% respectively from the burn wound infections.20, 44 CONS, although is a normal skin flora, but is a common contaminant of the burn wounds.
The antimicrobial profile of our study indicates the emergence of MDR strains in our hospital set up. The gram-negative isolates exhibited a high degree of resistance to the commonly used antibiotics like ampicillin, amoxy-clav, ceftriaxone, ciprofloxacin, cefuroxime, gentamicin and penicillin, the observation which was in contrast to the previous studies.15,16,41,42Various predisposing factors documented for the acquisition of MDR strains include prolonged/previous hospitalization, invasive procedures, comatose state and advancing age. In addition to the above, indiscriminate use of broad-spectrum antibiotics and poor compliance with hospital antibiotic policy can also provide a conducive environment for MDR strains. Piperacillin-tazobactam, imipenem and cefoperazone-sulbactam showed maximum activity against gram-negative isolates. Similar findings were reported by Mundhada et al. and Guggenheim et al. who also observed imipenem and meropenem to be the most effective drugs against gram-negative isolates.42,45 Colistin and tigecycline are among the antibiotics used as last resort for the treatment of MDR or extensively drug resistant (XDR) isolates, and both these drugs were found to be effective against majority of the gram-negative isolates in our study. However, resorting to both these drugs can impose a considerable financial burden on the patient. In comparison to gram-negative isolates, the degree of resistance observed among gram-positive organisms was less. In addition to vancomycin, teicoplanin and linezolid, which showed 100% sensitivity to gram-positive isolates, amikacin and co-trimoxazole, were also found to be effective against gram-positive organisms.
The use of automated VITEK®2 COMPACT system for identification and antimicrobial susceptibility testing ensures accurate results for most of the clinical isolates and eliminates the requirement of human analysis and error of results.
Conclusion
The most common isolate from burn wound patients in our study was P.aeruginosa, S.aureus and A.baumannii, majority of them being resistant to commonly prescribed antimicrobials. The emerging drug-resistant strains and the scarcity of any newer antibiotic in the pipeline make active microbial surveillance in the clinical settings more imperative. Due to the increased morbidity and mortality associated with the burn wound infections, early detection of the causative agents and the intervention are a prerequisite for better clinical outcome of burnt patients. Although completely eliminating such infections seems to be difficult, but reducing the rate of burn wound infections to minimal will surely be beneficial in reducing patient morbidity and mortality, as well as in preventing the pharmacotherapeutic and pharmacoeconomic losses.
A multidimensional approach in this regard ensuring close clinical liaison between the surgical team, the microbiologist and the infection control team can surely turn the tide in favor of the patients as well as the clinicians. We realize that data extrapolated from our study may not be representative of the whole Indian scenario and must be interpreted cautiously. However, the findings of our study can serve as a template to optimize hospital antimicrobial policy and antimicrobial prescribing guidelines. The relevant and regular policy and protocol changes can definitely overcome the burn wound infection rate in any healthcare facility. Given the considerable clinical and economic consequences of burn wound infections, the goal of a healthcare system should be “zero tolerance” to such infections and the associated adverse events.
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.
Financial Support: None, Conflict of Interest: Nil
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June16Life SciencesCOVID-19 Situation at Chennai City – Forecasting for the Better Pandemic Management
English3747Kannamani RamasamyEnglish S. JayakumarEnglish Govindasamy ChinnuEnglishAim: The objective of this study was to investigate the current state of COVID-19 pandemic at Chennai city and understand the possible contributors to the highest number of confirmed and death cases. The secondary aim of the study is to forecast the confirmed cases for the forthcoming days for better planning and execution.
Sample, Technique and Methods: For this study, we have used the data from March 9 to June 6 2020 (89 days). For forecasting the number of COVID-19 cases for Chennai, we have used FORECAST.ETS function in Microsoft Excel. Forecasting calculated from June 7 to August 31 2020 (85 days). Data of Chennai city and Tamilnadu is used for the study.
Results: From the forecasting analysis for Chennai city, by the end of August, the forecasted positive cases would be 121027. The percentage of confirmed cases from the total sample tested may go up to 12.6 by August 31, 2020. The forecasting of Tamilnadu indicates that the majority contribution comes from Chennai city. By the end of August, the number of death cases would be 4565 in Chennai city.
Conclusion: There are various initiatives from the government agencies to control, treat and prevent COVID-19 at Chennai city. However, the number of cases is rising in an uncontrolled manner. Strategical disease management is needed to control the situation better. Forecasting is one of the critical factors that play a vital role in the pandemic management. By using the strategical approaches, we can have better planning, execution and monitoring.
EnglishChennai, Causes, Forecasting, COVID-19, CoronavirusIntroduction
Coronaviruses (CoV) are a large family of viruses that cause illness ranging from the common cold to more severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). Coronavirus disease (COVID-19) is a new strain that was discovered in 2019 and has not been previously identified in humans. Standard recommendations to prevent infection spread include regular hand washing, covering mouth and nose when coughing and sneezing, thoroughly cooking meat and eggs. Avoid close contact with anyone showing symptoms of respiratory illness such as coughing and sneezing. As of June 9, there are 6992010 Confirmed cases globally. There are 403128 Confirmed deaths across 216 Countries, areas, or territories1. Approximately 2.7 lacks of people affected in India from all the states. Maharashtra is the highly affected state with around 90000 confirmed cases. Sikkim is the least infected state with seven confirmed cases. (As on June 9, 2020)2,3. There are 33,229 positive cases in Tamilnadu state with a death count of 286. (As of June 8). Chennai is the highly affected place in Tamilnadu with 23298 cases, and Dharmapuri is the district with 18 cases that have the lowest confirmed cases4.
Overview of Chennai City:
Chennai city is the capital of Tamilnadu state and located on the coast of the Bay of Bengal. Being the biggest city in south India, Chennai city played a crucial role in the historical, cultural, educational and health sector growth of the country. During British period, Chennai (Madras) was the regional capital of South India, which comprises five states (Currently Tamilnadu, Kerala, Andhra Pradesh, Telangana and Karnataka). Chennai city played an essential role in the Dravidian civilization. Chennai is the 4th largest city of India and has many principal government offices such as High court and Reserve Bank of India. Chennai is one of the most leading commercial centers of South India and well-integrated with the neighbour states for business activities. Various industries such as automobile manufacturing, IT services, which include hardware and software services, petrochemicals such as IOCL, financial services, textiles and hardware manufacturing are resulting in the economy of both Tamilnadu state and India as well. Chennai is well-connected to all the major cities of India as well as with the foreign nations due to its geographical location. Chennai is also considered the cultural hub of South India, which is famous for its rich heritage in classical dance, music, architecture, sculpture and crafts. The official language of the state is Tamil, and other most speaking languages are Telugu, English, Hindi, Urdu and Malayalam. The population of the city is around 6.4 Million and the area of the city is 178.20 sq. Km. The temperature in Summer varies between 21.10 °C to 37 °C Temperature in Winter varies between 19.81 °C to 32 ° C. The altitude of the city is 60 m above sea level5,6
As on June 6, 2020, the total confirmed cases in Tamilnadu are 30152 (Refer Table 2, Figure 1). 69.6 percent of the confirmed cases are only from Chennai city, and 36 districts across Tamilnadu are representing remaining 30.4% confirmed cases7
As on June 6, 2020, Chennai city has 20993 confirmed cases. Out of which, 10223 are active, and under treatment, 10572 patients discharged as they have recovered. 197 patients die due to COVID-19 from Chennai city (Figure 2). Table 3 talks about the positive cases details of Chennai and other parts of Tamilnadu from Day-1 of the confirmed case. Further, it explains about the statistics of the samples tested and percent of the confirmed cases across Tamilnadu which includes Chennai city.
Table 3 – shows the various statistics for Tamilnadu concerning COVID-19.7
Figure 3 shows the number of positive cases in Chennai and across Tamilnadu as of June 6, 2020. The total number of confirmed cases across Tamilnadu (other than Chennai) is not near the Chennai city's confirmed cases. The Graph indicates the outburst which is happening in Chennai concerning COVID-19 cases.
Figure 4 shows the COVID-19 increasing trend for Tamilnadu state (Except Chennai) and Chennai city. For better graphical representation, the data separated into two parts, below diagram representing from March 9, 2020 till April 22, 2020. Though we see the increasing trend for both Tamilnadu state (Except Chennai) and counts are less at Chennai City during this period.
Figure 5 shows the COVID-19 increasing trend for Tamilnadu state (Except Chennai) and Chennai city. Below diagram representing the data from April 23, 2020 till June 6, 2020. We see the growing trend for both Tamilnadu state (Except Chennai) and Chennai city till May 4. It is important to note that the Koyambedu vegetable market of Chennai was closed by the state government by 1st week of May 2020 and around 10000 people who worked in the market left to their native districts. The number of confirmed cases is tremendously increasing at Chennai city from May 5, 2020 onwards. As on June 6, 69.4 percent cases are in Chennai and 30.4 percent cases are at the whole Tamilnadu (other than Chennai).
Figure 6 shows the pattern of cases increased from first case to 20993. On March 18,2020, the first case identified at Chennai. On March 25, the number of confirmed cases increased to double-digit. On April 6, the number of confirmed cases reached triple-digit. With the constant increasing pattern, on May 1, the number of confirmed cases is 1082. As on May 24, 2020, within 24 days, the confirmed cases increased by ten times (10576). As per the data from the Tamilnadu government's health department, the total confirmed cases from Chennai city are 20993, as of June 6, 2020.
As on June 8, 234 people died in Chennai city due to COVID-19 (Refer Figure 7). The first death occurred on April 18, 2020. From May 5 onwards, there were continues deaths noticed. On June 8, authorities announced 12 death cases on that particular day in Chennai city. By seeing the increasing pattern, it looks like the death count may continue to rise in the coming days8
The percent of confirmed cases from the total sample tested on that particular day. From March 9 to April 22 2020, more cases were identified across Tamilnadu and less in Chennai city. (Figure 8 ). From April 23 onwards, more confirmed cases found in Chennai city. At one point in time, the proportional difference between Chennai city and the whole Tamilnadu was huge (figure 9). On June 6, 2020, 576695 sample tested, and 9.1 percent found positive. Out of which, 7.28percent from Chennai City alone and 1.82 percent from the other parts of Tamilnadu (36 districts).
From the date of first COVID-19 case till June 6 2020, 5,27,212 samples performed in total across Tamilnadu, which includes Chennai City (Refer Table 4, Figure 10). Out of which, 121950 samples tested in Chennai city alone and found around 17.21 percent positive (20993 cases) and out of 405262 samples performed across Tamilnadu (Except Chennai), only 2.26 percent found positive. Day by day, we see a huge increasing trend for Chennai city. [9]. It is important to note that, from the total sample (527212) tested across Tamilnadu, only 23.12 percent belong to Chennai city. However, the confirmed rate is high i.e. 17.21 percent. Whereas 2.26 percent confirmed cases found from the 76.88 percent of the sample performed from other parts of Tamilnadu.
Possible causes for more COVID-19 cases at Chennai:
HigherPopulation density
Public exposure in the Koyambedu market during lockdown10
Lockdown was not followed up properly11
People visit from profoundly impacted states and countries.
Quarantine and suspected people travel in the city without social responsibility.
Unaffected people roam with improper precaution11
Lack of awareness and negligence.
Forecasting analysis
In this paper, we have used FORECAST.ETS function in MS EXCEL to predict the future number of COVID-19 cases for Chennai. The Excel Forecast.Ets function uses an exponential smoothing algorithm to predict a future value on a timeline, based on a series of existing values. The forecasted number is a continuation of the past values in the defined target date, which should be a continuance of the timeline. This function can be used to foresee forthcoming marketing, asset and configuration requirements and or customer’s usage patterns12
Syntax:
FORECAST.ETS(target_date,values, timeline, [seasonality], [data_completion], [aggregation])
Point forecasts are obtained from the models by iterating the equations for t=T+1,…,T+ht=T+1,…,T+h and setting all εt=0εt=0 for t>Tt>T.
Therefore, ^yT+2|T=?T+2bT,y^T+2|T=?T+2bT, and so on. These forecasts are identical to the forecasts from Holt's linear method, and also to those from model ETS(A,A,N). Thus, the point forecasts obtained from the method and from the two models that underlie the method are identical (assuming that the same parameter values are used).ETS point forecasts are equal to the medians of the forecast distributions. The forecast distributions are normal for models with only additive components, so the medians and means are equal. For ETS models with multiplicative errors, or with multiplicative seasonality, the point forecasts will not be equal to the means of the forecast distributions.13
Forecasted positive cases in Chennai. June 7 - August 31, 2020
As on June 6, 2020, the number of confirmed cases is 20993. By the end of June, the forecasted positive cases would be48909. By the end of July, the predicted positive cases would be84968. By the end of August, the forecasted positive cases would be121027 (Table 5 and Figure 11). Figure 12 shows the positive cases in the past and the future forecast with lower and upper bound. Transparent data above orange indicates the upper bound and the line within orange shows the lower bound (figure 12)
Forecasted percentage of cases in Chennai from the samples tested (June 7 - August 31, 2020)
As on June 6, 2020, in Chennai city, the rate of confirmed cases from the total sample tested is7.28. From the forecasting analysis, by the end of June, the forecasted percent of the positive cases from the samples would be 8.95. By the end of July, the predicted percent of positive cases from the total sample would be 11.23. By the end of August, the predicted percent of positive cases would be 12.6. (Table 6 and Figure 13,14).Transparent data above orange indicates the upper bound and the line within orange shows the lower bound (figure 14)
Forecasted percentage of confirmed cases (Tamilnadu)from the total samples tested on a particular day)
As on June 6, 2020, at Tamilnadu state (Including Chennai), the percentage of confirmed cases from the total sample tested is9.10. From the forecasting analysis, by the end of June, the forecasted percent of the positive cases from the samples would be 10.08. By the end of July, the predicted percent of positive cases from the total sample would be 11.36. By the end of August, the forecasted percent of positive cases would be 12.63. ForecastingTamilnadu pattern is critical as we need to understand how Tamilnadu’ s overall number is influenced by the Chennai city’s count. (Table 7 and figure 15,16).Other than the forecasted percentage of confirmed cases for Tamilnadu Vs. sample tested, the upper bound (above organge line) and lower bound (below orange line) is indicated for better understanding(figure 16)
3.Forecasted Death cases in Chennai) June 9 - August 31, 2020
As of June 8, 2020, at Tamilnadu state, the number of death cases is 234. From the forecasting analysis, by the end of June, the number of death cases would be around 773. By the end of July, the number of death cases is 2255. By the end of August, the number of death cases in 4565 (Table 8, Figure 17).
Discussion and interpretation
Chennai is one of the cities in India severely affected by the COVID-19. Tamilnadu state has 38 districts (table 1). The number of positive cases and the percent of death cases of all 37 districts is pretty less when compared with the Chennai city. As of June 6, 69.4 percent are from Chennai, and 30.6 percent cases from other parts of Tamilnadu (figure 1). Twenty thousand nine hundred ninety-three cases were confirmed from Chennai and 9,159 cases from all other parts of Tamilnadu state(table 2). The first case identified at Tamilnadu on March 9 and until March 23, it was a single-digit case. On March 24, the number of confirmed cases was 15(table 3). The reason for sudden changes in the number of cases was the contribution from Chennai city. The first case identified at Chennai on March 18. On March 24, the number of confirmed cases was 7(table 3). On March 25, the number increased to double-digit. On April 6, the confirmed cases reached triple-digit(table 3). With the constant increasing Patten, on May 1, the number of confirmed cases is 1082(figure 4). As on May 24, within 24 days, the confirmed cases increased by ten times (10576). As per the data from the Tamilnadu government's health department, the total confirmed cases from Chennai city are 20993, as of June 6, 2020(figure 5)
It is evident that the majority of the top cities such as Mumbai, Delhi and Chennai are poorly affected due to COVID-19 and Kolkata is exceptional. There could be various reasons for this worst situation. Population density at the Chennai city is one of the primary reasons for more confirmed cases. The Koyambedu market was kept open and operational during lockdown even after the confirmed cases at Chennai, which was another contributor. At one point of time, Government of Tamilnadu closed the market in the first week of May 2020, which made the workers to return to the native places. However, infected people might have roamed around without knowing that they are affected.
It appears that lockdown 1.0 was productive and successful. Lockdown 2.0 announced with no relaxations. However, the effectiveness was less comparatively. Further, lockdowns were not much helpful as people perceived the negligence and started roaming across the city. People who were healthy and unaffected by COVID-19 were moving around, which added more cases as an opportunity to pick the disease from others. Also, some of the people who were affected and quarantine at home were roaming without social responsibility and infected others. Additionally, there are so many people affected by coronavirus without any symptoms, which is a significant cause to add more confirmed cases at Chennai city. Symptoms vary from person to person, which is also adding more difficulties to medical professionals. The first death happened on April 18. From May 5 onwards, there were continues deaths noticed. On June 8, authorities announced 12 death cases in Chennai city and the total death count is 234(figure 7).
The neighbour districts and borders of Chennai cities such as Kanchipuram, Thiruvallur and Chengalpattu also impacted severely than other regions of Tamilnadu. This is because of the people's exposure to Chennai and people are roaming between these districts as Chennai city is well connected with all those cities. We have used FORECAST.ETS in MS Excel function to predict the expected number of COVID-19 cases for Chennai in the future. If the current pattern continuous, by the end of August, the forecasted positive cases would be 121027(figure11,12). As on June 6, 2020, in Chennai city, the percentage of confirmed cases from the total sample tested is 7.28. and it may go up to 12.6 by August 31, 2020(figure 13,14). As on June 6, 2020, at Tamilnadu state, the percentage of confirmed cases from the total sample tested is 9.10 but the majority contribution for Tamilnadu comes from Chennai city. From the forecasting analysis, by the end of August, the forecasted of positive cases would be 12.63 percent(figure 15,16). The forecasting of Tamilnadu indicates that the majority contribution comes from Chennai city. As on June 6, 2020, at Tamilnadu state, the number of death cases is 197. From the forecasting analysis, by the end of August, the number of death cases 4565(figure 17).
The forecasting is predicted based on the recent past trend on confirmed cases, percent of sampling and number of death cases. Prediction is carried by using the Excel Forecast.Ets function with the use of an exponential smoothing algorithm to predict a future value on a timeline, based on a series of existing values. The forecasted numbers will remain valid if the current conditions exist. If the people get more awareness, Chennai corporation takes additional measures to control the pandemic, announce the lockdown in the severely affected zones and the nature of the virus changes itself, may contribute to the lower numbers in the future, which may be different from the forecasted figures. Another side, there could be various factors that may play a role for an increasing number of cases. They are: If the virus changing the nature of the symptoms, more people affected without any symptoms, more positive cases due to unexpected reasons, and recent and forthcoming returnees from other state and countries due to lockdown relaxations.
Understanding the forecasted number is critical for pandemic management. Government of Tamilnadu, Chennai Corporation, disaster management from the revenue department, health department and Police department should have a better understanding of the current number of confirmed cases, future predicated cases, death cases and the various contributors for the same. Public awareness is critical in this pandemic situation. By involving famous personalities, awareness programmes can be conducted. Before it becomes a tragedy, the administrators should attempt to find the ways to control the spread of COVID-19, which will help them to prove the forecasted numbers are wrong, which can save the life of valuable human being's life.
Recommendations
Health workers can be deployed ward by ward and door to door for accessing and identify the symptomatic people as a preventive method.
Government of Tamilnadu and Chennai corporation may initiate the control of private hospitals across the Chennai city and neighbour districts for a certain period (Say 1 year) on compensation basis.
Hospitals, Doctors, Technicians, Labs and infrastructure facilities from the neighbour districts can be used to treat the COVID-19 patients of Chennai city. The availability of Human resources and infrastructure should not become a barrier to manage the contemporary situation.
Batch sampling test can be attempted by understanding the segment of the most affected people so that the disease can be detected in advance and a higher number of suspicious people filtered at the earliest.
Government of India, Government of Tamilnadu and Chennai corporation, either collaboratively or individually to take necessary steps for research related to the vaccination and therapeutic medicine by funding for such activities. While we are focusing on identifying the affected people, this approach is much needed as long term approach. Though there are few such initiatives, the rigorous research approach is needed by considering the present situation.
Severely affected areas to be identified as containment zones and implement the lockdown for that particular zones, including the movement restriction in and out the zone.
Health workers to be assigned to various zones in the Chennai city from other parts of Tamilnadu and do the necessary inspection at the different zones at Chennai, as a proactive approach.
Chennai Corporation should be equipped well with various factors such as a more significant number of doctors, nurses, health workers, hospitals, beds and testing equipment so that more testing and treatments can be done as a proactive approach and reactive approach as well.
The number of sampling per day should be increased so that affected cases can be identified earlier, which can help to treat them in the initial phase itself without any advance medical treatment, which includes ventilation. Also, this will help to prevent further spread to other people.
As the number of cases is increasing exponentially in Chennai city due to the dense population, sealing of Chennai city can be considered to avoid further spreading to other Tamilnadu regions.
It is worth considering getting an expert opinion from the health and statistical organizations of other state and central government medical organizations such as ICMR and AIIMS. By doing this, we would be able to gather better and adequate ideas, methodologies, tools, and techniques to control and flatten the pandemic's spread.
Finance plays a critical role in Pandemic management. It is understood that there are fund allocations from the government of Tamilnadu and government of India. However, for better and improved management of the COVID-19 situation, a committee can be formed by including the financial, administrative, statistical and medical experts who can appropriately work with the respective authorities in the central government which can help to get more financial support based on the actual facts and figures in the state.
Conclusion
Disaster and pandemic come suddenly and make an enormous change in society with substantial negative impacts. The human community cannot predict, and a proactive approach is not appropriate to the Disaster and Pandemic. The reactive approach is more suitable as we need to deal with it once we affected by them. When COVID-19 identified first in Wuhan city in China, it was just news for others from various part of the world. Now, India is one of the majorly affected countries and stands at 6th place. Most of the states and big cities are affected. Chennai, which is the capital of Tamilnadu, is severely affected by a considerable number, and the count is increasing day by day. There are various initiatives from the Tamilnadu government and Chennai corporation to control, treat and prevent COVID-19. However, the number of cases is rising in an uncontrolled manner. Strategical disease management is needed to control the situation better. Forecasting is one of the critical factors that play a vital role in the pandemic management. Unless otherwise, we predict the future trend in increasing spread, it is challenging to deal and control infection and death rate. As mentioned in the recommendations sections, few additional measures and actions to be taken by the respective authorities will help manage the situation better. Though the COVID-19 falling under medical, biological, and health departments, combined management initiatives are essential. Doctors can treat the patients, but it is challenging to manage other administrative and associated activities related to the pandemic. It is possible with the strategical approaches where we can have proper planning, execution and monitoring.
Acknowledgement
Our sincere and heartfelt thanks to all the authors, Chennai corporation and government of Tamilnadu whose articles/reports/data are cited and included in references to this manuscript.
Source of Funding – No funding.
Conflict of interest – The authors declare that there is no conflict of interests.
Englishhttp://ijcrr.com/abstract.php?article_id=2693http://ijcrr.com/article_html.php?did=2693
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411212EnglishN2020June25HealthcareRelationship between Hypothyroidism and Body Mass Index in Women: A Cross-Sectional Study
English4851Suraj P WaghEnglish Shweta P BhagatEnglish Nandkishor BankarEnglish Karan JainEnglishIntroduction: Hypothyroidism is mainly caused due to deficiency of hormones. It is categorised into congenital and acquired depending on the level of endocrinal dysfunction in primary and secondary or central and the severity of severe or clinical hypothyroidism and mild or subclinical.
Method: 50 Women with hypothyroidism and 50normal healthy individuals were included in the present hospital-based case control study with proper inclusion and exclusion criteria. BMI and their relationship with Central Hypothyroidism were estimated using different methods with proper handling of samples.
Result and Observation: The mean value of T3, T4, TSH were more in control as compared to cases and this difference was significant. Correlation between TSH and BMI was positive and highly significantat pEnglishHypothyroidism, BMI, TSH, T4http://ijcrr.com/abstract.php?article_id=2694http://ijcrr.com/article_html.php?did=2694