Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareNew Surge of COVID-19 Infected Cases in Thailand English0101Pongsak RattanachaikunsoponEnglish Parichat PhumkhachornEnglishEnglish COVID-19, Thailand, Center for COVID-19 Situation Administration (CCSA), SamutSakhon seafood markethttp://ijcrr.com/abstract.php?article_id=3298http://ijcrr.com/article_html.php?did=3298

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareLed Light Photobiomodulation Effect on Wound Healing Combined with Phenytoin in Mice Model English0208Tarek ElwakilEnglish Mahmoud S. ElbasiounyEnglish Hatem ElnajarEnglish KawkababdelazizEnglishBackground: Impaired wound healing is a disastrous medical problem associated with chronic diseases and ageing. To accelerate skin regeneration many techniques have been researched laser and LED has been used for these purposes. Topical phenytoin is simple to use, safe, inexpensive and readily available drug and plays a significant role in the rate of healing of wounds. Objective: We aimed to evaluate irradiation of a LED light 670-nm for wound healing. Using ulcer mice model with and without the combination of phenytoin drug. Methods: Four groups 24 mice per group received treatment as follows. Group I: Ulcers followed up without any treatment modality.Group II: Ulcers subjected to topical Phenytoin spray twice daily, Group III: Ulcers irradiated with red LED 670 nm at a fluence of 5 J/cm2 . Group IV: Ulcers treated by combined topical Phenytoin spray and red LED670 nm at a fluence of 5 J/cm2 . All treatments started from the 1st day postoperatively and for up to three consecutive weeks or till complete healing of the ulcer. Results: The results showed the fastest healing in the combined group with more deposition of collagen fibres, larger amounts of granulation tissue, less oedema. The second best treatment was the red LED 670-nm only treated group as mice showed less evident features with fewer collagen fibres deposition. Conclusion: Red LED 670nm combined with phenytoin is an effective enhancer of wound healing that stimulates the secretion of growth factors in the wound bed and induce many changes during the skin healing process, especially in favouring neo collagen fibres to be better organized and led more deposition of collagen fibres. English Wound healing, Biomodulation, Phenytoin, Laser therapyINTRODUCTION Many light based systems had effects on wound healing; these outcomes were noted irrespective of whether a laser, light emitting diode (LED) or broadband polarized light source used as a Low-level Laser therapy (LLLT) 1. This form of therapy is currently being used to treat various conditions based on the principles of photobiomodulation2. That influences different biological processes, such as acceleration of wound healing. It is important to know that there is amost favorable light energy needed for wound healing, and higher or lower energy than the favorable value may have no beneficial effect3. Wound healing effects are generally observed at fluences between 1 and 10 J/cm2, while photoinhibitory effects are typically observed at higher fluenciestreatment 4. Low level Laser therapy through Photobiomodulation may induce a decisive impact on the course of biological events that take place during wound healing, as it enhances collagen synthesis in the wound area with gradual fibroblastic proliferation and the amount of collagen being synthesized can be particularly affected during tissue regeneration 5 it has been demonstrated that collagen fibers appeared thicker and better organized by a 660 nm wavelength laser application6-9 Several studies have demonstrated that LLLT has a significant influence on a variety of cellular functions. Increased mitochondrial respiration and adenosine triphosphate (ATP) synthesis, cell proliferation, enhancement, and promotion of tissue regeneration following injury. Stimulation of cell proliferation results from an increase in mitochondrial respiration and ATP synthesis. It is assumed that this absorption of light energy may cause photodissociation of the inhibitory nitric oxide, leading to the enhancement of enzyme activity, increased electron transport, oxygen consumption, mitochondrial respiration, and ATP production6. In turn, LLLT, by altering the mitochondrial or cellular redox state, can induce the activation of numerous intracellular signaling pathways and alter the affinity of transcription factors concerned with cellular migration, proliferation, survival, tissue repair, and regeneration. 7 The basic light interaction behind the effects of LLLT is thought to be through the absorption of photon by chromophores, in particular cytochrome c oxidase (CCO), which is part in the respiratory chain positioned within the mitochondria several exogenous factors may interfere with the structural patternand the amount of collagen fibers being deposited during the healingprocess.8,9 The possibility of using phenytoin for wound healing was observed in a double -blind, placebo controlled clinical study involving the use of phenytoin inleg ulcers when the author demonstrated that phenytoin is effective in promoting healing. As it is readily available, safe, inexpensive, and easy to use,It was suggested as a drug for healing ulcers However, no evidence supporting these assumptions of positive healing effect of phenytoin 10. The RCTs reported Variable treatment outcomes may be attributed to different doses and forms, different healing assessment tools, topical application of phenytoin powder may improve the rate of healing and is not associated with any serious side effects 11. The possible mechanism of action by which phenytoin promotes wound healing has been contribute to An increase in the proliferation of fibroblasts hence increase in the deposition of collagen, increase in Neovascularisation enhanced granulation tissue formation. A decrease in the action collagenas and decrease in bacterial contamination that may be a primary antibacterial effect of phenytoin or if it is due to a secondary effect of phenytoin, such as neovascularisation and/or collagenisation and there has been at least one study which refutes its beneficial healing effect 12. MATERIALS AND METHODS Animals Model After the Research Ethics Committee of Cairo university with no. 281472, granted a total of 96 mice between 6 and 9 weeks of age and weighing 18–20 g, were used in this study. The animals were housed one per cage (to prevent cage-mate attacks on wounds) and had access to food and water, free access/ad-libitum. The mice were maintained on a 12-hour light/dark cycle under a room temperature of 21 °C.     To produce the surgical wound mice were anesthetized by an intraperitoneal injection of a ketamine–xylazine cocktail (90 mg/kg ketamine and 10 mg/kg xylazine) before wounding the dorsum of the anesthetized mice were shaved using an electric fur clipper, and the underlying skin was cleaned with sterile 70% isopropanol. The anticipated area of the wound to be created was outlined on the back of the animals with methylene blue using a circular stainless steel stencil, to ensure comparable wound size in all the mice. A full thickness excision wound diameter 12mm, along the markings using toothed forceps, a surgical blade and pointed scissors, the wound was left uncovered during the whole period of experiments. Their wounds were cleaned with 0.9% saline once a day in the morning. Animals was monitored daily looking for adverse effects of wounding on their general health. Light source The Phototherapy unit used in the study was the LED-based phototherapy system (Photo Therapeutics, Limited, Fazely, Tamworth, UK) which consists of a base unit fitted with interchangeable LED at 670nm nm (visible red). The illumination performed daily for three weeks, beginning 6h after the induced wound surgery, until 24h before sacrifice. The LED was be used in continuous and directly in non contact mode with the ulcer surface. The output power of LED was 40mW with fluence 5J /cm2 and Fluence rate (12mW/cm2) Spot size was defined by the area of the square window in the aluminum foil (1.5×1.5 cm) used to cover the mouse body. Each wound measured approximately 1.2×1.2 cm Time of irradiation/day (min) 6.6 Study design            Mice were randomly divided into four groups according to the therapy applied 24 mice per group. The study groups were divided into four groups receives treatment in form of phenytoin or LED or combination of both as follows. Group I (Control Group): Ulcers was followed up without any treatment modality. Group II (Phenytoin Group):  Ulcers was be subjected to topical Phenytoin spray twice daily starting from the 1st day postoperatively and for up to three consecutive weeks or till complete healing of ulcer as denoted by its complete closure. Group III LED (670 nm) Group):  Ulcers was be subjected to LED (red spectrum) daily illumination starting after 6 hours postoperatively and for up to three consecutive weeks or till complete healing of ulcer as denoted by its complete closure. The LED treatments were given at a fluence of 5 J/cm2. Group IV (Combined Phenytoin and LED (Red Spectrum) Group):  Ulcers was be subjected to combined topical Phenytoin spray and LED (red spectrum) at the same conditions and parameters as mentioned in groups II and III. Methods of Assessments Wound area measurement Maximum diameters of ulcers was measured daily by Vernier’s caliber and ulcer area was be calculated. The relative change in the surface area of ulcers with respect to the initial surface area was determined. Moreover, reepithelization and healthy granulation tissue was be grossly evaluated and timings of complete closure of wounds was be assessed for each. Ulcers were photodocumented at different timings of assessments by using a digital camera at the same distance and lighting conditions. Wound images were acquired every other day using a digital camera. Wound surface area was monitored by capturing the video images of each ulcer area together with a ruler (mm) using the digital camera and downloaded to a computer. The first image of each wound from the different groups was obtained on the day of injury (day 0). The subsequent images were captured on third, fifth, seventh, twelfth and fourteenth day post-injury. The wound area analysis was performed by Fiji (ImageJ) software and values were expressed in mm2. Repeated measurements were accurate to within 2%. B. Histological Evaluations: Animals were randomly sacrificed at each evaluation time by using an intraperitoneal overdose of ketamine at (3-5-7-10-12-14) day’s postoperativly postoperatively, as well as, after complete healing of ulcers as denoted by the complete ulcer closure. Standardized rectangular specimens were harvested across the wound using a double-blade cutting instrument then preserved in 10 % formalin and then embedded in paraffin. Serial tissue sections of 4-μm thickness were prepared, stained with hematoxylin and eosin (H&E), and observed for histological changes under a light microscope to assessreepithelialization, epidermis thickness, inflammatory cell infiltration, collagen deposition, and blood vessel proliferation. Staining with Methyl trichromon paraffin sections done to determine the amount of collagen at the wound the most representative findings was be documented by photomicrography. Immunohistochemical Analysis: Basic fibroblast growth factor vascular endothelial growth factor (VEGF) and tumor necrosis factor was investigated. Statistical Analysis: Data was be presented as means ± standard deviation (SD). Student’s t-Test was be used to determine significant differences between treatment groups. Differences between pairs of means was be analyzed by one–way analysis of variance (ANOVA) test. Values of P≤0.05 were being considered statistically significant. Results Results of Wound area measurements In the present study, we compared the effect of red wavelength at 635 nm ranges delivered at a constant fluence (5 J/cm2) and fluence rate (12 mW/cm2) with and without the combination on of Phenytoin drug that increases angiongesis and promotes healing to study mice dermal wound healing response variation with wavelength. Wound areas was determined after surgery day after day during the ongoing wound healing process, wound areas decreased in all groups compared to the initial wound area measured after surgery. However, low level light therapy by red LED 635 nm combined with Phenytoin markedly influenced this parameter, there was no difference on day 3 post-OP, but on day 7 the wound area was 50% smaller (p < 0.05) in the combined LED 635 nm and Phenytoin group compared to not illuminated control to elucidates the effect of light (Fig.1). In contrast, red LED 635 nm light seemed to delay wound closure, and the difference was even greater compared to the Phenytoin group although these finding were not significant. Results of Morphological wound Assessment No significant difference could be detected regarding the degree of granulation (Fig. 2). However, light effected reepithelialisation as there was a strong trend to enhanced epithelialisation. Wounds treated with different wavelengths exhibited wound contraction from day 1 until observation of day 21 after wounding. However, non-treated control wounds initially expanded on day 1 post-injury, and at day 2, control wounds were the same size as the original size on day 0. From day 4 onwards, control wound exhibited a gradual reduction in wound area. Histological Evaluations: Assessments were carried out at (3-7-14-21) days postoperatively where at those times healing/healed ulcers were excised and subjected to multiple cross-sections of H&E-stained sections of wound tissues obtained from control group and treated groups of mice the evaluations aimed for:haemorrhage, epidermis thickness, inflammatory cell infiltration, collagen deposition, and blood vessel proliferation. Control group: Cross-sections of H&E-stained sections of skin wound from, untreated mice at day 3 showed necrosis associated with oedema and inflammatory infiltrate at day 7 showed necrosis associated with oedema and massive dermal inflammatory infiltrate, at day 14 ill developed granulation tissue appeared, At 21 days granulation tissue formation with inflammatory cells infiltration and congested newly formed blood capillaries were noticed. Phenytoin treated group: at day 3 H&E-stained sections showed necrosis, oedema and inflammatory cells infiltration at day 7 it showed necrosis, dermal inflammatory cells infiltration and no haemorrhage, at  day 14 showed granulation tissue formation with epithelization well developed neo angiogenic blood vessles and inflammatory cells infiltration. At day 21 showed epithelization granulation tissue formation collagen fibers. The  Red LED group: at day 3 H&E-stained sections showed necrosis, highly vascularized dermal blood vessel and dermal inflammatory  (7days) showing dermal inflammatory infiltrate and congested dermal blood vessel   (14 days) showing epithelization and granulation tissue formation The  combined phenytoin and Red LED group: at day 3 H&E-stained sections showed necrosis, dermal inflammatory cells infiltration and haemorrhage  at day 7  showed necrosis and massive dermal inflammatory cells infiltration at day 14 showed granulation tissue formation and inflammatory cells infiltration at day 21 showied  well developed granulation tissue formation   with few inflammatory infiltrate  well oriented epithelization. Results of the histopathological comparison scors On days 3 and 7, the phenotyon and combined phenotyon and red LED groups had significantly higher angiogenesis than other two groups (p< 0.05). Treatment groups were not significantly different among each other of groups 1 and 2 in terms of angiogenesis is. Epithelialization There were no significant differences on days 3 and 21.Epithelialization on day 7 was higher in all the treatment groups compared with control group (p < 0.05). All treatment groups had significantly lower inflammation on day 14 compared with control group (p< 0.05). Red LED ligh and combined group had faster epithelialisation than the other treated groups  There were no differences between groups on day 21 shown in Fig. 1 Collagen Analysis: It Fibroblastic activity, and collagen deposition was determine the amount by Masson trichrom(MTC stain).were not statistically different between treatment groups and the control group Skin of mice from control group (14 days) showing haphazardly arranged, ill developed granulation tissue. Notice massive haemorrhage between the granulation tissue  Skin of mice from treated with phenytoin (14 days) showing well oriented granulation tissue with collagen fibers deposition  Skin of mice from treated with combined phenytoin and led (14 days) showing well oriented, well developed dense stained granulation tissue with collagen fibers deposition Skin of mice from treated with combined phenytoin and led (14 days) showing well oriented, well developed dense stained granulation tissue with collagen fibers deposition Skin of mice from treated with led (Red Spectrum)  (14 days) showing well oriented, well developed dense stained granulation tissue with collagen fibers deposition  Skin of mice from treated with led (Red Spectrum) (14 days) showing well oriented, well developed dense stained granulation tissue with collagen fibers deposition Skin of mice treated with LED (IR spectrum) (14 days) showing haphazardly arranged, ill developed granulation tissue kin of mice from treated with combined phenytoin and LED (Red Spectrum) (14 days) showing well oriented, well developed dense stained granulation tissue with collagen fibers deposition (fig. 3) . Results of immunehistochemical study of the Inflammatory Mediators Tumor necrosis factor TNF:           Immunohistochemical staining of TNF in skin of control mice showing strong positive expression of TNF  in skin of mice treated with H showing moderate positive expression of TNF skin of mice treated with H showing moderate positive expression of TNF  skin of mice treated with HL showing no expression of TNF (negative immunoreaction for TNF). skin of mice treated with HL showing no expression of TNF (negative immunoreaction for TNF). skin of mice treated with R showing strong positive expression of TNF  skin of mice treated with R showing moderate positive expression of TNF skin of mice treated with RH showing weak positive expression of TNF  skin of mice treated with RH showing moderate positive expression of TNF Vascular endothelial growth factor (VEGF): Immunohistochemical staining of VEGF in skin of control mice showing weak positive expression of VEGF  Whereas the skin of mice treated with phenytoin showing moderate positive expression of VEGF  The skin of mice treated with combined phenytoin and LED (Red spectrum)  showing moderate positive expression of VEGF  skin of mice treated with combined phenytoin and LED (Red spectrum)  showing strong positive expression of VEGF  skin of mice treated with LED (Red spectrum)  showing strong positive expression of VEGF  skin of mice treated with LED (Red spectrum)  showing strong positive expression of VEGF skin of mice treated with LED (IR spectrum)  showing moderate positive expression of VEGF  skin of mice treated with combined phenytoin and LED (IR spectrum)  showing strong positive expression of VEGF  skin of mice treated with combined phenytoin and LED (IR spectrum)  showing strong positive expression of VEGF (fig 4). Transforming growth factor (TGF): was investigated. Immunohistochemical staining of TGF in skin of mice from control group showing no expression of TGF. In skin of mice treated with phenytoin showing positive expression of TGF  in skin of mice treated with combined phenytoin and LED (Red spectrum) showing positive expression of TGF skin of mice treated with combined phenytoin and LED (Red spectrum) showing positive expression of TGF  skin of mice treated with LED (Red spectrum) showing strong positive expression of TGF  skin of mice treated with LED (Red spectrum) showing strong positive expression of TGF skin of mice treated with LED (IR spectrum) showing moderate positive expression of TGF  skin of mice treated with combined phenytoin and LED (IR spectrum) showing strong positive expression of TGF  skin of mice treated with combined phenytoin and LED (IR spectrum) showing strong positive expression of TGF (fig 5, 6). DISCUSSION Various treatment methods are used for the aim of developing wound care products and strategies such as local or systemic agent use, and even surgical treatment 13- 15. The use of light in wound healing experimental studies and clinical applications remains popular among clinicians. Mechanism of Actions of light have been widely investigated to understand the molecular basis and to extend their clinical use 16. Topical phenytoin had been knownhelpful for a broad variety of wounds. Clinical studies using topical phenytoin as a treatment suggest that it may be useful for the therapy of both acute and chronic wounds of diverse etiologies17. To our knowledge no other study had tested the combination between phenytoin and LED light therapy for wound healing. The cellular, biochemical, and molecular effects start to build up early in healing wound, as in the cicatricial context 18. Therefore, the present study aimed to characterize the process of fibrous tissue formation in later stages of tissue healing. In addition to this aspect, an investigation was conducted to ascertain whether the combination of phenytoin and laser stimulation could affect tissue repair on the basis of cellular level. The use of laser therapy for wound healing was initially described as early as 1960. Because of its ability to either stimulate or inhibit tissue responses, the term “biostimulation” was changed to “biomodulation. Several reports have shown that major components of the healing process are affected by several wavelengths, which include: fibroblastic proliferation, proliferation of keratinocytes, collagen synthesis and deposition, and increased angiogenesis 19. Collagen synthesis and other components of the connective tissue are important for the healing process at early stages. However, this process has to be self-controlled in order to prevent the formation of hypertrophic scars. The positive biomodulation of laser therapy on fibroblastic proliferation, and on collagen synthesis and deposition are well described in current literature. In the present investigation, a number of fibroblasts were observed on irradiated subjects when compared to their controls. These cells were predominantly young and very active in collagen production. Despite the fact that the collagen organization observed in the present study suggested that laser therapy influences collagen synthesis but does not significantly affect collagen organization 20. Our results indicated that non-coherent LED light 670-nm had better stimulatory effects when combined with phenotoyn and was superior to it when used alone. On the cellular level, LED light 670-nm modulates fibroblast proliferation, increases collagen bond and synthesis, promotes angiogenesis, improves energy metabolism and produces biological effects during the healing phase. The collagen deposition varied according to the period and according to the group analysed; it was minor in the great majority of animals in the four groups on the 10th day of examination. Our results harmonize with the findings of previous research that employed wavelengths of 660 and 780 nm and a dosage of 5 J/cm2 on four points and found a small and moderated number of immature and fragmentary collagen fibres on the 14th day of treatment using optical microscopy 21. Conclusions The combined phentoyn and LED light have a positive healing effect on dorsal mice wounds regardless of the radiation dose. LED light was considered more effective compared to phenotyon in terms of fibroblast proliferation and collagen fiber density. However, further randomized clinical studies are required to determine the effect of combination of these two modalities of therapy on wound healing in humans. Founding This studies as no fund from any authorities and there is no any conflict of interest. Englishhttp://ijcrr.com/abstract.php?article_id=3299http://ijcrr.com/article_html.php?did=3299 WiererJr JJ, Tsao JY, Sizov DS. Comparison between blue lasers and light?emitting diodes for future solid?state lighting. Laser & Photonics Reviews. 2013 ,7(6):963-93. Lucas C, Criens-Poublon LJ, Cockrell CT, de Haan RJ. Wound healing in cell studies and animal model experiments by Low Level Laser Therapy; were clinical studies justified? A systematic review. Lasers in medical science. 2002 , 1;17(2):110-34. Avci P, Gupta A, Sadasivam M, Vecchio D, Pam Z, Pam N, Hamblin MR. Low-level laser (light) therapy (LLLT) in skin: stimulating, healing, restoring. InSeminars in cutaneous medicine and surgery 2013, 32, 1, pp. 41). NIH Public Access. Gupta A, Dai T, Hamblin MR. Effect of red and near-infrared wavelengths on low-level laser (light) therapy-induced healing of partial-thickness dermal abrasion in mice. Lasers in medical science. 2014, 29(1):257-265. Arany PR, Nayak RS, Hallikerimath S, Limaye AM, Kale AD, Kondaiah P. Activation of latent TGF-β1 by low power laser in vitro correlates with increased TGF-β1 levels in laser-enhanced oral wound healing. Wound repair and regeneration. 2007, 15(6):866-874. Chaves ME, Araújo AR, Piancastelli AC, Pinotti M. Effects of low-power light therapy on wound healing: LASER x LED. Anaisbrasileiros de dermatologia. 2014;89(4):616-23. deFreitas LF, Hamblin MR. Proposed mechanisms of photobiomodulation or low-level light therapy. IEEE Journal of selected topics in quantum electronics. 2016 Jun 9;22(3):348-64. Fortuna T, Gonzalez AC, Sá MF, Andrade ZD, Reis SR, Medrado AR. Effect of 670 nm laser photobiomodulation on vascular density and fibroplasia in late stages of tissue repair. International wound journal. 2018 Apr;15(2):274-82. Medrado AP, Soares AP, Santos ET, Reis SR, Andrade ZA. Influence of laser photobiomodulation upon connective tissue remodeling during wound healing. Journal of Photochemistry and Photobiology B: Biology. 2008 Sep 18;92(3):144-52. Hao XY, Li HL, Su H, Cai H, Guo TK, Liu R, Jiang L, Shen YF. Topical phenytoin for treating pressure ulcers. Cochrane Database of Systematic Reviews. 2017(2). Bhatia A, Prakash S. Topical phenytoin for wound healing. Dermatology Online Journal. 2004;10(1). Swamy SM, Tan P, Zhu YZ, Lu J, Achuth HN, Moochhala S. Role of phenytoin in wound healing: microarray analysis of early transcriptional responses in human dermal fibroblasts. Biochemical and biophysical research communications. 2004 Feb 13;314(3):661-6. Kay?r S, Demirci Y, Demirci S, Ertürk E, Ayaz E, Do?an A, ?ahin F. The in vivo effects of Verbascumspeciosum on wound healing. South African Journal of Botany. 2018, 1;119:226-9. Asfaw M and Fentahun T. Treatment trials of epizootic lymphangitis with local medicinal plants: a review. Online Journal of Animal and Feed Research,2020, 10(4): 158-161. Al Johny BO. Efficacy of silver nanoparticles synthesized on Commiphoragileadensis (Balsam) extract against infectious bacteria. Journal of Experimental Biology and Agricultural Sciences, 2019. 7(3): 301-307 Fushimi T, Inui S, Nakajima T, Ogasawara M, Hosokawa K, Itami S. Green light emitting diodes accelerate wound healing: characterization of the effect and its molecular basis in vitro and in vivo. Wound Repair and Regeneration. 2012 Mar;20(2):226-35. Pendse AK, Sharma A, Sodani A, Hada S. Topical phenytoin in wound healing. International journal of dermatology. 1993 Mar;32(3):214-7. Fortuna T, Gonzalez AC, Sá MF, Andrade ZD, Reis SR, Medrado AR. Effect of 670 nm laser photobiomodulation on vascular density and fibroplasia in late stages of tissue repair. International wound journal. 2018 Apr;15(2):274-82. Chung TY, Peplow PV, Baxter GD. Laser photobiostimulation of wound healing: defining a dose response for splinted wounds in diabetic mice. Lasers in surgery and medicine. 2010 Nov;42(9):816-24. Grbavac RA, Veeck EB, Bernard JP, Ramalho LM, Pinheiro AL. Effects of laser therapy in CO2 laser wounds in rats. Photomedicine and Laser Therapy. 2006 Jun 1;24(3):389-96. Meirelles GCS, Santos JN, Chagas PO, Moura AP, Pinheiro ALB (2008) A comparative study of the effects of laser photobiomodulation on the healing of third-degree burns-a histological study in rats. Photomed Laser Surg 26(2):159–166. doi:10.1089/pho.2007.2052

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareInfluence of Collected Modified Risk Factors on the Development and Progression of Chronic Kidney Disease English1317Akhmedova Nilufar SharipovnaEnglish Ergashov Bobir BakhodirovichEnglish Nuralieva Hafiza OtaevnaEnglish Safarova Gulnoza AvazkhonovnaEnglishBackground: Numerous studies have shown that in patients with chronic kidney disease (CKD), the clinical manifestations of this pathology often appear in an advanced stage of the disease when the patient needs pathogenetic therapy or substitution therapy. Introduction: In this regard, screening examinations of the functional state of the kidneys is of great importance. We analyzed the incidence of risk factors for CKD among the subjects. Results: Of the 21 risk factors studied, the most significant were 10 factors that had a modifying nature, the detection rate per patient was, respectively, from 3.40 to 4.58 risk factors. Conclusion: The presented comparative analysis of the obtained results shows that overweight is more common among the population aged 40–59 years, and indicates that this age with the association of overweight is one of the risk factors for the development and progression of CKD in patients. EnglishAkhmedova Nilufar Sharipovna, Bukhara State Medical Institute, Bukhara, UzbekistanIntroduction Chronic kidney disease (CKD) is a common disease associated with increased risk factors for the development of this disease.1,2 Several global, widespread, and growing chronic non-communicable diseases are high-risk factors for the development of CKD.3,4 The criteria for the diagnosis of CKD are markers of kidney damage identified during the clinical, laboratory, and instrumental examination and persisting for more than three months, regardless of the nosological diagnosis.5,6 Materials and Methods We analyzed the incidence of risk factors for the development of CKD among the subjects. Of the 21 risk factors studied, the most significant were 10 factors that had a modifying nature, the detection rate per patient was, respectively, from 3.40 to 4.58 risk factors. Analyzes of the research results show that with the most well-known traditional risk factors (age, hypertension, diabetes mellitus, and obesity) for the development and progression of CKD in rural residents, some non-traditional risk factors are also of no small importance.7 Results and Discussion Frequently encountered non-traditional risk factors for the development and progression of CKD were the following: the presence of chronic foci of infection (91.48%), hyperlipidemia (60.88%), a history of nephropathy of pregnant women among women (58.4%), the abuse of nephrotoxic drugs (56, 47%), overweight (53.94%), dysuria of unknown aetiology (37.85%), bad habits (smoking, alcohol, abuse of salty and bitter foods (34.7%). These factors are gradually becoming the leading risk factors for the development of CKD in the population. Microalbuminuria detected in the subjects was assessed as a risk factor for the progression of CKD. Considering the above, we considered it appropriate to study and analyze in more detail the frequency of occurrence of these factors in a comorbid form, as risk factors for the development of CKD among rural residents and their impact on the functional state of the kidneys. Analysis of the results showed that the following types of combined occurrence of risk factors for the development and progression of CKD are often identified.7 1 - hypertension + overweight + abuse of nephrotoxic drugs + the presence of foci of chronic infection; 2 - overweight + presence of foci of chronic infection + abuse of nephrotoxic drugs + history of nephropathy and/or hypertension of pregnant women in women; 3 - overweight + hyperlipidemia + the presence of foci of chronic infection; 4 - hypertension + overweight + dysuria of unclear aetiology + the presence of foci of chronic infection; 5 - hypertension + ischemic heart disease + obesity + abuse of nephrotoxic drugs + the presence of foci of chronic infection; 6 - diabetes mellitus + hypertension + obesity or overweight + the presence of foci of chronic infection. From the above, it can be seen that there are often aggregates consisting of more than 4 components (risk factors). Among the examined individuals (n = 317), the 1st type of cumulative occurrence of risk factors was found in 54.25 ± 3.79% (n = 172), the 2nd type of the population was found in 38.8 ± 4.39% (n = 123 ), 3rd type of aggregate in 36.9 ± 4.46% (n = 117), 4th type of aggregate in 34.38 ± 4.56% (n = 109), 5 and 6 species, respectively 25.23 ± 4.86% (n = 80) and 15.77 ± 5.15% (n = 50). At the next stages, a comparative analysis of the incidence and degree of development of CKD with different combinations of risk factors was carried out (Figure 1). Figure 1. Degree of development and incidence of CKD in different combinations of risk factors (%). CKD, chronic kidney disease; RF, risk factor. The distribution of CKD by stages was as follows: grade I CKD is often detected with combinations of risk factors for the development and progression of types IV and III, respectively 57.7% and 39.1%; CKD II degree in combinations of V, III, II and I types, respectively, 63.7%, 48.8%, 48.9%, and 30.6%; Grade IIIA CKD is often detected in combination types VI, VII, and V, respectively 53.8%, 37.5%, and 27.1%. Thus, the degree of development and progression of CKD not only depends on the number of influencing risk factors, but the nature of the influence of this factor on the pathogenesis of the development and progression of CKD is of great importance. The results of our studies have shown that unconventional modifying factors, such as a history of nephropathy of pregnant women among women, abuse of nephrotoxic drugs, overweight and hyperlipidemia, affect the quality of risk factors for the development of CKD. At the same time, their cumulative occurrence with traditional risk factors for CKD affects the progression of the disease.2,8 Recent studies have shown that kidney damage in overweight and obese patients goes through several successive stages. 1. Stage of hyperfiltration is an early and potentially reversible stage of CKD. They practically do not show specific symptoms, they are detected by accident or during preventive medical examinations. 2. Stage of normal filtration - production of type I collagen, under the influence of leptin, which increases in the blood of obese individuals. These processes stimulate the proliferation of renal vascular endothelial cells and glomerular hypertrophy. Damage to glomerular endothelial cells is associated with microalbuminuria. 3. Stage of hyperfiltration - the formation of nephrosclerosis with the development of chronic renal failure, irreversible stage of CKD. With this research work, we wanted to study the visceral obesity index (IVO) as a diagnostic marker of kidney damage and its potential for predicting the risk of developing and progression of CKD. These data indicate an emerging interest in the relationship between obesity and kidney disease.4-6 To determine visceral (abdominal) obesity, VAI was calculated using the above formula. To conduct the research, the cohort group included 317 respondents who had been previously identified in screening studies in rural areas based on the detection of microalbuminuria as an early diagnostic predictor of CKD. The clinical characteristics of these subjects were shown in Table 1. Note: BMI - body mass index; WC - waist circumference; HC - hip circumference; HDL – high-density lipoprotein; LDL – low-density lipoprotein; TG - triglyceride; VOI - visceral obesity index. Of the entire contingent of the surveyed (n = 317), overweight was detected in 171 patients (53.94 ± 4.98%), and obesity was detected in 52 respondents (16.40 ± 3.70%). These identified individuals, depending on the parameters of BMI, were divided into 2 groups: group 1 - overweight (BMI = 25.0–29.9 kg / m2 - n = 171; Group 2 - patients by whom obesity was determined (BMI> 30 kg / m2 - n = 52. The parameters of the given survey groups were studied in a comparative aspect (Table 2). Note: absolute in the numerator, relative (%) indicators in the denominator: * - a sign of a significant difference in the parameter; ↑ ↓ and ↔ - increase, decrease, or no difference between the indicator and the compared group. Analysis of the data presented in Table 2 shows that the anthropometric parameters of the comparative groups differ statistically significantly. The average BMI, WC, HC, and WC / height were significantly higher in the 2nd group (p Englishhttp://ijcrr.com/abstract.php?article_id=3300http://ijcrr.com/article_html.php?did=3300 Duncan L, Heathcote J, Djurdjev O, Levin A. Screening for renal disease using serum creatinine: who are we missing? Nephrol Dial Transpl 2001;16(5):1042-1046. Vaziri ND. Disorders of lipid metabolism in nephrotic syndrome: mechanisms and consequences. Kidney Int 2016;90(1):41-52. Seng JJB, Tan JY, Yeam CT, Htay H, Foo WYM. Factors affecting medication adherence among pre-dialysis chronic kidney disease patients: a systematic review and meta-analysis of literature. Int Urol Nephrol 2020;52(5):903-916. Sharipovna AN. The importance of proteinuria as a predictor of diagnosis and a risk factor for the development of chronic kidney disease. Eur Sci Rev 2018;(7-8):84-85. WorkGroup CK. Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int 2013;12:30-150. Levey AS, Coresh J, Bolton K, Culleton B, Harvey KS, Ikizler TA, et al. K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Am J Kidney Dis 2002; 39(2):5-11. Damtie S, Biadgo B, Baynes HW, Ambachew S, Melak T, Asmelash D, Abebe M. Chronic kidney disease and associated risk factors assessment among diabetes mellitus patients at a tertiary hospital, Northwest Ethiopia. Ethio J Health Sci 2018;28(6):58-62. Kobalava ZD, Villevalde SV, Bagmanova NKh BM, Orlova GM. The prevalence of markers of chronic kidney disease in patients with arterial hypertension, depending on the presence of diabetes mellitus: the results of an epidemiological study of chronographs. Russ J Cardiol 2018;2(154):1-01.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareThe Rationale for the Application of Bone Grafts in Periapical Surgery: A Review English0912Mubashir Baig MirzaEnglishFollowing periapical surgery, restoration of the destroyed bony architecture is a pre-requisite. Previous studies had shown that supplementing with artificial bone substitutes, growth factors or barrier membranes in the osseous defects is essential in influencing the healing following surgical intervention. This review is intended to focus on whether tissue regeneration with the aid of bone grafts coupled with a membrane barrier will suffice or is there a need for recruiting progenitor/stem cells. A literature search was conducted on several medical databases. All studies that used bone graft following periapical surgery were included Around 38 relevant articles were selected for this review. Literature shows that the mere use of a membrane barrier and/or bone graft following surgery would not yield the desired outcome. Previous studies show that some substitutes are capable of generating progenitor/stem cells and induce the undifferentiated mesenchymal cells to differentiate. Bone augmentation with the aid of bone graft materials along with biologically active molecules in addition to a mechanical barrier in the form of a membrane would enhance the healing of periapical tissues following periapical surgery. Better bone fill, gain in clinical attachment level is achieved with the use of various grafts as compared to non grafted sites. English Endodontics, Periapical surgery, Allogenous bone grafts, PRF, Guided tissue regeneration, Vital toothIntroduction A periapical pathology inevitably results in the presence of a nonvital tooth which is left unattended. This ultimately will result in osseous destruction in the periapical area. It is also a familiar observation that despite an accurately accomplished endodontic treatment failure can be encountered due to microbial infection. This can lead to the formation of a periapical lesion as a result of an inflammatory response to bacterial infection within the root canal.1 An important goal in periapical surgery is to enrich healing along with removing the unhealthy tissues.2 Periapical surgery not only eliminates the unhealthy tissues in the periapical region but also cleanses the root surface along with contouring the surrounding bone. However, few studies have suggested that the healing of the tissues by the newly formed tissue generally fails to fully restore the architecture of the pre-existent bone.3,4 The concept of tissue regeneration has been introduced to improve the quality of healing. The kind of cells that repopulates the wound initially determines the quality of healing.5 Literature shows that the use of either bone graft materials or incorporation of biologically active molecules in addition to the placement of a mechanical barrier following periapical surgery enhances tissue regeneration in the periapical tissues. Bone grafts It is a well-known fact that periapical lesions that are relatively small in size would heal satisfactorily with the aid wound healing but larger lesions would require recruitment of stem cells and their differentiation. In huge osseous defects, insufficient osseous regeneration occurs.6 Numerous studies in the past have demonstrated a better outcome with regards to tissue healing following periapical surgery with the aid of regenerative technique using bone graft compared to the same lesions without regenerative techniques.7,8 It is believed that a simple enucleation of the periapical cyst usually leaves a bony defect. Because the maxilla demonstrates a relatively high regenerative capacity, optimal obliteration of this osseous defect in presence of a background of an inflammatory reaction may be hindered.9 Inadequate or less optimal bone healing results when the regenerative technique is not employed due to the invagination of overlying tissue into the osseous defect, preventing osteogenesis.10 According to Jansson et al., the survival rates of periapical surgery was found to be 68% in molars and 77% in single-rooted teeth over 10 years.11 This highlights the fact that augmentation with the aid of bone grafts is essential to facilitate optimal tissue healing in the periapical region following periapical surgery. Augmented bone graft plays a key role by acting as a template for osteogenesis and slowly resorb to permit replacement by new bone.10Bone grafts have either osteogenic, osteoinductive or osteoconductive properties. 12 Hydroxyapatite can be considered to be a very effective alloplastic material particularly in large bone destruction caused by periradicular lesion where it can facilitate effective bone replacement in the later stages as well as provide functional support to the tooth in the initial stages.10 A recent study evaluated bone regeneration in the periapical region using Platelet-rich fibrin(PRF) and nanocrystalline hydroxyapatite with collagen in combination with PRF and their effects on healing and concluded that the combination of PRF and nanocrystalline hydroxyapatite with collagen produced a significantly faster bone regeneration and that conventional technique and PRF were less predictable with its healing response.13,14 Biologically active molecules             PRP play a critical role in enhancing wound healing due to the discharge of some growth factors via α granules.12,14 These growth factors generally act both locally and systemically.15 It increases early wound strength by enhancing collagen synthesis and angiogenesis. Few studies suggested that the use of a triple antibiotic paste for canal disinfection along with PRF strengthens the effectiveness of sterilization in carious teeth, infected dentin, periapical lesions and necrotic pulp.16 Huang et al. in his study concluded that PRF can multiply pulp cells in addition to enhancing the expression of osteoprotegerin and Alkaline phosphatase activity.17 In vitro studies have demonstrated that PRF has shown no cytotoxicity toward many normal cells present in the periapical region.18 A recent study showed that the PRF membrane has a slow sustained release of growth factors for 7-28 days.19 A recent study used PRF with tricalcium phosphate (TCP) bone graft for treating a periapical cyst and advocated that usage of PRF and TCP together would yield enhanced results than the usage of biomaterials alone.20 Study done by Keswani et al on the revascularization of immature pulp apices concluded that PRF acts as a biological connector for neoangiogenesis and vascularization.21 This highlights the fact that augmentation with the aid of bone grafts coupled with biologically active molecules is essential to facilitate optimal tissue healing in the periapical region following periapical surgery. Barrier membranes To prevent invading of the overlying soft tissue into the osseous defect, it is advisable to use a mechanical barrier on top of the defect. This would create an environment for the cells to repopulate into the defect.22 Resorbable membranes are available alternatives to non-resorbable membranes.23 They are resorbed by proteolytic enzymes and excreted via kidney.24 An in vitro study advocated that resorbable membranes stimulate cellular proliferation more than non-resorbable membranes.25 Literature shows that collagen membrane coupled with a bone graft significantly enhances the preservation of alveolar bone.26 Membranes containing greater than 5% metronidazole show antibacterial activity deprived of any cytotoxic effects.27 Amnion membrane is derived from the human placenta. It incorporates growth factors presenting anti-inflammatory and antimicrobial properties.28 The thickness of the amnion membrane is lesser than collagen membranes which assist a proper adaption over the osseous defect.29,30 Amnion membrane facilitate the proliferation of endothelial cells and angiogenesis in addition to recruitment of mesenchymal progenitor cells assisting accelerated wound healing.31,32 Inference The application of graft materials in the form of hydroxyapatite, tricalcium phosphate or xenograft alone would lead to the formation of fibrous encapsulation of the graft material and thereby interfere with the ideal healing in the periapical tissues following surgical intervention.32 It is believed that a blood clot plays a key role in stabilizes the wound matrix in the event of wound healing. Platelet alpha granules of PRP act as a source of growth factors that facilitate cellular proliferation and bone formation.33 PRF facilitates the preservation of the integrity of the bone graft material by revascularizing the bone graft particles through neo-angiogenesis.2,34 Once PRF starts resorbing slowly it releases growth factors that maintain a viable field to enhance healing.35,36 In addition to this placement of a barrier membrane would avoid the invagination of soft tissue into the osseous defect thereby enhancing the wound healing. Recent advances Conventional periapical surgical generally results in a big osseous defect. With the aid of the 3D printed template, the osseous defect resulted in surgical intervention is limited to 3–4 mm. This confines injury to osseous tissues resulting in less bleeding, less postoperative complications, shorter healing time and better prognosis.37 A recent study employed Cone Beam Computed Tomography(CBCT) imaging, 3D printing technology and a 3D surgical guide designed with computer-aided software. A hollow trephine bur was used to perform the osteotomy, resection of the root, and enucleation of the lesion. The intact cortical plate was salvaged and used as a graft along with plasma-rich fibrin acquired preoperatively from the patient&#39;s blood. The positioning guide allowed the clinicians to precisely achieve targeted tissues and shorten the procedure time. Modified soft tissue management helped achieve a small surgical wound for uneventful healing.38 Conclusion Guided tissue regeneration acts as an adjunct to surgical intervention that can employ an extensive range of biomaterials. Augmentation with the aid of bone graft materials along with biologically active molecules in addition to a mechanical barrier in the form of a membrane would enhance the healing of peripheral tissues following periapical surgery. We conclude that that better bone fill, gain in clinical attachment level are achieved with the use of various grafts as compared to non grafted sites. Acknowledgement: Authors acknowledge the enormous help received from the authors 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=3301http://ijcrr.com/article_html.php?did=3301 Alnemer NA, Alquthami H, Alotaibi L. The use of bone graft in the treatment of the periapical lesion. Saudi Endod J 2017;7:115-118. Uppada UK, Kalakonda B, Koppolu P, Varma N, Palakurthy K, Manchikanti V, et al. Combination of hydroxyapatite, platelet-rich fibrin and amnion membrane as a novel therapeutic option in regenerative periapical endodontic surgery: Case series. Int J Surg Case Rep 2017;37:139–144. Gokul K, Arunachalam D, Balasundaram S, Balasundaram A. Validation of bone grafts in a periodontal therapy-A review. Int J Curr Res Rev 2014;6(14):7-16. Bashutski JD, Wang HL. Periodontal and endodontic regeneration. J Endod 2009;35:321-328. Goyal B, Tewari S, Duhan J, Sehgal PK. Comparative evaluation of platelet-rich plasma and guided tissue regeneration membrane in the healing of apicomarginal defects: A clinical study. J Endod 2011;37:773-780. Tsesis I, Rosen E, TamseA, Taschieri S, Del Fabbro M. Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: A systematic review and meta-analysis. J Endod 2011;37:1039?1045. Taschieri S, Del Fabbro M, Testori T, Saita M, Weinstein R. Efficacy of guided tissue regeneration in the management of through?and?through lesions following surgical endodontics: A preliminary study. Int J Periodontics Restorative Dent 2008;28:265?271. Yoshikawa G, Murashima Y, Wadachi R, Sawada N, Suda H. Guided bone regeneration (GBR) using membranes and calcium sulphate after apicectomy: A comparative histomorphometric study. Int Endod J 2002;35:255?263. Lalabonova H, Daskalov H. Jaw cysts and guided bone regeneration (a late complication after enucleation). J Int Med Assoc Bulg Annu Proc 2013;19:401?403. Sreedevi P, Varghese N, Varughese JM. Prognosis of periapical surgery using bone grafts: A clinical study. J Conserv Dent 2011;14(1):68–72. Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Development of periapical lesions. Swed Dent J 1993;17:85?93. Smith RG, Gassmann CJ, Campbell MS. Platelet-rich plasma: Properties and clinical applications. J Lanc Gen Hosp 2007;2:73?77. Thanikasalam M, Ahamed S, Narayana SS, Bhavani S, Rajaraman G. Evaluation of healing after periapical surgery using platelet-rich fibrin and nanocrystalline hydroxyapatite with collagen in combination with platelet-rich fibrin. Endodontology 2018;30:25-31. Elgendy EA, Abo Shady TE. Clinical and radiographic evaluation of nanocrystalline hydroxyapatite with or without platelet-rich fibrin membrane in the treatment of periodontal intrabony defects. J Indian SocPeriodontol 2015;19:61?65. Naag S, Savirmath A, Kalakonda BB, Uppada UK, Kamisetty S, Priyadarshini E. Platelet concentrates Bioengineering dentistry&#39;s regenerative dreams. J Dent Res Rev 2015;2:86-90. Tischler M. Platelet-rich plasma. The use of autologous growth factors to enhance bone and soft tissue grafts. N Y State Dent J 2002;68:22?24. Windley W 3rd, Teixeira F, Levin L, Sigurdsson A, Trope M. Disinfection of immature teeth with a triple antibiotic paste. J Endod 2005;31:439?443. Anantula K, Annareddy A. Platelet-rich fibrin (PRF) as an autologous biomaterial after an endodontic surgery: Case reports. J NTR Univ Health Sci 2016;5:49-54. DohanEhrenfest DM, de Peppo GM, Doglioli P, Sammartino G. Slow release of growth factors and thrombospondin-1 in Choukroun’s platelet-rich fibrin (PRF): A gold standard to achieve for all surgical platelet concentrates technologies. Growth Factors. 2009;27:63-69. Huang FM, Yang SF, Zhao JH, Chang YC. Platelet-rich fibrin increases proliferation and differentiation of human dental pulp cells. J Endod 2010;36:1628?1632. Jayalakshmi KB, Agarwal S, Singh MP, Vishwanath BT, Krishna A, Agrawal R. Platelet-rich fibrin with ß?tricalcium phosphate?A novel approach for bone augmentation in chronic periapical lesion: A case report. Case Rep Dent 2012;90:58. Keswani D, Pandey RK. Revascularization of an immature tooth with a necrotic pulp using platelet-rich fibrin: A case report. Int Endod J 2013;46:1096?1104. Villar CC, Cochran DL. Regeneration of periodontal tissues: guided tissue regeneration. Dental Clin North Am 2010; 54:73-92. Rodriguez IA. Barrier membranes for dental applications: A review and sweet advancement in membrane developments. Mouth Teeth 2018;2(1):1-9. Kasaj A, Reichert C, Götz H, Röhrig B, Smeets R, et al. In vitro evaluation of various bioabsorbable and non-resorbable barrier membranes for guided tissue regeneration. Head Face Med 2008;4:22. Kher VK, Bhongade ML, Shori TD, Kolte AP, Dharamthok SB, et al. A comparative evaluation of the effectiveness of guided tissue regeneration by using a collagen membrane with or without decalcified freeze-dried bone allograft in the treatment of infrabony defects: A clinical and radiographic study. J Indian Soc Periodontol 2013;17: 484-489. Xue J, He M, Niu Y, Liu H, Crawford A, et al. Preparation and in vivo efficient anti-infection property of GTR/GBR implant made by metronidazole loaded electrospun polycaprolactone nano fibre membrane. Int J Pharm 2014;475:566-577. Tsesis E. Rosen A. Tamse S. Taschieri, M. Del Fabbro, Effect of guided tissue regeneration on the outcome of surgical endodontic treatment: a systematic review and meta-analysis. J Endod 2011;37:1039–1045.  Chen EH, Tofe AJ, A literature review of the safety and biocompatibility of amniontissue. J Impl Adv Clin Dent 2010;2 (3): 67–75. Koob TJ, Biological properties of dehydrated human amnion/chorion composite graft: implications for chronic wound healing. Int Wound J 2013;10(5):493–500. Chopra A, Thomas BS, Amniotic membrane: a novel material for regeneration and repair. J Biomim Biomater Tissue Eng 2013;18: 1-8. Koob TJ. Angiogenic properties of dehydrated human amnion/chorion allografts: therapeutic potential for soft tissue repair and regeneration. Vas Cell 2014;6:1-10. Stahl SS, Froum SJ, Histologic and clinical responses to porous hydroxyapatite implants in human periodontal defects. Three to twelve months postimplantation. J Periodontol 1987;58(10):689–695. Su CY, Kuo YP, Tseng YH, Su CH, Burnouf T, In vitro release of growth factors from platelet-rich fibrin (PRF): A proposal to optimize the clinical applications of PRF. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;108:56–61. Simonpieri AM. Corso D, Sammartino G, Ehrenfest DD. The relevance of Choukroun’s platelet-rich fibrin and metronidazole during complex maxillary rehabilitations using a bone allograft. Part II: Implant surgery, prosthodontics, and survival. Implant Dent 2009;18 (3):220–222. Pradeep AR, Bajaj P, Rao NS, Agarwal E, Naik SB. Platelet-rich fibrin combined with a porous hydroxyapatite graft for the treatment of three wall intrabony defects in chronic periodontitis: a randomized controlled clinical trial. J Periodontol 2012;83(12):1499-1507. Ye S, Zhao S, Wang W, Jiang Q, Yang X. A novel method for periapical microsurgery with the aid of 3D technology: a case report. BMC Oral Health 2018;18:85. Popowicz W, Palaty?ska-Ulatowska A, Kohli MR. Targeted Endodontic Microsurgery: Computed Tomography-based Guided Stent Approach with Platelet-rich Fibrin Graft: A Report of 2 Cases. J Endod 2019;45(12):1535-1542.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareFabrication and Evaluation of Mini Tablet Filled Capsules for the Prevention of Post Bypass Surgery Heart Stroke English1825S.B. Thirumalesh NaikEnglish M. PurushothamanEnglish K.B. ChandrasekharEnglishObjective: The work aimed at making mini-tablets filled capsules for the prevention of post bypass surgery heart stroke using Atorvastatin (ATN), and Acetyl Salicylic Acid (ASA). Methods: The mini-tablets (MTs) of ATN were uncoated, and ASA was enteric-coated. A novel approach was adopted in tackling gastric irritation of ASA, by using Plantago ovata seed mucilage as a binder in making the MTs. MTs of ATN and ASA were placed in capsules. ATN and ASA compatibility with excipients used were checked by DSC and FTIR studies. All prepared MTs were prosecuted for post-compression constraints. Results: The prepared MTs confirmed no interaction by FTIR and DSC studies. All the MTs passed the physicochemical constraints. ATN was released within 60 min, whereas enteric-coated ASA, showed its resistance to release in an acidic environment (2h) and favour in an alkaline buffer (within 45 min). Conclusion: The study concludes that by using P. ovata as a binder in making tablets will resolve the issues related to gastric irritation. English Mini-tablets, Atorvastatin, Plantago ovata, Gastric irritationINTRODUCTION Many fixed-dose combination therapies prescribed to tackle heart stroke after bypass surgery, among them Atorvastatin (ATN) and Acetyl Salicylic Acid (ASA) combination is a popular choice.1 ATN is an HMG-CoA reductase inhibitor that slows down cholesterol manufacture in the body, and in term prevents its accumulation in blood capillaries, majorly the vital organs like the heart and the brain.2 Additionally, ATN reduces low-density lipoproteins and Cholesterol and in term increases high-density lipoproteins.3 ASA has anti-platelet action at a lower dose and popularly prescribed for preventing recurrent development of blood clots.4 Longterm therapy of ASA, causes stomach ulcers5 that can be prevented by co-administration of proton pump inhibitors (PPIs). But many clinical studies revealed that ATN and ASA interact with PPIs.6,7 Mini-tablets (MTs) are tiny tablets which are uniform in shapes, sizes, and weights. Wide varieties of MTs can be easily filled in capsules for attaining the anticipated effects.8 They are desired to owe their uniformity in drug, sizes, ease of preparation, and low cost equated to pellets and granules.9 A few attempts were made by giving PPTs for patients with ATN and ASA therapy but raised the issues related to drug compatibilities.10,11 So, a need came to resolve such issues, the authors made an innovative effort to add some gastroprotective excipients during formulation. By doing an extensive literature survey the authors found Plantago ovatamucilage has gastric protective activity12, 13 and tablet binder properties.14, 15 In this investigation, the authors used P. ovata seed mucilage as a binder during tablet granulation, and compressed them to MTs (uncoated ATN and enteric-coated ASA), and filled into capsules. MATERIALS AND METHODS Materials Atorvastatin was gifted from USV Pvt. Ltd, Mumbai, Acetylsalicylic acid from Waksman Selman pharmaceutical Pvt ltd Anantapur, AP, India. Lactose, MCC, Magnesium stearate, Talc, Ethylcellulose, and HPMC Phthalate were purchased from Qualigens, Fine chemicals, Mumbai. Empty hard gelatin capsules (size ‘1’) were gifted from Hetero drugs, Hyderabad, Telangana. The remaining ingredients used were of AR grade. Preformulations Investigations Fourier Transform Infrared (FTIR) spectral analysis The matching of ATN and ASA with excipients used in this study was done with a sample (2 mg) mixed with 200 mg of KBr, compressed to pellet, and scanned (400-4000cm-1) with a resolution of 1cm-1 (Perkin Elmer, Spectrum-100, Japan). DSC studies DSC thermograms of ATN, and ASA; and their mixture with excipients were documented using Diffraction scanning calorimeter (DSC 60, Shimadzu, Japan), by heating (30-350oC) with 10oC/min rate. Experimental Methods Isolation of P. Ovata seeds mucilage The P. Ovata seeds were drenched in distilled water (~20 times) for 48 h, boiled for 10 min (for the discharge of mucilage). Later passed through a muslin cloth (marc removed) and the filtrate was collected. Acetone was added in equal proportion (mucilage precipitates). Then the mucilage was detached and dried in an oven (4Kg/cm2), representing physical strength for which required during handling & transport. The hardness is not an absolute gauge of strength, so friability was also performed and the loss on friability was 75% dissolved within 45 min in pH 6.8 buffer (Figure 6), which reveals the firmness of the enteric coat on MTs of ASA. The mechanism of drug release from the formulations when tried to fit Zero order, First order, Higuchi, Korsmeyer Peppa’s, and Hixon Crowell’s plots. The regression and interpretation of release exponent value (n) were assessed and graphically represented in Figures 7 (A, B, C, and D) and 8 (A, B, C, and D). Based on these dates, it was confirmed Higuchi’s model is best fit and the release was non-fiction for all ATN MTs, whereas for ASA formulations i.e., ASM-4, ASM-5, ASM-6, and ASM-7 followed fiction and remaining ASA formulations followed non-fiction release. CONCLUSION The distinct mini-tablets of uncoated Atorvastatin and enteric-coated Acetyl Salicylic Acid were effectively made, filled in capsules, and recapped. The gastric irritation caused by Acetylsalicylic acid is encountered with the addition of Plantago ovata seed mucilage as a tablet binder (as it already proved for its gastric protective actions). Thus, mini-tablets filled capsules of Atorvastatin and Acetyl Salicylic Acid for treating post bypass surgery heart stroke, without any gastric irritation. ACKNOWLEDGEMENTS: The authors are thankful to USV Pvt. Ltd, Mumbai, and Waksman Selman pharmaceutical Pvt. Ltd, for providing gift sample of pure drug. Funding: Not Applicable Conflicts of Interests: All the authors declare that they have no conflicting interests Englishhttp://ijcrr.com/abstract.php?article_id=3302http://ijcrr.com/article_html.php?did=3302 Varon J, Acosta P, Varon J. Handbook of critical and intensive care medicine. New York: Springer; 2010. Stern RH, Yang BB, Hounslow NJ, MacMahon M, Abel RB, Olson SC. 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Isolation and physicochemical characterization of Ficus reticulata fruit mucilage. Intl J Green Pharm 2011;5(2). Murakami H, Kobayashi M, Takeuchi H, Kawashima Y. Utilization of poly (DL-lactide-co-glycolide) nanoparticles for preparation of mini-depot tablets by direct compression. J Cont Rel 2000;67(1):29-36. Fukui E, Miyamura N, Uemura K, Kobayashi M. Preparation of enteric-coated timed-release press-coated tablets and evaluation of their function by in vitro and in vivo tests for colon targeting. Int J Pharm 2000;204(1-2):7-15. Leane MM, Cumming I, Corrigan OI. The use of artificial neural networks for the selection of the most appropriate formulation and processing variables in order to predict the in vitro dissolution of sustained release minitablets. Aaps Pharm Scitech 2003;4(2):129-140. Hadi MA, Raghavendra Rao NG, Rao AS. Formulation and evaluation of mini-tablets-filled-pulsincap delivery of lornoxicam in the chronotherapeutic treatment of rheumatoid arthritis. Pak J Pharm Sci 2015;28(1). Li YH, Zhu JB. Modulation of combined-release behaviors from a novel “tablets-in-capsule system. J Cont Rel 2004;95(3):381-389. Ahad HA, Reddy BK, Ishaq BM, Kumar CH, Kumar CS. Fabrication and in vitro evaluation of glibenclamide Abelmoschus esculentus fruit mucilage controlled release matrix tablets. J Pharm Res 2010;3(5):943-946. Ahad HA, Kumar CS, Kumar K. Designing and evaluation of Diclofenac sodium sustained release matrix tablets using Hibiscus Rosa-Sinensis leaves mucilage. Int J Pharm Sci Rev Res 2010;1(2):29-31. Hindustan AA, Chitta SK, Anil Kumar B. Fabrication and evaluation of Nimesulide Azadirachta indica fruit mucilage based sustained release matrix tablets. Int J Chem Tech Res 2010;2(2):937-941. Abdul HA, Sreeramulu J, Sreenivasulu R, Suma Padmaja B, Narasimha Reddy M. Fabrication of glimepiride Hibiscus esculentus fruit mucilage and povidone sustained release matrix tablets: In vitro evaluation. Der Pharmacia Sinica 2011;2(2):91-100. Harada T, Narazaki R, Nagira S, Ohwaki T, Aoki S, Iwamoto K. Evaluation of the disintegration properties of commercial famotidine 20 mg orally disintegrating tablets using a simple new test and human sensory test. Chem Pharma Bull 2006;54(8):1072-1075. Fukui E, Miyamura N, Uemura K, Kobayashi M. Preparation of enteric-coated timed-release press-coated tablets and evaluation of their function by in vitro and in vivo tests for colon targeting. Int J Pharm 2000;204(1-2):7-15. Chawla PA, Pandey S. Various analytical methods for the analysis of atorvastatin: A review. J Drug Del Therap 2019;9(3):885-899. Khalil YI, Toma NM. Formulation and evaluation of bilayer tablets containing immediate-release aspirin layer and floating clopidogrel layer. Iraqi J Pharm Sci 2013; 22(1):40-49. Vora DN, Kadav AA. Validated ultra HPLC method for the simultaneous determination of atorvastatin, aspirin, and their degradation products in capsules. J Liquid Chrom Related Techn 2008;31(18):2821-2837.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareTransient Hearing Loss in Patients after Surgery Under Spinal Anaesthesia: A Tertiary Care Centre Based Study English2628Aparna Girish BenareEnglish Aditya KhotEnglishIntroduction: In most of the surgical interventions, spinal route of anaesthesia is the very frequent type of regional anaesthesia & it’s been used for with minimal complications. But few cases report hearing loss post-spinal anaesthesia, mostly affecting the low range frequency. Objective: To study the post-spinal anaesthesia hearing loss observed in the patient at a tertiary care centre. Method: The current study was done in a total of 60 cases who went for surgical intervention under spinal anaesthesia. Informed written consent was obtained from each patient. The pre-anaesthetic check-up was done in all the cases. Audiometry was done in all the cases before surgery. Post-operative hearing loss was recorded on 2nd and 5th day after surgery. The audiogram was done again after 1 month of surgery to verify whether hearing loss is temporary or permanent. Also resulting complications if any have been recorded. Results: Maximum cases (40%) in our study were in the age group of 21-30 years followed by 31-40 years of age. Majority of them were male (60%) and 90% of patients were of the American Society of anaesthesiologists (ASA grade I. Temporary hearing loss was diagnosed in 13.33% cases. Post spinal headache was observed in 16.67% cases and post-spinal hypotension was observed in 23.33% cases. Two cases were having a hearing loss at 2000Hz while at 250Hz and 6000Hz one case each was diagnosed. This hearing loss was completely revered in one month. Conclusion: Transient hearing loss was diagnosed in 13.33% patients and it was found that hearing loss was completely reversible. English Hearing loss, Spinal anaesthesia, Audiogram, Surgical interventionINTRODUCTION             In a tertiary care centre, many people undergo surgical intervention for some or the other reason. Every individual wants this experience to be painless both during the surgery & afterwards. Spinal anesthesia is the most commonly preferred method for its minimal complications1,2. Its advantages are many like, its very cost effective technique, need for intubation is not there and hence in turn there is no risk of aspiration pneumonia due to gastric contents. But this procedure is for shorter duration only (upto two hours). Hearing loss after spinal anesthesia has been well known complication yet it’s infrequently documented & it affects mostly the lower frequency range3,4.             Such hearing disorders after spinal anesthesia is frequently linked with the “postspinal headache syndrome”. These clinical symptoms result from Cerebrospinal fluid (CSF) leakage via the spinal puncture hole. In turn, this CSF loss leads to a corresponding reduction in intracranial and intracochlear pressure. Spinal needle size can be associated with the occurrence of hearing loss. 5-6 In addition, the auditory symptoms may be the result of drainage of inner ear fluid (perilymph) via the cochlear aqueduct that links CSF and cochlear fluids. Apart from that, there is a long list of post-surgical complications ranging from lumbar headache, vertigo, nausea, vomiting etc. Apart from spinal aneshtesis, there are many clinical scenarios where transient hearing loss can occur like myelography, acoustic neuroma surgeries, vp shunts, neurosurgeries etc7-9. Aims and Objective: To study the post spinal anesthesia hearing loss observed in patient at a tertiary care centre. MATERIALS AND METHOD Current study was performed at a tertiary care centre with following inclusion & exclusion criteria for selection of the study population: Inclusion Criteria • Patients admitted for various surgeries under spinal anesthesia. • Patients from the age group of 20 to 60 years. • Patients with Normal hearing power. • Patients in ASA grade I or II classification. Exclusion Criteria • Patients not willing for Spinal anesthesia or nervous or very apprehensive patients • Patients with pre-existing hearing impairment. • Patients with ASA grade III or more.             So finally, total 60 cases were selected for the study. Informed written consent was obtained from each patient. Pre-anesthetic examination was done in all the patients. Detailed physical examination was carried out. Spine was examined to see presence of any skin infection, deformity, calcification, movements and history of previous operation. Audiometry was performed in all the patients before surgery in a sound-proArphi portable audiometer. Post-operative hearing loss was recorded on 2nd& 5th day following surgery. The audiogram was repeated after one month post-surgery to verify if return of normal hearing power had occurred. The complications that have occurred had also been recorded. All the findings were recorded on a Preformed proforma. RESULTS It was observed that majority of the patients (40%) in our study were in the age range of 21 to 30 years followed by 31-40 years of age (26.67%). Majority of the patients were male (60%) and 90% patients were of ASA grade I. The mean preoperative systolic blood pressure was 126.45±12.78 and mean post-operative systolic blood pressure was 114.65±12.38 mm of Hg. The mean pre and post operative diastolic blood pressure was 82.21±8.43 and 61.93±7.34 mm of Hg respectively. Eight cases showed transient hearing loss, ten cases showed post spinal headache while fourteen cases had post spinal hypotension. In our study, we have observed that, four cases were having hearing loss at 2000 Hz while at 250 Hz & 6000 Hz, two cases each were having hearing loss. All the cases were strictly followed for a month & we found out that, this hearing loss was completely reversed after one month. DISCUSSION             Current study was conducted at a tertiary care centre with the main objective was to study the post spinal anesthesia hearing loss observed in patients. We found out that the maximum cases in our study group were in the age group of 31-40 years (table no 1) & majority of them were males10-11. Ninety percent of the cases were of ASA grade I. similar findings were observed by the previous studies. The average preoperative systolic blood Pressure (BP) was 126.45±12.78 & mean postoperative systolic BP was 114.65±12.38 mm of Hg. The average pre & post-operative diastolic BP was 82.21±8.43 & 61.93±7.34 mm of Hg (table no 2). Temporary hearing loss was diagnosed in 13.33% of the cases (table no 3).             Lumbar headache after spinal anesthesia was seen in 16.67% of the cases whereas post spinal hypotension was seen in 23.33% of the cases. Sirsamkar in their study observed that 8% cases were suffering from temporary hearing loss. Whereas Lasisi12 observed that bone conduction hearing impairment after spinal anesthesia was around 15%. In study conducted by Yildiz et al13, 7.5% of the study population reported the hearing impairment. In our research it was observed that four cases were having hearing loss at 2000Hz while at 250Hz and 6000Hz two cases each was diagnosed (table 4). All the study subjects were followed for a month and it was observed that the hearing loss was totally revered in one month. Bansode et al10 in their study observed significant hearing impairment in overall 7.7% of their study subjects after spinal anesthesia.             In Group Y (young) of their study 2 patients (6.6%) developed significant hearing loss at 1000Hz. In groups M (middle-aged) 4 patients (13.3%) had significant hearing loss. One developed hearing loss at 125Hz while the other 3 patients had hearing loss at 6000Hz and 8000Hz (table 4). In group E (elderly) only one patient (3.3%) developed significant hearing loss at 250 Hz. L.P. Wang et al conducted the similar study and their findings are in agreement with our study findings.             Many researchers have suggested that there a strong association between post dural puncture headache & this transient hearing loss14-16. They say that both these conditions i.e post dural puncture headache & transient hearing loss have the same mechanism which is drop in intracranial tension due to Cerebrospinal fluid  (CSF) leak. Hughson et al17 says that drop in CSF pressure predisposes to the decrease in intralabyrinthine pressure which ultimately results in transient hearing loss. CONCLUSION From the observations of our study we can conclude that transient hearing loss was diagnosed in 13.33% patients and it was found that hearing loss was completely reversible. And strong association between post dural puncture headache & this transient hearing loss. Acknowledgement Ethical clearance- Taken from institutional ethics committee. Conflict of Interest: Nil Source of Funding: Nil Englishhttp://ijcrr.com/abstract.php?article_id=3303http://ijcrr.com/article_html.php?did=3303 Walsted A. Effects of cerebrospinal fluid loss on hearing. Acta Otolaryngol. 2000; 543:95-98. Lee C. Hearing loss after spinal anaesthesia. AnesthAnalg. 1990; 71:561-569. Rajan, R., S.N. Gosavi, V. Dhakate, and S. Ninave. “A Comparative Study of Equipotent Doses of Intrathecal Clonidine and Dexmedetomidine on Characteristics of Bupivacaine Spinal Anesthesia.” Journal of Datta Meghe Institute of Medical Sciences University. 2018 13(1); 4–8. Finegold H. Does Spinal Anesthesia Cause Hearing Loss in the Obstetric Population? AnesthAnalg. 2002; 95:198-203. Hafer J. The effect of needle type and immobilization on postspinal headache. Anaesthesist. 1997; 46:860-866. Rajan, R., S. Gosavi, V. Dhakate, and S. Ninave. “A Comparative Study of Equipotent Doses of Intrathecal Clonidine and Dexmedetomidine on Characteristics of Bupivacaine Spinal Anesthesia.” Journal of Datta Meghe Institute of Medical Sciences University 2018;13(1); 4–8. Schaffartzik W. Hearing loss after spinal and general anesthesia: A comparative study. AnesthAnalg. 2000; 91:1466-1472. Malhotra S. Spinal analgesia and auditory functions: a comparison of two sizes of Quinoke needles. MinerveAnaesthesiol 2007; 73: 395-9. Palan, A., and N.K. Agrawal. “Control of Intraoperative Shivering under Spinal Anaesthesia- A Prospective Randomized Comparative Study of Butorphanol with Tramadol.” Journal of Krishna Institute of Medical Sciences University 6, no. 1 (2017): 57–65. Bansode A. Age comparative study on spinal anaesthesia and auditory functions. Journal of Evolution of Medical and Dental Sciences. 2012; 1(6): 1026-33. Nefissa M. Hearing Loss after Spinal Anaesthesia: A Too Little Appreciated Complication? Med. J. Cairo Univ. 2014; 82(1): 321-329. Lasisi A. Effect of Spinal Anaesthesia on Hearing Threshold. East and Central African Journal of Surgery. 2010; 15(2):80-84. Yildiz T. Hearing loss after spinal anesthesia: the effect of different infusion solutions. Otolaryngol Head Neck Surg. 2007; 137:79-82. Planning B. Transient low frequency hearing loss following spinal anaesthesia (in German) Anaesthetist 1984; 33: 593-5. Vandan L. Long term follow up of patients who received 10098 spinal anaesthetics JAMA 1956; 161:586-5913. Arnvig J. A transient hearing loss after lumbar puncture – A personal experience which throw some light on aqueduct of cochlea. Acta otolaryngologica, 1963:56:699-705. Hughson: American Journal of Physiology; A note on relationship of cerebrospinal fluid and intralabyrinthine pressure, 1932, 101, 396-407.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareRelationship between Thyroid Disorder and Abnormal Menstrual Bleeding English2932Anjana ChaudharyEnglish Baljeet Kaur BhatiaEnglishIntroduction: Menstrual disorders pose a huge burden on gynaecology OPD, accounting for approximately 20 % of attendance of OPD. Thyroid disorders are prevalent globally, and thyroid conditions are 10 times more prevalent in women than in men. Thyroid dysfunction can prompt menstrual problems and infertility. Thyroid autoimmunity is associated with different forms of thyroid dysfunction. Objective: To assess the relationship between thyroid disorder and abnormal menstrual bleeding. Methods: Study was conducted in 100 women (age 15-45 years) suffering with menstrual disorders. Women with complaints other than menstrual disorders were in the control category. Following demographic characteristics, general physical examination and pelvic examination were performed with special reference to thyroid dysfunction. Patients were subjected to routine investigations (to rule out coagulation defects) such as Hb, BT, CT and platelets. All patients were subjected to Electro Chemiluminescence assay for T3, T4 and TSH estimation in their serum. Results: Off all the kinds of menstrual irregularities, woman with amenorrhea, menorrhagia, oligomenorrhea, polymenorrhea and metrorrhagia were recorded. 55% of the cases in the study group were euthyroid while 45% of the cases were diagnosed with having thyroid disorder. In study group out of 45 cases having thyroid disorder of which 18 (18%) were overt hypothyroid and 11 (11%) were subclinical hypothyroid. Overt Hyperthyroid were 11 (11%) and subclinical hyperthyroid were 5% in the study group. Of the total 3 amenorrhea cases 2 (2%) were euthyroid while 1 case was hypothyroid. Out of 52 menorrhagia cases, 28 were euthyroid, 14(14%) were hypothyroid and 10 (10%) were hyperthyroid. 19 were oligomenorrhea cases of which 7 (7%) each were euthyroid and hypothyroidism while one case was hyperthyroid. Conclusion: Strong correlation of thyroid dysfunction with menstrual disorders has been observed. Morbidity due to thyroid dysfunction in women can be reduced if diagnosed timely and treated accordingly and unnecessary hormonal treatment and surgery can be avoided. English Pelvic, Menstrual irregularities, Oligomenorrhea, Polymenorrhea, MetrorrhagiaINTRODUCTION Menstruation is a natural phenomenon regarding the discharge of blood from the uterus through the vagina, taking place at extra or less regular monthly durations during the reproductive age of females[i].Menstrual disorders pose a huge burden on gynecology OPD, accounting for approximately 20 % of attendance[ii]. It has been described clinically in different ways, such as menorrhagia, metrorrhagia, menometrorrhagia, polymenorrhea, polymenorrhagia and oligmenorrhea[iii]. Normal cyclic period results from the arranged connection between the endomertium and its managing factors. Changes in both of these oftentimes brings about strange bleeding. It influences upto 33% of ladies of child bearing age[iv]. Thyroid hormones assume a significant part in reproductive physiology through direct impacts on the ovaries and by implication by communicating with sex hormone-binding globulin. Thyroid dysfunction can prompt menstrual problems and infertility[v]. The onset of thyroid disorders is growing with age, and 26% of premenopausal and menopausal women are reported to be diagnosed with thyroid disease[vi]. Thyroid disorders are prevalent globally, and thyroid conditions are 10 times more prevalent in women than in men[vii]. Since the 1950s, the effect of hypothyroidism on the menstrual cycle has been recognised, leading to changes in cycle length and blood flow[viii]. Menorrhagia is commonly observed in women with hypothyroidism. On the other hand, hyperthyroidism is associated with amenorrhea and oligomenorrhea, and the drop in flow is proportional to the magnitude of thyrotoxicosis[ix]. Thyroid autoimmunity has been shown to be associated with different forms of thyroid dysfunction. Operational intervention such as curettage and hysterectomy may be prevented through early diagnosis of thyroid dysfunction in patients with menstrual disorders and their management[x]. MATERIAL AND METHODS The current research was performed in the Department of Obstetrics and Gynecology. 100 women each from the 15-45-year reproductive age group were chosen in study as well as in control group . The research group included women with menstrual disorders such as menorrhagia, oligomenorrhea, polymenorrhea, metrorrhagia, hypomenorrhea and amenorrhea and no detectable disease in the genital tract. Women with complaints other than menstrual disorders were in the control category. The research excluded patients with menstrual disorder with any known organic pathology, such as uterine fibroid, adenomyosis, tuberculosis, polyps, uterine malignancy, etc., and patients with intrauterine contraceptive device in utero. Detailed demographic and personal history regarding age, parity, age of menarche, menstrual disorders and dysmenorrhea was taken. In women with menstrual complaints, general physical examination and pelvic examination were performed with special reference to thyroid dysfunction; in cases with a provisional diagnosis of AUB. To rule out the structural causes associated with menstrual irregularities, ultrasonography (USG-Abdomen and Pelvis with endometrial thickness) was performed. Patients were subjected to routine investigations (to rule out coagulation defects) such as Hb, BT, CT and platelets. All patients were subjected to Electro Chemiluminescence assay for  T3, T4 and TSH estimation in their serum. If TSH, T3, and T4 were within the normal range (TSH level = 0.39-6.16 μIU / ml, free T3 level = 1.4-4.2 pg / ml, and free T4 level = 0.8-2.0 ng / ml), patients were considered as euthyroid; when TSH was elevated with T3 and T4 below the normal range, they were classified as subclinical hypothyroidism. Overt hypothyroidism was diagnosed with high TSH and low levels of T3 and T4, subclinical hyperthyroidism with low TSH and normal levels of T3 and T4, and overt hyperthyroidism with low levels of TSH and high levels of T3 and T4. Statistical analysis was done, for qualitative data to measure p value, Chi-square test and fisher exact test were used, and unpaired student t test and non-parametric Wilcoxon-Mann-Whitney test were used to statistically compare the quantitative data between two classes for T3, T4, TSH, and anti-TPO antibody values. The difference was deemed statistically significant with a p value of < 0.05. RESULTS Various parameters analyzed were • Age • Parity • Menstrual irregularities • Thyroid status • Association of menstrual irregularities with thyroid dysfunction. The study and control groups were comparable in respect of age Of all the kinds of menstrual irregularities, 3 (3%) had amenorrhea, 52 (52%) had menorrhagia, 19 (19%) had oligomenorrhea, 15 (15%) had polymenorrhea and 11(11%) had metrorrhagia. Table 1: Menstural Irregularities 55% of the cases in the study group were euthyroid while 45% of the cases were diagnosed of having thyroid disorder. While in control group 85% of the cases were euthyroid while 15% were having thyroid disorder Table 2: Thyroid disorder in study and control group In study group out of 45 cases having thyroid disorder of which 18 (18%) were overt hypothyroid and 11 (11%) were subclinical hypothyroid. Overt Hyperthyroid were 11 (11%) and subclinical hyperthyroid were 5% in study group. In control group one (1%) case was overt hypothyroid and 8 (8%) were subclinical hypothyroid, while  4 (4%) were over hyperthyroid and 2 (2%) ware subclinical hyperthyroid. Thyroid anti TPO antibodies were present in 25 (25%) of the cases in study group as compared to 3 (6%) cases in control group. This difference was statistically significant (pEnglishhttp://ijcrr.com/abstract.php?article_id=3304http://ijcrr.com/article_html.php?did=3304 House S, Mahon T, Cavill S, editors. Menstrual hygiene matters. A resource for improving menstrual hygiene around the world. Module one: Menstrual hygiene –the basics. Available from URL: www.wateraid.org/~/media/Files/Global/MHM%20files/Compiled_L Albers JR, Hull SK, Wesley RM. Abnormal uterine bleeding. Am Fam Physician. 2004 Apr 15; 69(8):1915-26. Talukdar B, Mahela S (2016) Abnormal uterine bleeding in perimenopausal women: Correlation with sonographic findings and histopathological examination of hysterectomy specimens. J Midlife Health 7(2): 73-77. Nicholson WK, Ellison SA, Grason H, Powe NR. Of ambulatory care use for gynecologic conditions; A national study. Am J Obstet Gynecol. 2001;184(4):523-30. Poppe K, Glinoer D. Thyroid autoimmunity and hypothyroidism before and during pregnancy. Hum Reprod Update. 2003 Mar-Apr; 9(2):149-61. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, Braverman LE. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002 Feb; 87(2):489-99. Cappola AR, Ladenson PW.  Hypothyroidism and atherosclerosis. J Clin Endocrinol Metab. 2003 Jun; 88(6):2438-44 Bals-Pratsch M, De Geyter C, Müller T, Frieling U, Lerchl A, Pirke KM, Hanker JP, Becker-Carus C, Nieschlag E. Episodic variations of prolactin, thyroid-stimulating hormone, luteinizing hormone, melatonin and cortisol in infertile women with subclinical hypothyroidism. Hum Reprod. 1997 May; 12(5):896-904. Manjeera LM, Kaur P. Association of thyroid dysfunction with abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynecol 2018;7:2388-92. Ajmani NS, Sarbhai V, Yadav N, Paul M, Ahmad A, Ajmani AK. Role of Thyroid Dysfunction in Patients with Menstrual Disorders in Tertiary Care Center of Walled City of Delhi. J Obstet Gynaecol India. 2016;66(2):115-119. doi:10.1007/s13224-014-0650-0 Pahwa S, Shailja G, Jasmine K. Thyroid dysfunction in dysfunctional uterine bleeding. J Adv Res Bio Sci. 2013;5(1):78–83. Padmaleela K, Thomas V, Lavanya KM. Thyroid disorders in dysfunctional uterine bleeding (DUB) among reproductive age group women- a cross-sectional study in a tertiary care hospital in Andhra Pradesh India. Int J Med Pharma Sci. 2013;4(1):41–46. Kaur T, Aseeja V, Sharma S. Thyroid dysfunction in dysfunctional uterine bleeding. Web Med Central Obstet Gynaecol. 2011;2(9):1–7 Gowri M, Radhika BH, Harshini V. Role of thyroid function tests in women with abnormal uterine bleeding. Int J Reprod Contracept Obstet Gynecol. 2014;3(1):54–57.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareEffectiveness of Toys in Relieving Acute Stress Measured by Heart Rate Variability in Young Adults English3338Husrav SadriEnglish Shailaja S. MoodithayaEnglishIntroduction: The responses of the human body to stress are well documented. Usage of toys like slime and fidget-spinners has been a recent trend among the public to mitigate the harmful effects of stress on health. Objective: This study aims to evaluate the effectiveness of slime and fidget-spinners in relieving acute stress in young adults. Methods: Thirty healthy subjects were studied. Each subject underwent phases of rest, acute stress using mental arithmetic, and stress with simultaneous usage of either slime or fidget-spinner toys. The power spectrum of short term heart rate variability (HRV) was analysed in all three phases. The values obtained were compared using the Wilcoxon signed-rank test. A p-valueEnglish The autonomic nervous system, Mental arithmetic, Mental stress, Power spectrum, Stress relief, Sympathovagal balance Introduction The National Institute of Mental Health, USA, states that stress is a response of the human body to any demand placed upon it.1 Acute stress is known to increase heart rate and blood pressure transiently, through the action of the autonomic nervous system.2,3 The effects of stress may be objectively perceived by using quantifiable surrogate markers which respond to stressors. The autonomic nervous system regulates the effect of stress on the heart through the sympathetic and parasympathetic systems, the balance of which may be measured using heart rate variability or HRV.4 HRV is the variation of instantaneous heart rate and the series of intervals between successive peaks of the R-waves on an electrocardiogram (ECG). Analysing the power spectrum gives us various parameters like total power, low-frequency power (LF), and high-frequency power (HF). The ratio of LF/HF is the indicator of the balance between the sympathetic and parasympathetic nervous systems. Several studies have demonstrated that HRV is the best tool to quantify mental stress based on autonomic function and sympathovagal balance, denoted by the LF/HF ratio. LF/HF ratio reliably rises when the subject is under stress, and that frequency domain measures consistently supported the idea that during stress there is a general depression of HRV and displacement of sympathovagal balance towards sympathetic activation due to elevation of LF, which accounts for sympathetic and parasympathetic system activation, and depression of HF, which is associated with the parasympathetic system only.5,6 Due to greater recognition being given to the various detrimental effects of mental stress on human health, the focus is now on attempting to counteract it before health is impacted adversely. Various techniques and methods have been employed for this purpose, including yoga and aerobic exercise, music, and exposure to nature.7-9 In 1993, a lady by the name of Catherine Hettinger, who suffered from myasthenia gravis, created the prototype of the fidget-spinner as a means of bonding with her daughter. The palm-sized spinners consist of a ball bearing which sits in a three-pronged plastic device which can then be flicked and spun around.  She applied for a patent, which lapsed in 2005, after which small manufacturers marketed the toy as a therapeutic tool for children with attention deficit hyperactivity disorder (ADHD), anxiety, and autism, to help them focus and relieve stress. Nearly ten years later, the publicity surrounding the toy and its purported uses grew rapidly, creating a trend of using it as a stress-relief toy among both adults as well as children.10,11 While such toys have been extensively touted to provide immediate relief from stress, the public opinion has not yet been backed up by any significant research. This study is, as such, the first of its kind as it attempts to objectively evaluate the impact of such toys on the physiological markers of acute stress. The objectives of this study were to evaluate the effectiveness of and to compare the levels by which slime and fidget-spinners relieve acute stress by assessing heart rate variability in young adults. MATERIALS AND METHODS Pre-experiment protocols The study was conducted from April to June 2019 on 30 male and female healthy students between the age of 18 and 22 years. Students having any history of autonomic or cardiovascular dysfunction, or those students who were on any medication that might alter autonomic or cardiovascular function were excluded from the study. The experimental protocol was performed only after obtaining approval from the Institutional Ethics Committee (INST.EC/EC/033/2019-20). Written informed consent was obtained from all participants. All subjects were requested to refrain from strenuous physical activity for at least 24 hours before recording, and not consume any caffeinated/non-caffeinated beverages for 2 hours before recording. After taking a brief history, the participants underwent the following experimental protocol: Height was measured by a wall-mounted stadiometer to the nearest 0.1 cm. The subjects were instructed to stand erect, without shoes, and with their hands by their sides. Weight was measured to the nearest 100 gm using electronic weighing machine. Body mass index (BMI) was calculated as weight (kg) divided by height squared (m2). Resting Blood pressure was recorded using a non-invasive intermittent automated blood pressure monitoring device – Omron IA2 model. Assessment of Heart rate variability Heart rate variability (HRV) measurements were performed in three sessions in a quiet, temperature-controlled room (23±1°C). The three sessions included are i) baseline, ii) during mental stress task iii) during mental stress task with toy exercise. Following 15 minutes of rest, Lead II Electrocardiogram (ECG) was recorded in the sitting position for 5 minutes in each session. The arm leads were placed on the shoulders to minimize interference with HRV when the subject played with the toy in the third session. Baseline recording Initially, the baseline ECG of the subject was recorded for five minutes (from time t=0 minutes to t=5 minutes). The subjects were asked to sit still and not move their limbs when the ECG was being recorded. This instruction was maintained across sessions.  Mental stress test For five minutes after baseline recording (from t=5 minutes to t=10 minutes), ECG was recorded while mental stress was being concurrently induced in the subject using mental arithmetic. The mental arithmetic protocols commonly followed are variations of the serial subtraction of seven tests which is frequently used as an assessment tool in clinical practice to evaluate the ability of an individual to concentrate.12 This was done by instructing the subject to quickly subtract the number seven serially from a random three- or four-digit number, and verbally state the next number in the series.13,14 For example, if the subject was given the number 589, he would have to give answers as 582, 575, 568, and so on. In an attempt to build up stress in the subject, the investigator constantly encouraged them to answer faster, and randomly changed the starting number of the series. If the subjects gave an incorrect answer, they were informed and told to correct themselves before proceeding. A break of three minutes (from t=10 minutes to t=13 minutes) was given between this session and the next in an attempt to bring the autonomic function back to baseline. Intervention with toy Once stress has been induced in the subject, one of two toys (either slime or a fidget-spinner) was given at random to the subject. The subject was instructed to play with the toy moving only his hands, and keeping the rest of the body as still as possible as they simultaneously performed the mental stress task described above, and the ECG continued to be recorded for five minutes (from t=13 minutes to t=18 minutes). The ECG recording was then analyzed for HRV indices. Analysis of recordings Heart rate was obtained by R-R interval for which Lead II ECG was recorded using a bio amplifier data acquisition module, Powerlab 26T (AD Instruments, Australia). ECG was recorded at a sampling rate of 1000Hz. Raw recordings were manually edited to eliminate ectopics and artefacts above 5% and 2% respectively. From the obtained raw ECG data, the power spectrum of HRV was analyzed using HRV module of Lab Chart V7 (AD Instruments) based on non-parametric Fast Fourier Transformation. The power spectrum was expressed as total power in absolute units, LF (0.04-0.15Hz), HF (0.15-0.4Hz), LF normalized unit (LFnu), HF normalized unit (HFnu) and LF/HF ratio. In the power spectrum, the LF reflects cardiac sympathetic activity while the HF is a surrogate of cardiovagal function and therefore the ratio of LF to HF indicates sympathovagal balance.4,6 Statistical analysis Mean and standard deviation of the anthropometric parameters as well as baseline blood pressure was calculated. Indices of heart rate variability (HRV) among the three sessions were presented as the mean and standard error of the mean. The variables were tested for normality of distribution, and the skewed data were compared using non-parametric tests. Wilcoxon signed-rank test was used to compare the various components of HRV. All the data were analyzed using IBM SPSS Statistics (version 20). A p-value < 0.05 is considered statistically significant. Results ECG data were collected for 36 subjects of whom only 30 were utilised since the software was unable to analyse the HRV indices of the other 6. The mean age of the participants was 20.17±0.87 years, with a mean body-mass index (BMI) of 21.90±3.42 kg/m2. The subjects’ basic data, including age, height, weight, BMI, and blood pressure are given as mean ± standard deviation in Table 1. The HRV indices were described in terms of mean ± standard error. Histograms were plotted and it was found that each variable did not have a normal distribution. Thus, variables were compared using a non-parametric, Wilcoxon signed-rank test. A p-value < 0.05 is considered to be statistically significant. First, HRV indices of subjects in the resting and mental stress phases of the experimental protocol were compared (Table 2). As is evident from the table, differences in all the variables were found to be statistically significant, except the absolute values for high frequency. Tables 3 and 4 show the comparisons made between mental stress phase and the phase of intervention with fidget-spinner and slime toys respectively. None of the comparisons was statistically significant except the normalised low-frequency values in the fidget-spinner experiment. Discussion The amount of mental stress faced by an individual in today’s world is indisputably detrimental to the health of the individual. There are various ways of identifying and subsequently quantifying the amount of stress an individual may perceive including, but not limited to galvanic skin response (electrodermal activity) and skin temperature. However, the best known physiological marker of acute stress is widely known to be heart rate variability derived from an electrocardiogram since it gives information about instantaneous changes in heart rate which is used as a surrogate for autonomic function.15 While the heart rate of a subject appears to be regular clinically, there are a remarkable amount of minute variations between individual heartbeats. These variations can be found by analysing the RR-intervals recorded on an ECG, from which one may derive the heart rate variability power spectrum. The power spectrum consists of total power, low frequency (LF), high frequency (HF), each of their normalised units (LFnu and HFnu respectively) as well as the LF/HF ratio. The various parameters of the power spectrum give extensive data regarding the autonomic status of the individual using the beat-to-beat variations in heart rate as the basis for variation in autonomic function.10-12 The present study evaluated the differences between HRV power spectrum parameters between the resting phase and the phase of mental stress-induced by mental arithmetic. Predictably, the mean absolute LF and mean LFnu both increased significantly during the phase of mental stress as compared to the resting phase. This depicts that the sympathetic nervous system was activated in the phase of mental stress.12,13 The mean absolute HF showed an increase from resting phase to the phase of mental stress, but this increase was not statistically significant. Nonetheless, the mean HFnu values decreased significantly from the resting phase to the phase of mental stress, indicating that parasympathetic action was substantially dampened during the phase of mental stress. These findings are consistent with the consensus on the effect of mental stress on heart rate variability, which is to say that the stressor (in this case verbalised mental arithmetic) decreases the RR interval, pushing the frequency of RR into the LF band, increasing the LF power and simultaneously decreasing the HF power leading to an ultimate statistically significant increase in LF/HF ratio.9,14,16 Such a shift to sympathetic predominance is also seen in hypertensive patients and may be associated with increased risk of cardiac mortality as well as predict an increased risk of cardiac events.17 Attempting to intervene in the induced mental stress with a toy (either fidget-spinner or slime) has shown a relative decrease in the mean values of average heart rate, an increase in mean total power, LF, and LFnu from the phase of mental stress. In the fidget-spinner toy, a decrease was seen in mean absolute HF while the slime toy showed an increase; in both toys, absolute HF was reduced, and the mean LF/HF ratios were increased as compared to the phase of mental stress. Considering these values alone, it could be said that the toys potentiated the stress created in the subject. This is a surprising finding, considering that the toys were expected to alleviate the mental stress faced by the subject. However, none of these comparisons is statistically significant (except LFnu in the fidget-spinner experiment) and it would therefore be misguided to draw such conclusions based on this data. Furthermore, it is futile to compare the slime and fidget-spinner toys since both have shown that they do not decrease the induced stress at all but rather insignificantly increase it.14,15 Since this study appears to be the first of its kind, there is no other data to compare these findings. Based on this study, it could be inferred that slime and fidget-spinner toys have no significant effects on the physiological markers of stress.  Nevertheless, it cannot be disallowed that these toys have any impact on the effects of acute stress; they may act by placebo or by mechanisms that this study has not taken into account. It is entirely possible that the sample size of this study is very small, and has thus not given significant results.16,17 Further studies with larger experimental groups are needed to verify the findings of this study. Other parameters assessing stress levels in an individual, both before and after intervention with these toys also need to be included in further studies; they may encompass a wide variety of tools ranging from stress questionnaires to salivary cortisol secretion. Conclusions The heart rate variability parameters of subjects responded significantly to the induction of acute mental stress by mental arithmetic, although the present study noted that an attempted intervention with either toy (slime or fidget-spinner) produced no significant change in the same parameters. It would thus seem that further studies are required to verify these findings, perhaps with larger sample sizes as well as evaluation of other mechanisms by which these toys may act, which this study has not accounted for. Firm conclusions regarding the effectiveness of these toys may only be drawn when all possible avenues of investigation have been exhaustively explored.  Acknowledgements and Funding: This work was supported by the Indian Council of Medical Research – Short Term Studentship (grant number 2019-00774). The authors would like to thank the subjects for their wholehearted participation as well as Dr. Krishna Bhat U for aiding with the statistical analysis. Conflict of Interest: The authors have no conflicts of interest to declare. Contribution of Authors: Husrav Sadri : Conceptualisation, data collection, data analysis, writing Dr. Shailaja S. Moodithaya : data analysis, writing Englishhttp://ijcrr.com/abstract.php?article_id=3305http://ijcrr.com/article_html.php?did=3305 National Institute of Mental Health (US). 5 Things You Should Know About Stress. Bethesda: National Institute of Mental Health; 2019. Yaribeygi H, Panahi Y, Sahraei H, Johnston TP, Sahebkar A. The impact of stress on body function: A review. EXCLI J. 2017; 16:1057–1072. Brotman DJ, Golden SH, Wittstein IS. The cardiovascular toll of stress. Lancet 2007 Sep; 370(9592):1089-100. Patil K, Singh M, Singh G, Anjali SN, Sharma N. Mental Stress Evaluation using Heart Rate Variability Analysis: A Review. Int J Public Ment Health Neurosci 2015 Apr; 2(1):10-16. Castaldo R, Melillo P, Bracale U, Caserta M, Triassi M, Pecchia L. Acute mental stress assessment via short term HRV analysis in healthy adults: A systematic review with meta-analysis. Biomed Signal Process Control 2015 Apr; 18:370-377. Malik M, Camm AJ, Bigger JT, Breithardt G, Cerutti S, Cohen RJ, et al. Heart rate variability. Standards of measurement, physiological interpretation, and clinical use. Eur Heart J 1996; 17(3):354–81. Jackson EM. Stress Relief: The Role of Exercise in Stress Management. ACSMs Health Fit J 2013 May;17(3):14-19. Gäbel C, Garrido N, Koenig J, Hillecke TK, Warth M. Effects of Monochord Music on Heart Rate Variability and Self-Reports of Relaxation in Healthy Adults. Complement Med Res 2017 Feb;24(2):97-103. Brown DK, Barton JL, Gladwell VF. Viewing nature scenes positively affects the recovery of autonomic function following acute mental stress. Environ Sci Technol 2013 Jun; 47(11):5562-5569. Williams A. The Hour’s Hot Toy Has a Long History. The New York Times. 2017 May 14; Sect. ST:9 Luscombe R. As fidget spinner craze goes global, its inventor struggles to make ends meet. The Guardian. 2017 May 05. Karzmark P. Validity of the serial seven procedure. Int J Geriatr Psych 2000 Aug; 15(8):677-679. Deepak A, Deepak AN, Nallulwar S, Khode V. Time Domain Measures of Heart Rate Variability during Acute Mental Stress in Type 2 Diabetics: A Case-Control Study. Natl J Physiol Pharm Pharmacol 2014; 4(1):34-38. Bernardi L, Wdowczyk-Szulc J, Valenti C, Castoldi S, Passino C, Spadaccini G, et al. Effects of controlled breathing, mental activity and mental stress with or without verbalization on heart rate variability. J Am Coll Cardiol 2000; 35(6):1462-1469. Palanisamy K, Murugappan M, Yaacob S. Multiple physiological signal-based human stress identification using non-linear classifiers. Elektronika ir elektrotechnika 2013; 19(7):80-5. Wang X, Liu B, Xie L, Yu X, Li M, Xhang J. Cerebral and neural regulation of cardiovascular activity during mental stress. Biomed Eng Online. 2016; 15 Suppl 2:160. Patil SS, Gnanajyothi. A study of heart rate, blood pressure and heart rate variability at rest, in normotensive and hypertensive adult male subjects. Int J Cur Res Rev 2015 Sep; 7(18):11-14.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareEffect of Video Game Music on Hand Dexterity Performance in Young Adults English3942Hriday ShahEnglish Mugdha OberoiEnglishIntroduction: Video game music genre has no lyrics, repeats indefinitely and has a 5-beat rhythm which acts as Rhythmic Auditory Stimuli. It can either be used as a stimulus providing rhythmic cues or as facilitating stimuli for training. It may activate various structures in the brain that help improve movement control and performance. Thus, the authors aimed to study the effects of video game music on hand dexterity performance. Objectives: 1) To assess hand dexterity performance without music. 2) To assess hand dexterity performance with video game music. 3) To compare the hand dexterity performance with and without video game music. Methods: In this cross over study design 230 asymptomatic individuals both male and female between the age groups 18- 35 years were evaluated for hand dexterity performance using Bimanual turning test of Minnesota manual dexterity test. Randomly half of the subjects performed the test with video game music and after 24 hours re-performed the test without video game music, for the remaining half of the subjects the test conditions were reversed. Results: The mean age of the population was 26.48 years where 50.9% were males and 49.1% females. The median time taken to finish the test with video game music was 138.07 (89.98, 597.29) seconds and without video game music was 133.73 (103.94, 216.61) seconds. The time taken to perform the test with video game music was 140.49 +18.09 seconds and without video game music was 142.28 +47.84 seconds. On comparing the two test conditions, the time taken to perform the test with video game music was less which was statistically significant with p-value < 0.0001. Conclusion: Hand dexterity performance with video game music is better as compared to without video game music. English Chiptunes, Hand function, Motor performance, Rhythmic auditory stimuli, Bi-manual turning testIntroduction Video game music is a soundtrack that accompanies the video game. This style of music is known as chiptunes, which combines simple melodic styles with more complex patterns or traditional music styles. Features of the video game music genre include a) music pieces designed to repeat indefinitely, that is a type of rhythmic auditory stimulus is present. b) The music pieces do not have lyrics hence act as auditory cues. c) A 5-beat rhythm is present that is used to create different effects. Video game music uses certain sound symbols helping the player to identify his goal in the task of the game he/she is playing and also focuses their perception on certain objects.1 Rhythmic Auditory Stimulation (RAS) is a neurological technique used for rehabilitation of rhythmic movements, intrinsically, and biologically.2 Hand dexterity includes hand and arm stability, reaction time, aiming, hand preference, finger tapping speed, wrist flexion speed and other different hand abilities and performance as the hand is the most involved, requited and participated part of the upper extremity.3 Authors of Oxford’s Handbook for Music Education have also suggested the need for further research to know how video game music impacts physical activity performance.4 Video game music can be diegetic or non-diegetic depending on its arrangement during different stages of the game. This music helps in intriguing the player in the game due to its immersion effect, thus helping him improve his/her gaming performance.5 Thus, the authors aimed to study the effect of video game music on hand dexterity performance in young adults. With the following objectives: 1) To assess hand dexterity performance without music. 2) To assess hand dexterity performance with video game music. 3) To compare the hand dexterity performance with and without video game music.  Bimanual turning test of the Minnesota Hand dexterity test was used as an outcome measure. MATERIALS AND METHODS Subjects This experimental cross over study included 230 asymptomatic young adults both male and female (n=230) of the age group 18-35 years. Subjects with any musculoskeletal, neuromuscular, cardiovascular conditions and any individuals with impaired hearing were excluded. Written consent was obtained from all eligible subjects before enrollment. Intervention Approval was taken from the Ethics Committee, outward no. KJSCPT/886/18-19. The study was conducted at the research lab of K. J. Somaiya College of Physiotherapy. Subjects were randomly divided by the computer-generated selecting system into two sets. Set one, (n=115) subjects first performed the hand dexterity test (Minnesota manual dexterity test: bimanual turning test) with video game music and after 24 hours re-performed the hand dexterity test without the video game music. Set two, (n=115) subjects first performed the test without video game music and then after 24 hours re-performed the hand dexterity test with video game music. Outcome Measure The Bimanual Hand dexterity test of the Minnesota Manual Hand dexterity test was used as an outcome measure. A practice trial was given to the subject before the test. Then as shown in figure 1, the subjects were required to perform the test thrice and the final score calculated by the addition of all the 3 readings measured in seconds. The test conducted was the same only the study settings varied, which is with or without video game music. Procedure The objective of this test is to see how fast you can pick up the disks with one hand, turn them with the other hand, and replace the disks into the holes on the board.  Subject with the LEFT hand, picks up the block from the upper right-hand corner. Turns the disk while passing it to your RIGHT hand and return it into the original hole in the board with the BOTTOM side facing UP. Continue to until you complete the entire TOP row.  As the subject starts the second row, say, with his/her RIGHT hand, picks up the first block in the second row. Turns the disk while passing it to LEFT hand and return it into the original hole with the BOTTOM side facing UP.  The subject always picks UP the blocks with the hand that LEADS and put them DOWN with the hand that FOLLOWS. Test will be carried with/without video game music accordingly. Statistical Analysis To determine the difference between the time taken to perform the Bimanual Hand dexterity test with and without video game music, the scores of the test for each subject was recorded. The data collected did not pass the normality test and hence Wilcoxon signed-rank test was performed with 5% significance. Results A total of 230 subjects participated in the study (N=230). The mean age of the population was 26.48 years where 50.9% were males and 49.1% females. The data collected did not pass the normality and Wilcoxon signed-rank test was used for analyses. On comparing the median values of the time taken to perform the test with video game music (89.98, 597.29) and without video game music (103.94, 216.61), the difference is bound to be statistically significant with p-value < 0.001. Discussion This study has assessed the effect of video game music on hand dexterity performance using the Minnesota Bimanual Hand Dexterity Test. It included young adults (n=230) both males (n=117) and females (n=113) within the range of 18-35 years of age (mean age = 26.48).  The hand dexterity performance was measured with and without video game music. Data analysis showed an extremely significant difference (pEnglishhttp://ijcrr.com/abstract.php?article_id=3306http://ijcrr.com/article_html.php?did=3306 Collins K. Game sound. 1st ed. Cambridge, Mass.: MIT Press; 2008, Chapter 7: Gameplay, Genre and the functions of Game Audio, 123-137. Thaut MH. Rhythm, Music and the Brain, New York and London: Taylor and Francis Group, Neurologic Music Therapy – Techniques and Definitions, Roultedge Publications 2005;1:1-12. 3. Martin JA, Ramsay J, Hughes C, Peters DM, Edwards MG, Age and Grip Strength Predict Hand Dexterity in Adults. PLoS One 2015;10(2): 4. Welch G, McPherson G. The Oxford handbook of music education. Volume 2. Oxford: Oxford University Press. Let’s Learn: Let’s Play, 2012;554 5. Zhang J, Fu X, The Influence of Background Music of Video Games on Immersion. J Psychoth 2015;05(04). 6. Lawrence D. The effect of musical tempo on video game performance [Post graduation]. Uni Jyvaskyla 2012; 3(5): 234-239. 7. Jang-won L, Yong KK, Jung HC, Soyoung L. The Effectiveness of Music Therapy on Cerebral Palsy Patients Receiving Rehabilitation Treatment, Int J Humanit Soc Sci Invent 2016; 5(9): 24-29. 8. Paul S, Ramsey D. Music therapy in physical medicine and rehabilitation. Aus Occup Ther J 2000;47(3):111-118. 10. Thaut MH, McIntosh GC, Hoemberg V. Neurobiological foundations of neurologic music therapy: rhythmic entrainment and the motor system. Front Psychol 2015;5:1185.  11. Thaut M, Schleiffers S, Davis W. Analysis of EMG Activity in Biceps and Triceps Muscle in an Upper Extremity Gross Motor Task under the Influence of Auditory Rhythm. J Music Ther 1991;28(2):64–88 12. Sobana R, Sundar S, Jaiganesh K. Music Therapy for Pulmonary Rehabilitation in Chronic Obstructive Pulmonary Disease [COPD] Patients- An Interventional Trial. Int J Curr Res Rev 2020;12(12):26-29.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareCirculating Serum Total Bilirubin as a Predictor for Hypertension in General Population English4346E. KeerthikaEnglish Siddhartha Sankar PalEnglish Harini SrinivasamoorthyEnglish R. SurekhaEnglish Potla YasaswiEnglish B. HariniEnglishIntroduction: Circulating total bilirubin is known to be inversely and independently associated with future risk of cardiovascular disease. However, the relationship of circulating total bilirubin with incident hypertension is uncertain. Objective: We aimed to assess the association of total bilirubin with future hypertension risk. However, data on the relationship between bilirubin and blood pressure are scarce and inconclusive. Methods: We analysed data with a 50 minimal sufficient adjustment set of variables (MSAS) needed to estimate the unconfounded effect of bilirubin on blood pressure and hypertension (systolic/diastolic blood pressure ≥140/90 mmHg or using antihypertensive medication) was identified using the back-door criterion and included in all regression models. Results: In this prospective study, after adjustment for the MSAS variables, systolic blood pressure decreased progressively up to -2.5 mm Hg (p < 0.001) and the prevalence of hypertension was up to 25% lower (P < 0.001) in those with bilirubin ≥1.0 mg/ dl-the highest two deciles-compared with those with 0.1-0.4 mg/dl-the lowest decile. Sensitivity analyses showed these results were unlikely to be explained by residual confounding or selection bias. Conclusion: High serum bilirubin may decrease the risk of hypertension by inactivating and inhibiting the synthesis of reactive oxygen species in vascular cells. Strategies to boost the bioavailability of circulating and tissue bilirubin or to mimic bilirubin’s antioxidant properties could have a significant impact on prevention and control of hypertension as well as coronary heart disease. EnglishSerum total bilirubin, Cardiovascular disease, Systolic/diastolic blood pressure, Hypertension, Minimal sufficient adjustment set, Regression and antioxidant propertiesIntroduction The part of aggravation in cardiovascular infection (CVD) is built up. Oxidative pressure assumes a significant part in atherosclerosis, which is an ongoing fiery reaction to vascular endothelial injury brought about by an assortment of variables advancing incendiary cell section and actuation.1 The acknowledgement of bilirubin as a significant endogenous mitigating and cell reinforcement particle has expanded in late many years. Bilirubin influences atherosclerosis by a few repressing systems, including low-thickness lipoprotein oxidation, vascular smooth muscle cell multiplication, and endothelial dysfunction. Although elevated blood pressure (BP) is a major cause of cardiovascular diseases in all populations and the leading risk factor for global disease burden,1Our knowledge on risk factors for the development of hypertension is still limited. Serum bilirubin is a powerful antioxidant2 and has been shown to decrease the risk of cardiovascular outcomes in prospective cohort studies.3 Experimental studies in animal models suggest that bilirubin may reduce BP by decreasing vascular oxidative stress,4 and a few epidemiological studies point to an association between bilirubin and BP. Moreover, the role of oxidative stress in the incidence of hypertension has been questioned, due in part to contradictory findings from epidemiological and clinical studies assessing the benefits of supplementing diets with antioxidants such as vitamins C and E.5 Given the potential clinical and public health significance of this association, in this study, we examined the role of serum bilirubin as a possible risk factor for hypertension. This case-control study will be carried out in the clinical biochemistry laboratory in Saveetha medical college and hospital with 50 hypertension patients and 50 age and sex-matched controls. Materials and Methods This study is based on data from November 2019 to July 2020. Participants ≥20 years old were eligible for this study, excluding pregnant women (n=4), individuals without BP data (n=6) with BP data (n=40). Three to four BP measurements were taken following standard procedures6 and the mean of all values, excluding the first one in those with more than one measurement, was used in our analysis. Individuals with an average systolic BP-140 mmHg and/or average diastolic BP-90 mmHg and/or taking prescribed antihypertensive drugs were considered as hypertensives. Serum total bilirubin levels were measured using vitros 5600 automated dry chemistry analysers and reported values were adjusted to make them comparable when needed. This study was approved by the Ethical committee of Saveetha medical college and hospital and its ID number: 020/03/098 Statistical analysis Estimating the effect of bilirubin: Excluding those individuals from the analysis would have reduced statistical power and increased the likelihood of selection bias, whereas excluding those variables would have increased the likelihood of residual confounding. 6 In consequence, we used multivariate imputation by chained equations (MICE) to fill out missing values and generated and analysed 50 imputed data sets. Also, the underlying BP, our outcome variable, could not be measured in 70% of the 38% (of total participants) with hypertension, because they were taking antihypertensive drugs. Excluding these individuals, treating observed BP as underlying BP values, and including treatment as a covariate in the analysis could have resulted in bias.7 To address this problem we considered the measured BP as a right-censored variable and imputed BP values among treated individuals using interval regression. BP was measured in the Physiotherapy department of Saveetha medical college. Multiple linear and logistic regression were used to estimate the effect of bilirubin on current systolic and diastolic BP and the prevalence of hypertension, respectively. An age-squared term and a gender-by-age interaction term were included in our regression models to account for the nonlinearity in the age-BP relationship and the age-dependent effect of gender on BP and hypertension risk. Also, a term for an abdominal obesity-by-age interaction was included and retained if it was statistically significant. It is well documented that survival is increased among individuals with higher levels of serum bilirubin, and is decreased among individuals with higher BP. Then we estimated the effect of bilirubin-0.7 mg/dl on hypertension excluding individuals with high values of the simulated collider and compared these estimates with the one obtained from the analysis with all individuals Results Our analysis included 50 individuals, with an average age of 50 years, 50% men, 38% hypertensive, and median serum bilirubin of 0.7 mg/dl (range 0.1 to 13.1; Table 1). Individuals with serum bilirubin 0.7 mg/dL had higher serum creatinine and uric acid, but had slightly lower systolic BP and prevalence of hypertension, and were considerably less likely to be African Americans, to have abdominal obesity, to smoke or to drink alcohol regularly. Multivariate adjusted models showed that systolic BP was lower among individuals with higher serum bilirubin (Table 2). After adjusting for variables in the minimal sufficient adjustment set MSAS, systolic BP decreased progressively with increasing levels of bilirubin, up to -3.4mmHg in those with the highest (1.2 mg/dl) as compared with those with the lowest (0.1–0.4 mg/dl) levels of bilirubin (PEnglishhttp://ijcrr.com/abstract.php?article_id=3307http://ijcrr.com/article_html.php?did=3307 Rodrigues C, Rocha S, Nascimento H. Bilirubin levels and redox status in a young healthy population. Acta Haematol 2013;130:57–60. Bélanger S, Lavoie JC, Chessex P. Influence of bilirubin on the antioxidant capacity of plasma in newborn infants. Neonatology 1997;71:233–238. Vítek L, Jirsa M, Brodanová M. Gilbert syndrome and ischemic heart disease: a protective effect of elevated bilirubin levels. Atherosclerosis 2002;160:449–456. Lin JP, Donnell CJ, Schwaiger JP. Association between the UGT1A128 allele, bilirubin levels, and coronary heart disease in the Framingham Heart Study. Circulation 2006;114:1476–1481. Pandey N, Gupta S, Yadav RK, Kumar S. Physiological jaundice: role in oxidative stress. Int J Curr Res Rev 2013;5(19):69-80. Djousse L. Effect of serum albumin and bilirubin on the risk of myocardial infarction (the Framingham Offspring Study). Am J Cardiol 2003;91:485–488. Levy D. Total serum bilirubin and risk of cardiovascular disease in the Framingham offspring study. Am J Cardiol 2001;87:1196-1200. Madhavan M, Wattigney WA, Srinivasan SR. Serum bilirubin distribution and its relation to cardiovascular risk in children and young adults. Atherosclerosis 1997;131:107–13. Pflueger A, Croatt AJ, Peterson TE. The hyperbilirubinemia Gunn rat is resistant to the pressor effects of angiotensin II. Am J Physiol Renal Physiol 2005;288: 552-558. Zucker SD, Qin X, Rouster SD. Mechanism of indinavir-induced hyperbilirubinemia. Proc Natl Acad Sci 2001; 98: 12671-12676. Chin HJ, Song YR, Kim HS.  The bilirubin level is negatively correlated with the incidence of hypertension in the normotensive Korean population. J Korean Med Sci 2009;24:S50–56.  Vera T, Granger JP, Stec DE. Inhibition of bilirubin metabolism induces moderate hyperbilirubinemia and attenuates ANG II-dependent hypertension in mice. Am J Physiol Regul Integr Comp Physiol 2009;297:738-743.  Papadakis JA, Ganotakis ES. Effect of hypertension and its treatment on lipid, lipoprotein(a), fibrinogen, and bilirubin levels in patients referred for dyslipidemia. Am J Hypertens 1999;12:673–681. Breimer LH, Mikhailidis DP. Is bilirubin a marker of vascular disease and/or cancer and is it a potential therapeutic target. Curr Pharm Des 2011;17:3644-3655. Perloff D, Grim C, Flack J. Human blood pressure determination by sphygmomanometry. Circulation 1993;88:2460-2470.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareRisk Factor Analysis of Covid-19 English4750John William Carey MeditheEnglishBackground: Coronavirus is an unpredicted anti-human biological calamity. This virus questions the entire globe on its state and characteristics, which lead physicians, virology practitioners to give conditional statements and fearful myths. Objective: This analysis aims to provide a probability to get infected with Covid-19 for patients with various health complications. Methods: Data set from Mexican government contains 566,602 Covid-19 test samples. Data analytics adhere to 16 parameters of habitual and health constraints on this data set are evaluated using R software. Results: 7 out of 16 parameters exhibited Extreme Severity in getting infected with Covid-19, while other 6 and 3 are categorised into moderate and less severity respectively. Conclusion: Risk factor analysis alerts the persons with these 16 parameters to take necessary precautions and preparedness for Covid-19. English Coronavirus, COVID-19, Risk factor analysisIntroduction As of now, there are seven types of coronavirus in humans that exhibit similar symptoms that cause disease. Four in this list are more often with symptoms of a cold. OC43 and 229E type coronavirus grounds common cold. HUK1 and NL63 are serotype coronaviruses that are also related to the common cold. These four viruses rarely effect on respiratory system in infants, aged, and less immune. But, another three of seven types of infections are more extreme and cause a noticeable impact on the respiratory system in humans.1,2 Middle East Respiratory Syndrome (MERS) is one of a severe type of coronavirus which first emerged in Saudi Arabia. Later prominently it is transmitted to the Middle East, Asia, Africa, and Europe.7 Severe Acute Respiratory Syndrome (SARS) is another type of coronavirus came into sight in china in 2002. Fortunately, there is no further notice of SARS cases identified. These types of coronaviruses are zoonotic that cause severe infections in the respiratory system, which originates from infected animals to humans.8 Now, in late 2019, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) is another type of coronavirus outbreak in China and soon transmitted all over the world. International Committee on Taxonomy of Viruses (ICTV) nomenclate novel coronavirus as COVID-19. This infection affects the respiratory system. Upper respiratory tract like nose, throat, and sinuses or lower respiratory like windpipe and lungs are severely damaged and leads to shortness of breath. Similar to other coronaviruses, it is prone to get transmitted from person to person. Infected patients have to undergo treatment identical to the procedure for Cold.9 The key symptoms of Covid-19 patients include Fever, Cough, Sore throat, Breathing problem (Shortness of breath or trouble breathing), Shivering, Body pains, Headache, Fatigue, Loss of smell or taste, vomiting, Diarrhea. Covid-19, in its extreme, leads to pneumonia, respiratory system failure, and death due to the release of cytokine which affects the immune system by making bloodstream with inflammatory proteins results in killing tissues.2 MATERIALS AND METHODS Dataset is collected from the official website of the General Directorate of Epidemiology, Mexican government which includes an enormous number of anonymised patient-related information.5 Dataset Total 566,602 tests conducted on the subjects who exhibit preliminary symptoms of COVID-19 given by WHO. 499,692 test results are declared, and 66,910 tests are waiting for the results. The study is performed on 499,692 test results and studies the risk factor associated with COVID-19 cases. 220,657 tests of 499,692, i.e. 44.15% results are tested positive with Covid-19. Now the study carried on data of 499,692 tests, and the percentage of risk associated with each risk factor is analyzed. Risk Factor Analysis Risk factors are parameters in Covid-19 infected patients that lead to severe illness if the patient shows COVID-19 symptoms along with abnormal health conditions. 16 prominent risk factors are identified from the dataset to estimate their percentage of positive cases in total positive cases and total tests. All analyses were executed using the R programming software, version 3.3.1. Results The impact of each risk factor on the total positively tested samples is analyzed and tabulated their percentages in different perceptions in Table 1. Pneumonia: This risk factor has a drastic outsized impact on resulted in positive cases; more than 67% of Pneumonia patients are tested positive. It took the share >10% in 499,692 tests performed and nearly 25% in total 220,657 positive cases. Diabetes: This is another risk factor that leads to severe illness along with Covid-19. Nearly 60% of diabetics are very much prone to infection and an increase in fatal rate. 7.24% of total tests and >16% of positive cases are associated with this risk factor. Age >60: The dataset is subdivided with a threshold of 60 years in patients age. Analysing the tests of senior citizens who are above the threshold and infected with this novel corona virus, more than 56% of this age group is tested positive, and > 20% in total positive cases are with this risk factor. It took nearly 10% of the share highlighting risk factors in 499,692 samples of tests. Age41% of age below 60 years are tested positive. Other Covid-19 Contact: This is the crucial source of transmitting coronavirus from person to person. Nearly 38% of infected patients have primary or secondary contact with other Covid-19 infected patients. More than 14% in total testes and >33% in total positive cases are infected from another Covid-19 contact. Obesity: More than 52% of tests resulted in positive for the patients with this risk factor. It shows that nearly 9% of total tests and 20% of positive cases are with this risk factor. Almost 13% of adults in the world and 39% in the USA are obese, steals one of the prominent seats among risk factors. Chronic Obstructive Pulmonary Disease (COPD): Troubled Breathing is a preliminary symptom of Covid-19. Along with risk factor, a positively tested patient has to face severe problem in taking a breath and probably need to be intubated. More than 46% of COPD patients are tested positive with Covid-19. 0.78 % of 499,692 tests and 1.76% of 220657 positive cases are with the risk factor. Asthma: More than 37% of Asthma patients are tested positive may lead to severe illness. 1.21% of total tests and 2.75% of total positive cases are with this risk factor. Hypertension: This is another extreme health complication towards Covid-19. More than 54% of Hypertension patients tested positive. >8% of total tests and 20.08 % of total positive cases are with this risk factor. Many studies prove that Hypertension varies with age. To justify that dataset is subdivided with a threshold age of 60 years and analyzed. Hypertension in Age>60: More than 58% of patients with more than 60 years of age are prone to Covid-19. Nearly 4% of total tests and 9.34% of positive cases are with this risk factor. Hypertension in Age60, Obesity, Hypertension in all ages Moderate: AgeEnglishhttp://ijcrr.com/abstract.php?article_id=3308http://ijcrr.com/article_html.php?did=3308 Coronavirus disease (COVID-19) – World Health Organization. 2020 [cited 9 September 2020]. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019 Coronavirus and COVID-19: What You Should Know. 2020 [cited 18 August 2020]. Available from: https://www.webmd.com/lung/coronavirus Novel coronavirus: What we know so far? Medicalnewstoday.com. 2020 [cited 1 September 2020]. Available from: https://www.medicalnewstoday.com/articles/novel-coronavirus-your-questions-answered Module 1: Virology, Coronaviruses, and COVID-19. Johns Hopkins Coronavirus Resource Center. 2020 [cited 9 November 2020]. Available from: https://coronavirus.jhu.edu/covid-19-basics/understanding-covid-19/module-1-virology-coronaviruses-and-covid-19 COVID-19 patient pre-condition dataset [Internet]. Kaggle.com. 2020 [cited 16 September 2020]. Available from: https://www.kaggle.com/tanmoyx/covid19-patient-precondition-dataset Park S. Epidemiology, virology, and clinical features of severe acute respiratory syndrome -coronavirus-2 (SARS-CoV-2; Coronavirus Disease-19). Clin Exp Pediatr 2020;63(4):119-124. Phillips J. Middle East Respiratory Syndrome (MERS). Workplace Health & Safety. 2014;62(7):308-308. Dorathy U, Bassey E. Coronavirus: COVID-19-Epidemiology, Treatment, Prevention and Control. J Adv Microbiol 2020;23:46-51.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareTo Measure the Role of Mother’s Acquaintance Concerning Their Kid’s Health English5154Krishan Veer SinghEnglishIntroduction: Child care is for the most part the duty of moms. A few examinations have uncovered that the mother’s instruction positively affects their insight and practice in youngster wellbeing matters. Kid demise because of lack of healthy sustenance, nutrient inadequacy and inappropriate immunization are most basic in our general public and these can be constrained by appropriate training of moms about their youngster’s wellbeing. Objective: The examination was embraced to evaluate the degree of mother’s information as to youngster wellbeing, dietary example, the pervasiveness of illnesses and issues among kids also, to improve this mindfulness. Methods: A people group interventional study was directed in chosen territories of Bharatpur. Scoring type various decision polls were planned and information gathered from two provincial and two princely territories. In the wake of directing the pretest and mindfulness, 10 days hole was given and later post-test was led in a similar populace. Results: Majority of respondents belong to the age group of 24-28 years of age (88.30%). Working ladies know about their youngster’s wellbeing however they face an issue of absence of time. Conclusion: Literate moms are having more information in dietary upkeep of kids than uneducated moms. Also, Urban territory moms are having more information in Dietary Maintenance and Up to date wellbeing registration Of Children than provincial area moms. Mother’s information about appropriate eating routine and inoculation is critical to keep up their kid’s wellbeing. English Kids vaccination, Immunization, Knowledge, Mother, Diet, HealthINTRODUCTION It was seen that a decent beginning toward the start of the youngster&#39;s life assists with making a productive individual later on society because the initial five-years in a kid development are a vital period especially for the improvement of the mind. Mother&#39;s information about kid wellbeing is a significant indicator of youngster&#39;s solid development. Nourishment is one of the essential prerequisites of any living life form to develop and support life. Be that as it may, the quality and number of supplements vital for ordinary development and to keep a life form healthy during its life expectancy shifts with the age of the life form1. Any significant deviation in the supplement consumption either in quality or in an amount from its prerequisite can likewise influence development and life expectancy in various manners especially in the later period/development is more affected by sustenance. Lack of healthy sustenance is the cell awkwardness between the gracefully of supplements and vitality and the body interest for them to guarantee development upkeep and explicit capacity.2 It is the overall medical issue, especially in creating nations. Wholesome status is the state of soundness of a person as impacted by supplement admission and usage in the body. Hence, great sustenance is fundamental for sound, flourishing people, families and a country. Healthfully taught moms can raise their kids in a more advantageous manner.3 Inoculation is a high need territory in care of newborn children and youngsters. High vaccination rates have nearly disposed of numerous irresistible infections which used to obliterate sizable of the populace for nations. Various fatal and impairing irresistible illnesses can be forestalled by the opportune organization of antibodies when the youngster is successfully vaccinated at the correct age, a large portion of these maladies are either completely forestalled or if nothing else altered so kid experience the ill effects of a gentle ailment with no handicap. Take-up of immunization administrations is needy on the arrangement of the administrations as well as on different variables including information and mentality of moms and thickness of wellbeing laborers.4 The open-door costs, (like-lost profit or time) acquired by guardians may likewise importantly affect take-up. Select breastfeeding for the underlying a half year of a child&#39;s life is a monetarily wise mediation in saving children&#39;s lives and it is proposed by the World Health Organization. Human milk is the ideal food for an infant&#39;s perseverance, advancement, and improvement. Particularly in unhygienic conditions, regardless, chest milk substitutes pass on a high threat of sullying and can be deadly in children.5,6 Chest milk contains all the enhancements a child needs in the underlying a half year of life.7 First-class chest dealing with infers that the infant youngster gets simply chest milk. Tiptop chest dealing with in the underlying a half year of life stimulates kids&#39; sheltered systems and shields them from the detachment of the guts and extreme respiratory illnesses. Select chest dealing with for the underlying a half year of life is directly considered as an overall open heath target that is associated with the decline of infant youngster terribleness and mortality, especially in the making scene. Moms who are learned about broad formative groupings may be bound to make a domain that is proper to their kids&#39; creating capacities, which thusly will bolster their youngsters&#39; psychological and social advances. Henceforth, maternal information can be conceptualized as in a roundabout way influencing formative results in kids. Experimentally, moms of preterm newborn children who are increasingly educated about baby advancement have been found to have infants with higher Bayley Mental Development Index and Physical Development Index scores. Moms are differentially educated about movements in youngsters&#39; play and variety among moms in exactness at requesting play exercises predicts their play with their kids.8 Thinking about the above realities, the requirement for giving mindfulness concerning kid&#39;s human services to mother&#39;s is significant in the present situation. Henceforth, we have thought of the title "To evaluate the job of mother&#39;s information in regards to their kid&#39;s wellbeing". MATERIALS AND METHODS Study design: Study was prospective Study period: this study was concluded between a period of six months from 2019 to 2020. Consideration standards: •        Mothers who are having kids matured between 2 to 5 years •        Mothers who are working and non-working •        Mothers who are educated and uneducated. •        Mothers from both atomic and joint family. Rejection standards: •        Mothers who are having long haul disease. •        Mothers who are over 35 years old. Sources of data: Patient’s Demographics Questionnaire Patient Interactions Study procedure: The study was done in the wake of getting the endorsement from the Institutional Ethics Committee. After taking the educated assent structure, from the subjects in the wake of clarifying the significance of the investigation and its advantages. Right off the bat, the examination subjects were offered a poll where the responses will be gathered and assessed, which was the pre-test. After the pre-test, organized instruction has been given as patient data flyers and other media. following a hole of ten days, post-test was completed on similar report subjects with a similar survey, which has been assessed. The survey was scoring type with different decision questions. Each right inquiry has been granted one imprint, while each off-base inquiry has been given zero imprints. Measurable investigation After the culmination of the investigation, the information gathered was gone into Microsoft Excel sheets and further examination is done by understudy combined "t" test in SPSS 24 rendition RESULTS Total no of 169 (Rural N=81, Urban N=88) themes were registered in this learning for 1st appointment, from which 154 (Rural N=78, urban N=76) topics were extant in the 2nd visit. Hereafter, we have elected the statistics of 154 topics for more study scrutiny and enduring focuses were omitted from the learning. The outcomes show in Figure 3, Among study subjects from chosen regions, the pre-test score of the mean (±SD) 2.458 (±2.045), a post-test score of the mean (±SD) 6.621 (±1.451) and Paired T-test esteem are 5.216 and 48.161 separately (Table 2). The p esteem for pre and post-test is 0.004 which is huge and 0.001 which is profoundly huge. Table 1 provides the details of the age-wise distribution of mother. Majority of respondents belong to the age group of 24-28 years of age (88.30%). Figure 1 presents the education status of the respondents. It is clearly evident that majority of respondent (87) in the present study are literate and only 13% are illiterate. Figure 2 provides details about the occupational status of mothers. Among 134 educated subjects, schoolings were 58, PUC were 32 and graduates were 43 according to the socioeconomics. In the examination, it was discovered that proficient moms are having more information concerning their kid&#39;s wellbeing. A sum of 154 subjects, 45 were working and 109 were non-working (Figure 2). Working ladies know about their youngster&#39;s wellbeing however they face an issue "absence of time". Through the examination mother&#39;s information was improved and mindfulness has been given concerning youngster&#39;s wellbeing. Details are provided in figure 2 below. Table 2. Shows comparison of mean scores of knowledge of mother’s knowledge regarding child health. Among study subjects from chosen regions, the pre-test score of the mean (±SD) 2.458 (±2.045), the post-test score of the mean (±SD) 6.621 (±1.451) and Paired T-test esteem are 5.216 and 48.161 separately. The p esteem for pre and post-test found to be 0.004 which is huge and 0.001 which is profoundly huge. Figure 3 provided below shows the graphical representation of pre-test and post-test results. It is evident from the figure that means the value is found to be significantly higher in the case of the post-test (6.621) as against the pre-test. DISCUSSION “Kids are our future" past the words it mirrors the significance of kid wellbeing.9 The maternal bond is the connection between a mother and her kid related with pregnancy and labour. As mothers assume a significant part in kid wellbeing.10 Unfortunate food propensities and nourishment related practices, which are regularly founded on inadequate information, customs, and restrictions or helpless comprehension of the connection among diet and wellbeing, can unfavourably influence a youngster&#39;s wholesome status.11,12 This study is the prospective interventional study conducted in selected areas in Bharatpur. Our examination intended to improve the information among moms identified with youngster wellbeing and the improvement in scores was discovered (mean pre and post-test scores were 2.458 and 6.621 separately), which sounds the same with the investigation led by me with some others. This study intended to find the relation between literacy of mother and dietary maintenance of the kid and concluded that Literate mothers are having more knowledge in dietary maintenance of kids than illiterate mothers which was found identical with the study.12 ASSUMPTION As per the examined outcomes and from the literature review, the assumptions are; Male patients are more. Patients of age > 60 are more. Patients of body weight> 50 are more. GFR Englishhttp://ijcrr.com/abstract.php?article_id=3309http://ijcrr.com/article_html.php?did=3309 Alkhazrajy LA, Aldeen ERS. Assessment of Mothers Knowledge Regarding the Developmental Milestone among Children Under Two Years in Iraq. Am J Appl Sci 2017; 14(9): 869-877. Abuya BA, Ciera J, Murage EK. Effect of mother’s education on child’s nutritional status in the slums of Nairobi. BMC Pediatrics 2012; 12(80):1471-1482. Saxena S, Mishra S. Malnutrition among School Children of Lucknow. Int J Sci Res 2014;6(3):1726-1730. Mary AJBL, Devi SM. Malnutrition among school children. World J Phar Pharmaceut Sci 2016;7(5):1275-1282. Hossain A, Haque MM, Parvin R, Saha PK, Parvin N, Masud JHB. Nutrition-related knowledge among mother having primary school-going children. Euro Acad Res 2014; 6(2):7567-7578. Rahman TAA. Mothers awareness and knowledge of under 5years children regarding immunization in the Minia City of Egypt. Life Sci J 2013;10(4):1224-34. Bofarraj MAM. Knowledge, attitude and practices of mothers regarding immunization of infants and preschool children at Al-Beida City, Libya 2008. Egypt J Pediatr Allergy Immunol 2011;9(1):29-34. Mumtaz Y, Mumtaz MZZ. Knowledge Attitude and Practices of Mothers about Diarrhea in Children under 5 years. J Dow Uni Health Sci Karachi 2014;8(1):6-3. Tamis-LeMonda CS, Chen LA, Bronstein H. Mothers&#39; Knowledge About Children&#39;s Play and Language Development: Short-Term Stability and Interrelations. Dev Psychol 1998; 34 (1): 115-124. Birenbaum E, Fuchs C, Reichman B. Demographic factors influencing the initiation of breastfeeding in an Israeli urban population. Paediatrics 1989; 83:519-523.  Yeung DL, Pennel Md, Leung M, Hall J. Breastfeeding: Prevalence and influencing factors. Can J Public Health 1981; 72: 323-330.  Kolahi AA, Tahmooresdeh S. First febrile convulsions: Inquiry about the knowledge, attitudes and concerns of the patients’ mothers. Eur J Pediatr 2009; 168:167-171. 

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareComparative Study to Evaluate the Apical Sealing Ability of MTA Plus and Biodentin Using a Bacterial Leakage Model: In Vitro Study English5561Revathi BashyamEnglish Ramesh KrishnanEnglish Kruthika MuraliEnglish Nandhini B. SelvarajanEnglish Suresh Kumar VasaviahEnglish Vinola DuraisamyEnglishIntroduction: The apical vessels may also be severed or damaged enough to interfere with the normal reparative process. Radicular lesions develop when microorganisms of sufficient pathogenicity and number gain access to periradicular tissues. When microorganisms are competent to colonize in an extraarticular biofilm, they may be principally resistant to abolition by host defence mechanisms and antimicrobial agents. Objective: To compare the apical sealing ability of two materials MTA plus andBiodentin as well as to evaluate bacterial microleakage using a bacterial leakage model for 28 days. Methods: Sixtysingle rooted extracted permanent teeth were selected. All the teeth should have straight pulp canals were included in the study while the tooth with root caries, multiple canals, lateral radicular canals Calcifications, periradicular resorptive changes excessive curvatures, developmental defects, root fractures, with internal resorption, previously end odontically treated cracks or root defects were excluded from the study. Samples used in this in vitro study had been extracted for orthodontic or periodontal reasons. Results: Biodentineand controls on day 1. There was no leakage observed for MTA plus and Biodentine. Only one sample of positive control leaked. The comparison was done using the Kruskal-Wallis test and the p-value was found to be 0.392 which was statistically not significant. Biodentineand control groups onday5.Onday5,13.33%ofMineral trioxide aggregate (MTA)plus group leaked(2 out of 15 samples) against 40% of positive controls leaked (6 out of 15 samples). Conclusion: The resent study concludes that MTA plus and Biodentinehave good apical sealing ability against E.faecalisat 28days. Biodentinewas better in performance than MTA plus in terms of apical sealing for accurately measuring the microleakage and quantify it further in-vitro models can be pursued. English Pulpal Hyperaemia, Periradicular Tissues, Pulpotomy, Apexogenesis, MicroorganismsINTRODUCTION Trauma to a tooth is invariably followed by pulpal hyperaemia, the extent of which cannot be always determined. Congestion and alteration in the blood flow in pulp initiate irreversible degenerative changes, which can result in pulpal necrosis. The apical vessels may also be severed or damaged enough to interfere with normal reparative process.1 Radicular lesion develop when microorganisms of sufficient pathogenicity and number gain access to periradicular tissues.2 Because of the complexity of the root canal system and the difficulty to completely clean it using the present techniques and instruments, root canals cannot always be adequately treated using a non-surgical orthograde approach.3 Periradicular surgery, when indicated should be considered an extension of non-surgical treatment as aetiology of the disease process and the objectives of the treatment are the same. The fundamental goal of a root-end filling material is to give an apical seal that forestalls the development of microbes and the dispersion of bacterial items from the root waterway framework into the periapical tissues. It has been recommended that an ideal root-end filling material ought to cling to the planning dividers shaping a tight seal in the root trench framework. It ought to be anything but difficult to control, radiopaque, dimensionally steady, and non-absorbable. Also, an ideal root-end filling material should not be affected by the presence of moisture.5-7 MTA was first recommended as a root-end filling material when developed, but it has been used for pulp capping procedures, pulpotomy, apexogenesis, apical barrier formation in teeth with open apexes, repair of root perforations, and as a root canal filling material. The advantages of ProRootMTA (Mineral trioxide aggregate)as a root-end filling material, concerning the other mentioned alternatives, include greater sealing ability andbettermarginal.6-8 But it has certain clinical disadvantages such asit is tedious to handle and have a long setting time which could be overcome by MTA  plus.  But the material MTA plus is not much explored.9 Biodentine (SeptodontUSA) was recently introduced to the dental market. This new bioactive cement has dentin - like mechanical properties and can be used as a root-end filling material, as well as a repair material for root perforations and resorptions. Biodentinecan is used in both the root and crown.10-12 So the present study aims to compare the apical sealing ability of two materials MTA plus andBiodentin as well as to evaluate bacterial microleakage using a bacterial leakage model for 28 days. MATERIALS AND METHODS The present study was conducted in the department of Pedodontics at Vinayaka Mission’s Sankarachariyar Dental College, Vinayaka Mission’s Research Foundation (Deemed to be University), Salem, Tamilnadu, India. Sixtysingle rooted extracted permanent teeth were selected. All the teeth should have straight pulp canals were included in the study while the tooth with root caries, multiple canals, lateral radicular canals Calcifications, periradicular resorptive changes excessive curvatures, developmental defects, root fractures, with internal resorption, previously end odontically treated cracks or root defects were excluded from the study. Samples used in this in-vitro study had been extracted for orthodontic or periodontal reasons. The study was approved by the institutional research committee and institutional ethical committee. The sample size was determined scientifically. Considering Alpha: 0.05 Power of the study: 0.8 Effect size: 0.4. Therefore, the estimated sample size for the study was 15 for each group. This was calculated using the software G Power 3.1. 15 samples were randomly categorized to each of the experimental group and control group. Group-1 : MTA PLUS group (n=15) MTA plus was manipulated as per the manufacturer’s instructions and incrementally placed into the root end cavity and condensed well along the cavity walls and against a flattened file which was placed in the root canal. Initial set was allowed, after 48 hrs the k-file was removed. Each tooth was placed in sterile gauze piece soaked in saline for 48 hrs for the initial hard setting. Group-2 : Biodentine group (n=15) Biodentinewas mixed as per the manufacturer’s instructions in an encapsulator and incrementally placed into the root end cavity and condensed well along the cavity walls and against a flattened file which was placed in the root canal. The initial set was allowed, after 24 hrs the k-file was removed. Each tooth was placed in sterile gauze piece soaked in saline for 48 hrs for the initial hard setting. Group-3 : Positive control (n=15) ThermoplasticizedGP was used without sealer to fill the root end cavity and condensed against the flattened K - file. The file was removed after 48 hrs and placed in moist sterile gauze piece. Group-4 : Negative control (n=15) Root end preparations were filled with sticky wax and condensed against the k-file. After 48 hrs, the file was removed and placed in moist sterile gauze piece. Materials Materials used For control and experimental group were MTA plus (PrevestDenproLtd, Jammu, India), Biodentine (Septodont, Saint MaurdesFosses, France), Thermo plasticized Guttapercha(Bee fill 2 in 1 obturation device, Germany), Stickywax (Hiflex, UK). Materials used For canal preparation were ultrasonic diamond tips (Kistips),5.25% sodium hypochlorite (Hyposol, PrevestDenpro),17%EDTA(DoloEndogelTM,PrevestDenpro). Materials used For bacterial leakage model were scintillation vials, orthodontic resin, cyanoacrylate, phenollactosered broth (SigmaAldrich), E. Faecalisin TSB agar to1×109CFU/ml. Types of equipment used in the study were ethylenedioxide sterilization chamber Statistical analysis This was done using Kruskal-Wallis test and post-hoc-Tuckey test to compare the intergroup difference and statistical significance was set at the level of P=0.05. RESULTS Leakage of samples for MTA plus, Biodentine and control groups and its percentage of failure has been shown in Table 1 and Table 2. Comparison of leakage of samples between MTA plus, Biodentine and controls on day 1. There was no leakage observed for MTA plus and Biodentine. Only one sample of positive control leaked.  The comparison was done using the Kruskal Wallis test and the p-value was found to be 0.392 which was statistically not significant (Table-3) On day 5, 13.33% of MTA plus group leaked (2 out of 15 samples) against 40% of positive controls leaked (6out of 15 samples). Statistical analysis was done using the Kruskal Wallis test and the p-value was found to be 0.003 which was statistically significant (Table-4) Table 5 illustrates the comparison of leakage of samples among MTA plus, Biodentine and control groups on day 7, 8 and 14. All the samples showed similar leakage on 7 th, 8th and 14th day. The percentage of samples leaked for, MTA plus was 40 % (6 out of 15 samples), whereas 20% of Biodentine showed leakage (3 out of 15 samples). When observed in control groups, 100% of positive controls leaked (15out of 15 samples); and negative control did not leak. Numerically, MTA plus samples leaked more than Biodentine group. Statistical analysis was done using the Kruskal Wallis test and the p-value was found to be 0.001 which was statistically significant. When the percentage of apical leakage was assessed at 28th day MTA plus samples showed 40%, Biodentine showed 20%, positive control showed100% and negative control showed 6.67% of leakage, in which MTA plus showed more leakage than Biodentine. Statistical analysis showed a significant p-value of 0.001 (Table-6). There was a statistically significant difference between the positive control and the MTA plus group and biodentine group and also negative control.  MTA plus group showed a significant difference with both the control groups. Biodentine group showed significant difference with positive control. Intergroup comparison between MTA plus and Biodentine group had a mean difference of 0.200 and with a standard error of 0.120, the p-value was 0.347, which was statistically insignificant (Table 7). There was a statistically significant difference between the positive control and the MTA plus and the biodentine group and also negative control. Intergroup comparison between MTA plus and Biodentine group had a mean difference of 0.200 and with a standard error of 0.128, the p-value was 0.411, which was statistically insignificant (Table-8). Discussion In the present study, these two tricalcium silicate cement are compared in terms of apical sealing ability. Several methods have been employed to evaluate apical microleakage. These include air pressure, neutron activation, radioisotope, electrochemical, fluid filtration, bacteria, and the use of the dyes. Numerous techniques such as scanning electron microscopy, transmission electron microscopy, and electron probe microscope analysis have been used to image and quantify leakage. There is no standardized leakage test to evaluate the sealing ability of endodontic materials.9 Bacterial leakage model can be used to study the bacterial penetration across the material. A bacterial leakage model was chosen for the present study because it is most relevant in clinical perspective.10 In vitro study with bacterial leakage test was conducted for 28 days. The thickness of the apical plugin this study is  3 mm as supported by Mehmet bani et al. 2015.11 The amount of apical microleakage was significantly lower for 3 and 4mm apical plugs than 1 and 2 mm subgroups of BiodentineandMTA in his study. In the present study, the rood end cavity was prepared with ultrasonic diamond tips. Khandelwal et al. 201512compared different retro preparations with MTA and Biodentine. Biodentinegroup prepared using ultrasonics for showed the best sealing than all the other tested groups. Irrespective of preparation techniques used,  Biodentinestill showed better sealing than MTA. Preparation of the root end using ultrasonics showed less microleakage than but prepared teeth for both filling materials. In this study, machine trituration has done for biodentine as Gupta et al. 201513 reported more microleakage when Biodentine was manually manipulated. The setting time is one of the most clinically relevant factors to be considered. Hence in this study, all the samples were kept in moist gauze piece for a period of 48 hrs to allow an initial setting time. Long-setting period may induce clinical problems because of the failure of cement to maintain shape and support stresses during this period. Accelerated setting reduces the risk of dislodgement and contamination of MTA?like cement when used as root-end filling material, which is very well satisfied in Biodentine by addition of accelerators (CaCl2).14-16 In the present study, MTA plus showed more apical bacterial leakage than Biodentine. In the negative control group only one sample leaked at the end of the study. The leakage in negative control can be attributed to nail varnish failure. Among the positive control group, there was a 100% apical bacterial leakage indicating the need for an ideal apical sealing material for the retrograde fillings. Under the experimental conditions of this study, biodentine showed less leakage than MTA plus which was statistically insignificant. Biodentineand MTA plus showed significant difference than positive control which signifies that both the materials have the good apical sealing ability. The formation of CSH gel also reduces the porosity with time. The crystallization of the biodentine continues up to 4 weeks, therefore, improving the strength as well as other mechanical properties (sealing ability). The high mechanical strength of Biodentinemay is ascribed to the abolition of aluminates that lead to weakening and fragility of the set material as testified by the manufacturer. The thickness of the Ca?and Si-rich layers increased over time, and the thickness of the Ca?and  Si-rich layer was significantly larger in Biodentine compared to  MTA after 30 and 90 days, concluding that the dentine element uptake was greater for Biodentinethan forMTA.14,17,18 The sealing ability of a material is estimated by various phenomena such as porosity, marginal adaptation, and hydrophilicity. On mixing calcium silicate cement with water, many porosities and microchannels are produced and play a vital role in the hydration reaction, but may also influence the early sealing ability of the cement. Kokate and Pawar15 conducted a study that compared the microleakage of glass ionomer cement, MTA, and Biodentin when used as a retrograde filling material and suggested that Biodentinhas the least microleakage in comparison to other materials used which supports the current study.16,19 Sulthan17carried out a study to evaluate the pH and calcium ion release of MTA and Biodentin when used as root-end fillings. He concluded that Biodentine presented alkaline pH and the ability to release calcium ions similar to that of MTA. Blood contamination affected the push-out bond strength of MTA Plus irrespective of the setting time18.Formosa etal19. Found that the anti-washout gel changed the rheology and properties of the material. In particular, it was noted that while MTA mixed with water had a sandy consistency, MTA mixed with anti-washout gel had a far more vicious and rubbery consistency and are almost dough-like. This increased viscosity may explain from a purely physical standpoint, why MTA-AW developed the threshold strength of 3.92 MPa sooner than MTA. The anti washout gel added to MTA did not affect the radiopacity of resultant material the observed an increase in compressive strength of MTA-AW compared to MTA-W. The present study has to be still explored with detail assessment of the leakage as it has certain experimental limitations invitro. It has certain limitations such as fewer sample size, limitation of in vitro model, quantifiable evaluation etc. The study can be further directed invitro by extending the longevity of the study and quantifying the microleakage. The above statements, however, should be addressed in future experiments before any conclusive recommendations can be made.   CONCLUSION MTA plus and Biodentinehave good apical sealing ability against E.faecalisat 28 days. Biodentinewas better in performance than MTA  plus in terms of apical sealing. For more accurate measurement of the microleakage further in vitro models can be pursued. Acknowledgment: Authors acknowledge the enormous help received from the authors 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=3310http://ijcrr.com/article_html.php?did=3310 McDonald RE, Avery DR, Dean JA. Management of trauma to the teeth and supporting tissues. 9th ed. St. Louis, Missouri: MOSBY. Dentis Child Adolesc 2011;404. Siqueira JF, Lopes HP.Bacteria on the apical root surfaces of untreated teeth with periradicular lesions: a scanning electron microscopy study.Int Endodon J 2001;34:216. TorabinejadM, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root-end filling material. J Endod1993;19:591–595. Fogel HM, Peikoff MD. Microleakage of root-end filling materials. J Endod 2001;27(7):456 -458. Ingle JI, Bakland LK. Endodontics. 5th ed. Baltimore: BC DeckerInc. (2002). Torabinejad M, Watson TF, Pitt Ford TR. Sealing ability of a mineral trioxide aggregate when used as a root-end filling material. J Endod 1993;19:591–595. Lee SJ, MonsefM, TorabinejadM. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations. J Endod1993;19(11):541-544. TorabinejadM, Hong CU, Pitt Ford TR, Kettering JD.Antibacterial effects of some root-end filling materials. J Endod 1995;21(8):403–406. Iwami Y, Shimizu A, Hayashi M,  TakeshigeF, Ebisu. Three-dimensional evaluation of gap formation of cervical restorations. J Dent 2005;33:325-333. Hirschberg CS, Patel NS, Patel LM, Kadouri DE, Hartwell GR. Comparison of sealing ability of MTA and EndoSequenceBioceramicRoot Repair Material: A bacterial leakage study. Quintessence Int 2013;44:e157–e162. Bani M, Sungurtekin-Ekçi E, Odaba? ME. Efficacy of Biodentineas an Apical Plugin Nonvital Permanent Teeth with Open Apices: An In Vitro Study. BioMed Res Int 2015;3(5):231-335. Khandelwal A, Karthik J, Nadig RR, Jain A.Sealing   ability of mineral trioxide aggregate and Biodentineas root-end filling material, using two different retro preparation techniques-An in vitro study. Int J Contemp Dent Med Rev 2015;3:321-326. Gupta PK, Garg, KalitaC, Saikia, SrinivasaTS, Satish G. Evaluation of Sealing  Ability of  Biodentineas Retrograde Filling Material by Using two Different Manipulation Methods: An In Vitro Study. J Int Oral Health 2015;7(7):111-114. Khetarpal A, Chaudhary S, Talwar S, Verma M. Endodontic management of open apex using Biodentineas a novel apical matrix. Indian J Dent Res 2014;25:513-6 Kokate SR, Pawar AM. An in vitro comparative stereomicroscopic evaluation of marginal seal between MTA, glass ionomer cement &biodentineas root-end filling materials using 1 % methylene blue as the tracer. End odontol 2012;24(2):36-42. Bolhari B, Ashofteh YK, Sharifi F, PirmoazenS. Comparative Scanning Electron Microscopic  Study of the Marginal Adaptation of Four Root-EndFilling. J Dent (Tehran) 2015;12(3):226–234. SulthanIR, RamchandranA, DeepalakshmiA, KumarapanSK. Evaluation of pH and calcium ion release of mineral trioxide aggregate and new root-end filling material. E J Dent 2012;2:166-169. Aggarwal V, Singla M, MiglaniS, Kohli S. Comparative evaluation of push-out bond strengthofProRoot MTA, Biodentine, and MTA Plus in furcation perforation repair. J Conserv Dent 2013;16:462 -465. Formosa LM, MalliaB, CamilleriJ. A quantitative method for determining the antiwash out characteristics of cement-based dental materials including mineral trioxide aggregate. Int Endod J 2013;46:179-186.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareEffectiveness of Structured Restorative Rehabilitation on Sleep Quality and Pain in Elderly Suffering with Osteoarthritis of Knee English6266S. AnandhEnglish Smita PatilEnglish G. VaradharajuluEnglish Mahendra M. AlateEnglish Dhirajkumar A. ManeEnglishIntroduction: Disturbance and pain is a tale of two common problems in the elderly. In the long-term, it leads to the debility and worsening of chronic health problems. Pain joins two related concerns stress and poor health as key correlates of shorter sleep durations and worse sleep quality. But there are restorative paths to resolve the problem. Objective: The study aims to compare the effectiveness of a structured restorative rehabilitation exercise program with conventional exercises on elderly suffering with chronic knee pain and sleep disturbance using the outcome scores of the KOOS score (Knee Injury and Osteoarthritis Outcome Score) and SQQ (Sleep Quality Questionnaire). Methods: The data has been collected from 96 elderly residents of Satara district suffering from chronic knee pain independent in ambulation. Inclusion criteria: Elderly aged above 60 years suffering from chronic knee pain more than six months duration and willing to take part in the study. Exclusion criteria: Institutionalized elderly, uncooperative patients, and mentally or physically disabled elderly. Outcome measures: KOOS pain score questionnaire measuring knee pain and function & Sleep quality questionnaire. Results: Group A (Structured Restorative Rehabilitation) has shown extremely significant improvement than Group B (Conventional Rehabilitation) with relation to KOOS score (Knee Injury and Osteoarthritis Outcome Score) and SQQ (Sleep Quality Questionnaire). Conclusion: Sleep and pain have a bidirectional and reciprocal relationship. Sleep impairments reliably predict new incidents and exacerbation of chronic type of pain. Deprivation of sleep which is happening as a result of aching is going to have an impact on life quality. It becomes pertinent in such case to understand the extent of relationships that exist if it exists between disorder relating to sleeping and the pain or aching. EnglishKnee Pain, Sleep quality, Restorative exercises, Reablement exercises, Reactive balance, Cognitive behavioural therapy, Fatigue fighting exercisesINTRODUCTION The deepest sleep resembles death and there are many references for it from the bible & Talmud. A sedentary lifestyle leads to an endemic of lifestyle disorders.1-4 A right restorative rehabilitation program consists of a series of therapeutic exercises to promote elderly towards a healthy and active lifestyle post health disorders or any form of trauma. The program should be fine-tuned to meet the needs of the person receiving the care and keep up the skills necessary to enjoy as much independence as possible. A successful program restores wellness and optimal functional levels promoting encouragement in even simple walking, providing necessary support to help maintain independence, happiness, and dignity of the elderly. It’s necessary to overlook specific causes of fatigue and sleep disturbance in the elderly. The majority of the symptoms, including depression, mood swings and anger are the response of fatigue. Further, physiological decline like anaemia, dehydration, hyperkalemia, thyroid as well as mental & emotional stresses lead to co-morbidity. Fatigue is a major side effect and it can be incredibly tiring in chronic pain. Non-pharmacological holistic approaches that can prove effective are to be practised. The study is based on the supportive mechanisms that have resulted in a guided exercise pattern and a cognitive-based approach aiming to restore sleep quality. Also, the research works on the restorative exercise pattern as a treatment for chronic knee pain and restless leg syndrome among the elderly. We aimed to assess the Pretest and post-test measures of pain and sleep quality of elderly undergoing structured restorative rehabilitation exercises using KOOS score (Knee Injury and Osteoarthritis Outcome Score) and SQQ (Sleep Quality Questionnaire).Then we assessed the pretest and posttest measures of pain and sleep quality of elderly undergoing conventional exercises using KOOS scores and SQQ and compared the effectiveness of structured restorative rehabilitation exercises and conventional exercises with the outcome scores of KOOS and SQQ. Restorative exercises is a form of exercise that focuses on easing pain and restoring joint function through simple movements. Reablement exercises is a planned exercise therapy approach that aims to restore joint function and establish daily living skills to get back on their feet. Cognitive behavioral therapy is mindful walking simply means being aware of each step and our breath to restore a sense of focus. Fatigue fighting exercises: Incorporating simple exercise therapy approaches into the daily routine to beat tiredness and worn out the situation. Modified mobility training: A scientific approach creating purposeful movement patterns to develop a lifelong movement practice. In this study, effectiveness refers to determining the extent to which the structured restorative rehabilitation has achieved the desired effect by reporting the reduction of pain and improvement in sleep quality. MATERIALS AND METHODS The data has been collected from 96 elderly residents of Satara district suffering from chronic knee pain independent in ambulation. It has further been tabulated to do the T-test.  Inclusion criteria: Elderly aged above 60 years suffering from chronic knee pain more than six months duration and willing to participate in the study. Exclusion criteria: Institutionalized elderly, uncooperative patients, and mentally or physically disabled elderly. Outcome measures: KOOS pain score questionnaire measuring knee pain and function5 & Sleep quality questionnaire 6. The study was carried out in Krishna Institute of Medical Sciences, Karad, (KIMS/IEC-043/2011). The specific designed Knee Injury and Osteoarthritis Outcome Score (KOOS) questionnaire is meant for assessment of short as well as long term results. There are five things that we check here namely a) symptoms, b) sport along with recreation function c) pain d) daily living activities e) knee-related life quality. Structured restorative rehabilitation The structured restorative rehabilitation approach has been framed acknowledging the barriers to regular rehabilitation and physical activity adherence as a pathway to change compulsion & boredom in promoting exercise participation among the elderly. Ref: Institute on Aging (IOA) Direct links and assistance regarding concerns about the needs of older adults and adults with disabilities as well as community services. 1. Restorative exercises: Active functional training program in the form of modified exercises promoting self-care with safety, activities of daily living & instrumental activities of daily living functions is recommended for the elderly struggling with fatigue. 2. Reablement exercises: Restorative active exercises which help improve osteo-kinematics of knee joint helps in decreasing pain and Reactive balance training. 3. Cognitive Behavioral Therapy: Cognitive behavioural therapy deviating attention processes and working towards improving functional activities is an ideal therapeutic remedy. Eg. Mindfulness practices, talking while walking. 4. Fatigue fighting exercises: Regular exercises in the form of chair aerobics, low-intensity gentle body movements promoting combined body movements helps to treat fatigue and enhance sleep quality. RESULT The statistical analysis done shows that the post-treatment scores improved in both the groups which were statistically extremely significant when the within-group analysis was done. The between-group analysis showed that pretreatment score there was no significant difference. The post-treatment analysis showed that there was an extremely significant improvement in Group A (experimental group) as compared to Group B (pEnglishhttp://ijcrr.com/abstract.php?article_id=3311http://ijcrr.com/article_html.php?did=3311 Granata C, Jamnick NA, Bishop DJ. Principles of exercise prescription, and how they influence exercise-induced changes of transcription factors and other regulators of mitochondrial biogenesis. Sports Med 2018;48(7):1541-1559. González K, Fuentes J, Márquez JL. Physical inactivity, sedentary behaviour and chronic diseases. Korean J Fam Med 2017;38(3):111. Park J, McCaffrey R, Dunn D, Goodman R. Managing osteoarthritis: comparisons of chair yoga, Reiki, and education (pilot study). Holistic Nurs Pract 2011;25(6):316-326. Wang X, Youngstedt SD. Sleep quality improved following a single session of moderate-intensity aerobic exercise in older women: Results from a pilot study. J Sport Health Sci 2014;3(4):338-342. Collins NJ, Prinsen CA, Christensen R, Bartels EM, Terwee CB, Roos EM. Knee Injury and Osteoarthritis Outcome Score (KOOS): systematic review and meta-analysis of measurement properties. Osteoarthr Cartil 2016;24(8):1317-1329. Girschik J, Heyworth J, Fritschi L. Reliability of a sleep quality questionnaire for use in epidemiologic studies. J Epidem 2012:1 22(3): 244–250. Zhang Y, Cifuentes M, Gao X, Amaral G, Tucker KL. Age-and gender-specific associations between insomnia and falls in Boston Puerto Rican adults. Qual Life Res 2017;26(1):25-34. Tel H. Sleep quality and quality of life among the elderly people. Neurol Psych Brain Res 2013;19(1):48-52. Eyigor S, Eyigor C, Uslu R. Assessment of pain, fatigue, sleep and quality of life (QoL) in elderly hospitalized cancer patients. Arch Gerontol Geriat 2010;51(3):e57-61. Rashid A, Ong EK, Wong ES. Sleep quality among residents of an old folk’s home in Malaysia. Iranian J Nur Midwifery Res 2012;17(7):512. Stoica C. Sleep, a predictor of subjective well-being. Procedia-Soc Behav Sci 2015;187:443-7. Rodriguez JC, Dzierzewski JM, Alessi CA. Sleep problems in the elderly. Med Clin 2015;99(2):431-439. Cole CS, Richards KC, Beck CC, Roberson PK, Lambert C, Furnish A, et al. Relationships among disordered sleep and cognitive and functional status in nursing home residents. Res Geront Nur 2009 Jul 1;2(3):183-191. Wu CY, Su TP, Fang CL, Chang MY. Sleep quality among community-dwelling elderly people and their demographic, mental, and physical correlates. J Chinese Med Asso 2012;75(2):75-80. Agmon M, Shochat T, Kizony R. Sleep quality is associated with walking under dual-task, but not single-task performance. Gait Posture 2016;49:127-131. Muir-Hunter SW, Wittwer JE. Dual-task testing to predict falls in community-dwelling older adults: a systematic review. Physiotherapy 2016;102(1):29-40. Sambandam CE, Alagesan J, Shah S. Immediate Effect of Muscle Energy Technique and Eccentric Training on Hamstring Tightness of Healthy Female Volunteers-A Comparative Study. Int J Curr Res Rev 2011;3(09):122-126.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareA Comparative Clinical Evaluation of Access Cavity Preparation Using Dental Operating Microscope and Conventional Preparation for Conservation of Tooth Structure English6770Manoj ChandakEnglish Pradnya NikhadeEnglish P. SindhuEnglish Anuja IkharEnglish Rakhi ChandakEnglish Abhilasha DassEnglish Nidhi MotwaniEnglishBackground: The outcome of endodontic therapy is associated with eradication of micro-organisms from the root canal system and avoidance of re-infection. Optical magnifications have extended the horizons of dental treatment. Recently, illumination and magnification have established to help provide precise anatomic details. The canal orifices can effortlessly be identified under a microscope than with surgical loupes or the naked eye. Objective: The comparison of the conservation of tooth structure during access cavity preparation under the microscope with the conventional method. Methods: Thirty patients were selected for whom root canal treatment where indicated. The patients were divided into two groups Group 1 – Access cavity prepared conventionally and Group 2 – Access cavity preparation under the microscope. The measurement between intercanal orifice was done using Vernier callipers. Results: In the present study, there was a reduction in measurement between mesiobuccal to the distal orifice and mesiobuccal to mesiolingual orifice but it was not statistically significant. There was a reduction in measurement from mesiolingual to distal orifice. The reduction was statistically significant (p=0.018) Less amount of tooth structure is removed therefore allowing for conservation of tooth structure resulting in improved strength tooth strength, which is clinically important. Conclusion: The conservative endodontic cavity (CEC) preparation to reduce the loss of tooth and preservation some of the roofs of the pulp chamber and peri-cervical dentin was reported in the literature. English Conservative endodontic cavity, Pre-operative radiograph, Distal canal orificeINTRODUCTION The mandibular first molar poses many anatomic challenges and most frequently endodontically treated tooth, but it also. The access cavity has an external outline form evolving from internal pulpal anatomy of the tooth. First mandibular molar generally has 2 roots and 3 root canals. However, due to genetic, ethnic and gender varieties, a wider range of anatomical, as well as morphological deviations, can be encountered. The difficulty lies in the location of the number and position of orifices on pulp chamber floors.1 This is particularly correct when the tooth is excessively restored, calcified or malpositioned. The commonly used method to evaluate the morphology of root canal involves staining of the root canal and tooth clearing, plastic injection, conventional and digital radiography and radiopaque gel infusion and radiography.2 The clinician should be clear and thorough about root canal morphology of tooth being treated since it can affect the treatment outcome3 The outcome of endodontic therapy is associated with eradication of micro-organisms from root canal system and avoidance of re-infection.4 Optical magnifications have extended the horizons of dental treatment. Recently, illumination and magnification have established to help provide precise anatomic details. The canal orifices can effortlessly be identified under a microscope than with surgical loupes or the naked eye.5 Based on lens system microscope can be classified into the simple or compound microscope. The lens system varies from double to 2 plano-convex. Based on magnification, the microscope can work under low, mid-range and high magnification. The microscope has higher magnification in the range of X2.5 to X30 with better illumination using fibre optic technology. The reflecting microscope wherein an opaque substance requires light that reflects from the object to the lenses in an optic tube.6 One of the uses of magnification in endodontics is the conservation of access opening.7 So the purpose of the present study was the comparison of the conservation of tooth structure during access cavity preparation under the microscope with the conventional method. The research question was does magnification using Dental operating microscope aid in the conservation of tooth during access cavity preparation in endodontic treatment as compared to the conventional method.8,9 In the present study, we aimed to assess the conservation of tooth structure using the conventional method in root canal treatment. Further, we assessed the conservation of tooth structure using a dental operating microscope in root canal treatment and compared the conservation of tooth structure using the conventional technique with dental operating microscope in root canal treatment. MATERIALS & METHODS The study was performed at Department of Conservative Dentistry and Endodontics Sharad Pawar Dental College & Hospital, Sawangi, Wardha after getting approved by ethical committee (IEC reference no. DMIMS(DU)/IEC/Dec-2019/8616). Selection of data Thirty patients were selected for whom root canal treatment where indicated. Patients were explained about the procedure in detail and informed consents were obtained. Mandibular 1st molars were selected for the study. Inclusion Criteria Teeth with caries involving enamel, dentin and pulp requiring root canal treatment. Teeth with completely developed roots. Exclusion criteria   Teeth with evident periapical pathology, tooth mobility, root resorption. Patients with medical conditions, Pregnant, lactating women. Informed written consents were obtained from each patient before treatment. Procedure Radographs A pre-operative radiograph (IOPA) was taken from different angulation to study the dimensions of the pulp chamber, number of canals and length of the root. This helps in the correct approach of access cavity preparation. 10 Access opening Patch test was performed to check for allergy for a local anaesthetic solution. After proper palpation of anatomical landmarks, Local anaesthetic was administered into the retromolar area to block the Inferior Alveolar nerve. Mandibular first molar was isolated with a rubber dam. The patients were divided into two groups ( Table 1) For Group 1 Conventional cavity preparation was done using #4 carbide or round diamond no 4 or #557 tapered fissure bur was used. The bur was advanced through the central fossa until a drop was felt. The drop indicates that the pulp chamber is explored. Safely ended bur was used to restrict the depth to avoid cutting of floor of the tooth. All canals orifices were located with DG16 explorer and enlarged with G.G drill. Measurement – Measurement between intercanal orifice was done using Vernier callipers and listed in the table. For Group 2 Standardized access cavity preparation was done under an operating microscope with 12 X magnification. The measurement between intercanal orifice was done using Vernier callipers and listed in the table Statistical Analysis The data was collected and analyzed using by comparing the mean and by Wilcoxon sign-rank test. RESULTS The strength of the tooth is directly proportional to the amount of removal of dentin. More the removal of dentin more will be the tooth structure loss and this causes weakening of the tooth. The destruction was evaluated by measuring the distance between the orifices using Vernier callipers.   Graph represent mean of distance between mesiobuccal to distal canal orifice(mbd): mesiolingual to distal canal orifice (mld) and mesiobuccal and mesiolungual canal orifice (mbml)  in access cavity prepared under microscope and conventional preparation DISCUSSION The scientific-technical advance in endodontics in the last years has been increasing the incidence of success of the treatment of root canals. The absence of spontaneous and provoked painful symptomatology, hermetic sealing, and dental element rehabilitated in masticatory function, and the healing of the apical and periapical tissue are clinical criteria of success in endodontic therapy.11 An endodontically treated teeth, one of the failures is the fracture of the tooth. The conservative access cavity preparation was anticipated to diminish fracture possibility of endodontically treated teeth.12 Since the 2000s in clinical practice, dental operating microscopes have been utilized as the best reliable aid. The microscopes aid in recognizing then dentinal coverage present over the orifice. Further, this dentinal coverage could be removed accurately with an ultrasonic instrument which would help in recognization of canal orifice.5 Further the microscope also helps to analyze the dentinal wall for the carious lesion.13 As stated by Dr. Carr “You cannot treat what you cannot see”. The conservative endodontic cavity (CEC) preparation to reduce the loss of tooth and preservation some of the roofs of the pulp chamber and peri-cervical dentin was reported in the literature. 14 Therefore, the removal of dentin was evaluated by measuring the distance between the orifices using vernier callipers. In the present study, there was a reduction in measurement between mesiobuccal to the distal orifice and mesiobuccal to mesiolingual orifice but it was not statistically significant. There was a reduction in measurement from mesiolingual to distal orifice. The reduction was statistically significant (p=0.018) Less amount of tooth structure is removed therefore allowing for conservation of tooth structure resulting in improved strength tooth strength, which is clinically important.15 Paul Krasner and Henry Rankow in 2004 stated that microscope enhances the capability of the location of the canal orifices/ number on pulpal floor. If there is the presence of anatomical landmarks, then the task of locating orifices will be more systematic and, consequently, with superior certainty. The law of change in colour aids in location canal orifice. However, the difference in colour between the floor and walls of the pulp chamber is stressful to differentiate with the unaided eye. Also, the walls of the pulp cavity were constantly concentric to the external surface of the tooth at the level of the CEJ, Also at the level of the CEJ, the distance from the external surface of the tooth to the wall of the pulpal chamber was equal all through the circumference.16 Magnification with illumination provided with the microscope is helpful to prevent the stress on the human eye. The microscope helps in the determination of the dentinal map that is of key importance in locating the canal. Carr et al reported that using the DOM clinically, their ability to identify MB2 canals in maxillary 1st  molars increased by 20%.17 According to Carr et al, the frequency of detection of the MB2 canal was 17% without magnification and was increased to 63% using loupes and 71% using the DOM. According to Enrique Merino, the microscope increases the ability of the dentist to locate and negotiate the hidden canal.18 The use of the microscope increases the predictability of the treatment. Ultimately this increases the success rate of the endodontic treatment. Mittal et al concluded that the number of orifices detected increased with  increasing  magnification.18 CONCLUSION The art of dentistry is based on precision. The unaided eye can only see up to canal orifice, Microscope function as 3rd eye for Endodontist. This study showed that access cavity prepared under dental operating microscope conserved more tooth structure as compared to the conventional technique. A statistically significant difference was noted with mesio lingual orifice to distal orifice in conventional access cavity preparation as compared to the dental operating microscope when the inter-orifice distance was measured. We can recommend that the access cavity preparation should be performed under magnification with the help of a dental operating microscope to retain the strength of dentin and prevent tooth fracture that will help in the long period success of the procedure. 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=3312http://ijcrr.com/article_html.php?did=3312 Karunakaran JV, Samuel LS, Rishal Y, Joseph MD, Suresh KR, Varghese ST. Root canal configuration of human permanent mandibular first molars of an Indo-Dravidian population-based in Southern India: An in vitro study. J Pharm Alli Sci 2017 Nov;9(1): S68. khlaghi NM, Khalilak Z, Vatanpour M, Mohammadi S, Pirmoradi S, Fazlyab M, Safavi K. Root canal anatomy and morphology of mandibular first molars in a selected Iranian population: an in vitro study. Iranian Endod J 2017;12(1):87. Nixdorf DR, Moana-Filho EJ, Law AS, McGuire LA, Hodges JS, John MT.  Frequency of persistent tooth pain after root canal therapy: a systematic review and meta-analysis. J Endod 2010 Feb; 36(2):224-230. Fabra-Campos H. Three canals in the mesial root of mandibular first permanent molars: a clinical study. Int Endod J 1989 Jan; 22(1):39-43. Gogiya RJ, Chandak MG, Modi RR, Bhutda P, Kela S, Chandak RM. Magnification in dentistry: A review. Int J Appl Dent Sci 2018;4(2):89-93. Pecora G, Andreana S. Use of the dental operating microscope in endodontic surgery. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1993;75:751-758. Low JF, Dom TN, Baharin SA. Magnification in endodontics: A review of its application and acceptance among dental practitioners. Eur J Dentistry 2018 Oct;12(04):610-616.  Reeh ES, Messer HH,  Douglas WH. Reduction in tooth stiffness as a result of endodontic and restorative procedures. J Endod 1989;15(11):512-516.  Ayse DK, Bulem UK, Erhan S. Determination of canal ori?ce co-ordinates and MB2 incidence of maxillary ?rst molars in a Turkish subpopulation. Odontologica Scandinavica. 2014; 72: 354-361. Corsentino G, Pedullà E, Castelli L, Liguori M, Spicciarelli V, Martignoni M, Grandini S. Influence of Access Cavity Preparation and Remaining Tooth Substance on Fracture Strength of Endodontically Treated Teeth. J Endodontics 2018;3(6):543-547.  Osman IA, Ahmed H. The Effect of Access Cavity Design on Fracture Resistance of Endodontically Treated First Molars: In Vitro Study. Dove Press 2017; 5(9):443-451. Özyürek T, Ülker Ö, Demiryürek EÖ, Yilmaz F. The Effects of Endodontic Access Cavity Preparation Design on the Fracture Strength of Endodontically Treated Teeth: Traditional Versus Conservative Preparation. J Endod 2018;44(5):800-805.  Rathi NV, Chandak MG, Mude GA. Comparative Evaluation of Dentinal Caries in Restored Cavity Prepared By Galvanic and Sintered Burs. Contemp Clin Denst 2018;9(1):S23-27. Saygili G, Uysal B, Omar B. Evaluation of the relationship between endodontic access cavity types and secondary mesiobuccal canal detection. BMC Oral Health 2018;18:121. Mukherjee P, Patel A, Chandak M, Kashikar R. Minimally Invasive Endodontics a Promising Future Concept: A Review Article. Int J Sci Study 2017;5(1):245-251. Krasner P. Rankow HJ. Anatomy of Pulp Chamber Floor. J Endod 2004;30(1): 5-16. Carr G.B, Murgel C. The use of the operating microscope in Endodontics. J Dental Clin 2010; 54(2;191-214. Endodontic Microsurgery, Ouintessence Company Ltd 2009.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcarePrognosis and Early Diagnosis of Preeclampsia Based on Clinic?-Genetic and Endothelial Predictors English7175Makhmudova Sevara ErkinovnaEnglish Agababyan Larisa RubenovnaEnglishIntroduction: Preeclampsia (PE) is a disease that continues to be the main cause of maternal and fetal mortality and complications in 5-8% of pregnancies characterized by hypertension and proteinuria and is one of the leading causes of maternal and perinatal mortality. Our group recently demonstrated that PIGF genetic polymorphisms affect the susceptibility to preeclampsia (PE). Objective: To improve the prognosis and early diagnosis of preeclampsia based on clinical-genetic and endothelial predictors for rational management of patients with preeclampsia, reducing maternal and perinatal mortality. Methods: We examined 160 pregnant women aged 18 to 40 years with a physiological course of pregnancy observed in the 2,3 –maternity complexes of Samarkand (11-40 weeks). The concentration of PIGF and sFlt-1 in the blood serum of pregnant women was determined. Total genomic DNA was isolated, single-nucleoid polymorphisms were detected by real-time polymerase chain. Results: In patients with preeclampsia, the concentration of PIGF, sFlt-1, and their ratio values significantly differed from those in patients with the physiological course of pregnancy, and the dependence of the detected changes on the severity of preeclampsia was also observed. Conclusion: Concentrations of PIGF, sFlt-1 and their ratio values are highly informative indicators of preeclampsia. Their ratio should be carried out in the first and second trimesters of pregnancy as part of screening programs. The determination of preeclampsia markers at the end of the second and third trimester of pregnancy can serve as a basis for the final diagnosis of preeclampsia and the development of tactics for prolonging pregnancy EnglishPreeclampsia, Placental growth factor, Pregnancy, Proteinuria, Prognosis, Clinic?-genetic predictors, PolymorphismIntroduction Preeclampsia is one of the most serious complications in obstetrics, which determines high rates of maternal morbidity and mortality.1 This pathology continues to be a dangerous complication of pregnancy and for the fetus, leading to delayed intrauterine development, premature birth, low birth weight, and perinatal mortality.2 There are many hypotheses for the occurrence of this pregnancy complication, among which the most relevant is the theory that considers preeclampsia as a multifactorial disease, where many genetic and environmental factors are involved in its development.3 The ability to identify risk factors before pregnancy will allow timely assess the likelihood of developing preeclampsia and prescribe preventive treatment.4 To date, it has been established that more than 100 polymorphic variants of genes are associated with preeclampsia, in particular, genes of metabolism, the main complex of histocompatibility, lipid metabolism, cytokines and growth factors, hemostasis, regulation of endothelial function, vascular system, etc.5,6 However, differences in methodology for determining the severity of preeclampsia, the ethnicity of the surveyed, and the combination of analyzed allelic variants in different samples determine the ambiguity of the results obtained by different authors.7 This dictates the necessity for in-depth research to identify the risk group, develop prognostic criteria, and conduct therapeutic and preventive measures to reduce perinatal losses and improve the maternal and child health.8 It was found out that the development of PE is based on a violation of placentation due to the defect in the remodelling of myometrial vessels, which leads to incomplete invasion of trophoblast in the early stages of pregnancy.9 In the future, the damaged ischemic placenta begins to secrete an excessive amount of a powerful antiangiogenic factor - a soluble receptor for vasculo endothelial growth factor (VEGF), identified as soluble fms-like tyrosine kinase 1 (sFlt-1).10 This factor inhibits both VEGF and placental growth factor (PIGF), which ensure normal placental development and function.11 Circulating in the mother&#39;s bloodstream, sFlt-1 can contribute to the development of systemic endothelial dysfunction, which is the basis of all clinical manifestations of PE.4,5 There is reason to believe that the severity of clinical manifestations of PE is due to the period of pregnancy when it first started: the earlier PE debuts, the more severe.12 Materials and methods We examined 160 pregnant women aged 18 to 40 years with a physiological course of pregnancy observed in the 2,3 –maternity complexes of Samarkand (11-40 weeks). The main and control groups were comparable in age, social characteristics, and obstetric and gynaecological history. All women delivered healthy babies at a term of 38-40 weeks, with a rating on the Apgar scale of 8-9 scores, with normal weight and growth indicators. The postpartum period was uncomplicated for all of them. The exclusion criteria were multiple pregnancies, hypertension, and a history of preeclampsia. When assessing the reproductive function, it was found that the majority of women in both groups were primiparas (p≥0.05). Pelvic inflammatory processes were equally common (p=0.05). The group of patients with preeclampsia consisted of 82 pregnant women at 20-40 weeks, including 52 women with moderate preeclampsia and 30 with severe preeclampsia. The diagnosis of preeclampsia was established based on generally accepted criteria-hypertension (blood pressure ≥140/90 mmHg) and proteinuria (protein content above 0.3 g in daily urine). The severity of preeclampsia was assessed based on objective indicators and the patient&#39;s clinical condition. The group of patients with mild preeclampsia included pregnant women with a blood pressure of 140-160/90 mm Hg, with proteinuria of more than 0.3 g, but not less than 2 g/day. The group of patients with severe preeclampsia included pregnant women with a blood pressure of 160/110 mmHg or more, with proteinuria of more than 2 g/day. The concentration of PIGF and sFlt-1 in the blood serum of pregnant women was determined using Elecsys PIGF and Elecsys sFlt-1 electrochemiluminescent diagnostic test systems of the Hoffmann La Roche concern (Switzerland) on a Cobas e411 automatic analyzer of the same company. The spectrum of the studied polymorphisms is presented in Table 3. Total genomic DNA was isolated from 100 µl of whole venous blood by the sorbent method using the set "Proba-GS Genetics", NP-480-100 (AGTR1_1166 rs5186), NP-476-100 (AGTR2 G1675A rs1403543); for endothelial nitric oxide synthetase, 3 sets were used: NP-554-100 (eNOS_786 rs 2070744), NP-555-100 (eNOS_774 rs 1549758), NP-419-100 (eNOS_298 1799983); single-nucleoid polymorphisms were detected by real-time polymerase chain reaction using the above sets (DNA technology, Russia). To obtain the serum, the samples were centrifuged for 15 min at 2000 rates and room temperature. The concentration of markers was determined on the same day, no later than 1.5 hours after blood collection. The concentration of PIGF and sFlt-1 in the blood serum of pregnant women was determined using Elecsys PIGF diagnostic test systems (Ref. no. 05144671190, Roche Diagnostics GmbH, Mannheim, Germany) and Elecsys sFlt-1 (Ref.no. 05109523190, Roche Diagnostics GmbH, Mannheim, Germany) on an automatic Cobas e411 electrochemiluminescence analyzer (Hitachi, Japan). The results were processed using the computer program Statistica®. Results The data obtained indicate that during the physiological course of pregnancy, the concentration of PIGF increases during 11-33 weeks of pregnancy and decreases sharply by the time of delivery. The concentration of sFlt-1 in healthy pregnant women begins to increase significantly from the 34th week of pregnancy and reaches its maximum values at 37-40 weeks of pregnancy, which is probably due to the necessity to reconstruct blood vessels to prevent massive bleeding during childbirth. The sFlt-1/PIGF ratio has maximum values in the period of 11-14 and 37-40 weeks of pregnancy, while the minimum values are observed in 24-33 weeks of gestation (Table 1). The obtained results allow us to form reference intervals of PIGF and sFlt-1 concentrations and their ratio values in the dynamics of physiological pregnancy from the 11th to the 40th week. Table 1 shows the medians and reference intervals as the 5th and 95th percentiles. It should be noted that these intervals were developed using the Elecsys PIGF and Elecsys sFlt-1 diagnostic test systems (Hoffmann-La Roche, Switzerland) and the Core diagnostic platform (Hitachi, Japan). In patients with preeclampsia, the concentration of PIGF, sFlt-1, and their ratio values significantly differed from those in patients with the physiological course of pregnancy, and the dependence of the detected changes on the severity of preeclampsia was also observed (Table 2). It was interesting to study indicators in the group of pregnant women with arterial hypertension (n=14) at 37-40 weeks of pregnancy (Table 2). Analysis of Table 2 shows that the concentration of both factors in patients with PE is about 2 times lower than in healthy pregnant women, while the ratio value is within the obtained reference interval. It was observed that in women with preeclampsia, the frequency of low-functional variants in the genes associated with the development of arterial hypertension (type 1 and 2 receptor genes for angiotensin II and nitric oxide synthase) was statistically significantly higher than in women with a physiological course of pregnancy (Table 3 and Table 4). It is known that the hormone angiotensin II causes vasoconstriction and is the main regulator of aldosterone synthesis. The result of this action is an increase in the volume of circulating blood and an increase in systemic blood pressure. Angiotensin II interacts with two types 1 and 2 angiotensin cell receptors encoded by AGTR1 and AGTR2 genes, respectively. Replacement of adenine (A) with cytosine (C) at position 1166 in the regulatory region of the AGTR1 gene leads to an increase in its expression. The amplification mechanism is caused by the following actions. During the synthesis of the receptor protein with non-coding regions of mRNA, translated from the AGTR1 1166A allele according to the complementarity principle, interact with microRNA miR155, and the translation process is inhibited, which leads to a decrease in protein synthesis. MicroRNAs cannot bind to the AGTR1 1166C polymorphic allele, which increases the synthesis of protein products and changes the functional activity of the receptors.10 The cardiovascular effects of angiotensin II-mediated by AT2 receptors are opposite to those caused by AT1 receptors, which means that the interaction of angiotensin II with type 2 receptors causes a decrease in blood pressure. An increase in the number of angiotensin II type 2 receptors on the cell surface is determined by AGTR2 1675G allele, since it is associated with activation of gene transcription. The nucleotide replacement of G1675A in the regulatory region of the gene negatively changes the nature of the regulation of gene expression. As a result, carriers of this low-functional polymorphism have a decrease in the number of type 2 receptors and a partial loss of their function (participation in NO production, vascular dilatation), which contributes to an increased risk of hypertension. This study revealed the higher frequency of homozygous carriage of this low-functional polymorphism in women with preeclampsia compared to women with a physiological course of pregnancy. Paying attention to the fact that the AGTR2 gene is localized in the X chromosome, the phenotypic manifestation of the heterozygous carrier of the 1675A allele can be smoothed due to the phenomenon of allelic exclusion during the process of inactivation in one of the sex chromosomes. In homozygotes, the phenotypic effect is not graded by this phenomenon, which probably determines the high frequency of the AGTR2 1675A/A genotype in the group of women with a complicated pregnancy. Endothelial dysfunction is of great importance in the pathogenesis of preeclampsia, it is manifested by an increase in the "sensitivity" of the vascular wall to the pressor effects of mediators with a simultaneous decrease in the production of vasodilators, such as nitric oxide (NO) 9. Nitric oxide is the main endothelial relaxation factor involved in maintaining vascular wall tone and thrombogenesis. Constitutional endothelial NO synthase type 3 (NOS3, synonym ?NOS) is involved in the synthesis of NO in the endothelium and, consequently, in the regulation of vascular tone, blood flow, and blood pressure.8 Currently, 3 allelic variants of endothelial NO synthetase (NOS3) gene is most actively studied: 4a/4b in intron 5, structural replacement 894G>T in exon 7, and polymorphism of the promoter region of gene – 786T>C. These polymorphisms are low-functional, which means that if they are present in the genotype, the expression of the NOS3 gene decreases. Reduced production of endothelial NO synthetase causes a decrease in the concentration of nitric oxide in the bloodstream, resulting in reduced vasodilation, which may be an important mechanism for the development of arterial hypertension. There is data in the literature about the association of low-functional variants of the endothelial NO-synthetase gene with various obstetric pathologies based on changes in vascular tone (PE, placental insufficiency, fetal growth restriction syndrome) 3,6. According to the results of this study, women with preeclampsia have an increased frequency of allele-786C in the NOS3 gene (Table 4). Discussion Analysis of the obtained data indicates significant differences in the dynamics of PIGF and sFlt-1 concentrations and their ratio during physiological pregnancy and pregnancy complicated by preeclampsia. The most pronounced changes are in the values of the sFlt-1/PIGF ratio, besides, the degree of deviation of the listed parameters correlates with the severity of preeclampsia. This indicator is the most informative in the early diagnosis of preeclampsia. The results obtained are fully consistent with the published data that the development of preeclampsia is closely associated with an imbalance in the synthesis of angiogenic and antiangiogenic factors.5,7,9 It is known that the process of placenta formation begins with the implantation of cells of fetal origin (cytotrophoblast) into decidual tissue (modified endometrial layer of the pregnant uterus). The cytotrophoblast is not only embedded into the endometrium layer (interstitial invasion) and spiral arteries (endovascular invasion) but also reaches the inner third of the endometrium. As a result, at the end of the first trimester, several dozen wide, gaping arteries are formed in the uteroplacental region and the uteroplacental blood flow begins to function actively. Before its formation, the function of a powerful stimulus of the first wave of cytotrophoblastic invasion (CTI) is carried out by local tissue hypoxia, which is characteristic of the embryo microenvironment up to 8-10 weeks of development. Hypoxic stimulus increases the expression of specific cell adhesion molecules, stimulates the synthesis of cytokines and vascular growth factors.1 The presence of polymorphisms of genes that regulate vascular tone (renin-angiotensin system and endothelial nitric oxide synthetase) that predispose to hypertension complications significantly increases the risk of preeclampsia developing. The associations identified in this study can be used as genetic markers of predisposition to the formation of preeclampsia, which will allow the timely formation of a risk group and correction of therapeutic and preventive measures (Figure 1). Figure 1. The ratio of sFlt/PIGF in normal pregnancies, moderate (MPE), and severe preeclampsia (SPE). The next stage of cytotrophoblast invasion (CTI) deep into the myometrium (the second wave of invasion) occurs at the 16th-18th week of pregnancy. ?ytotrophoblast transforms the larger arteries of the lower third of the myometrium, turning them into wide cavities. As a result, the volume of maternal blood entering the placenta increases.1,5,6 The separation of two waves of CTI is conditional since it is an ongoing process, which in its significance is a key mechanism for the development of normal pregnancy or the occurrence of preeclampsia. The statement that preeclampsia begins at the 20th week of pregnancy corresponds only to the time of occurrence of well-known symptoms, while the initial mechanisms are laid and implemented much earlier in the form of defects in the luteal phase of the cycle, violations of implantation and placentation, as well as background diseases of the mother.4,7 These and other factors are the cause of CTI insufficiency.3 Endothelial dysfunction plays a central role in the pathogenesis of preeclampsia. Increased synthesis of vasoactive mediators leads to a predominance of vasoconstriction and, as a result, insufficient blood circulation in the placental vessels.8,9 Before the appearance of clinical symptoms, the uteroplacental blood flow usually decreases and the resistance of the uterine vessels increases, placental ischemia develops.7 Apparently, in patients predisposed to the development of preeclampsia, a decrease in the concentration of PIGF and an increase in the concentration of sFlt-1 indicate abnormal placental development. The reasons for a patient’s predisposition to the development of preeclampsia are still not fully established, but it is noted that one of the possible causes is a genetic factor. It has been shown that the development of preeclampsia in the mother increases the risk of this pathology in her daughter.10,12 It is also believed that the aetiology and pathogenesis of preeclampsia are due to the presence of immunopathological mechanisms and several environmental factors. Prevention and treatment of preeclampsia is quite a complex task. In this regard, early diagnosis of preeclampsia before its clinical manifestations is one of the tasks in obstetrics, the solution of which will allow assessing the risk and feasibility of preserving the pregnancy.4,9 The availability of reference intervals of PIGF, sFlt-1 concentrations and their ratio is currently the most informative for the diagnosis of preeclampsia, which allows evaluation of peculiarities of these molecules secretion since the end of the first trimester of pregnancy. Previously, it was shown that already in the first trimester of pregnancy it is possible to diagnose an imbalance in the synthesis of PIGF and sFlt-1, as a result of which the ratio of these indicators increases.10 An increase in sFlt-1 concentration seems to disrupt the intracellular mechanism of PIGF synthesis regulation, which consequently leads to the development of systemic endothelial insufficiency and the progression of clinical signs of preeclampsia (hypertension and proteinuria), as well as to a delay in fetal development.3,9,11 Conclusion Based on the performed study, it was found that concentrations of PIGF, sFlt-1, and their ratio values are highly informative indicators of preeclampsia, and the reference intervals of PIGF, sFlt-1 concentrations, and their ratio values can be used as "standards". Besides, the determination of the concentration of these markers and the calculation of their ratio should be carried out in the first and second trimesters of pregnancy as part of screening programs for the diagnosis of intrauterine fetal pathology. The determination of preeclampsia markers at the end of the second and third trimester of pregnancy can serve as a basis for the final diagnosis of preeclampsia and the development of tactics for prolonging pregnancy. Conflict of Interest: None Declared Acknowledgement: None acknowledged Funding Information: None Agency Acknowledged Englishhttp://ijcrr.com/abstract.php?article_id=3313http://ijcrr.com/article_html.php?did=3313  Sukhoi GT, Murashko LEM.Preeclampsia. Guide. Library of a specialist doctor. Ed. GEOTAR-Media. 2010;576. Carty DM, Delles C, Dominiczak AF. Preeclampsia and future maternal health. J Hypertens 2010;28:1349–1355.  Foidart YM, Schaaps YP, Chantraine F. Dysregulation of anti-angiogenic agents (sFlt-1, PIGF and sendoglin) in preeclampsia- a step forward but not the definitive answer. J Reprod Immunol 2009;82:106-111. Hammerova L, Chabada J, Drobny J, Batorova A. Lonfi tudinal evaluation of markers of hemostasis in pregnancy. Bratisl Lek Listy 2014;115(3):140-144.  McElrath T, Lim K-H, Pare E, Rich-Edwards J. Longitudinal evaluation of predictive value for preeclampsia of circulating angiogenic factors through pregnancy. Am J Obst Ginecol. 2010;11:407e1-e7.  Verlohren S, Herraiz Y, Lapaire O. The sFlt-1/PIGF radio in different types of hypertensive pregnancy disorders and its prognostic potential in peeclamptic patients. Am J Obstet Gynecol 2012;1:58e1-e8. Lam C, Lim KH, Karumanchi SA. Circulating angiogenic factors in the pathogenesis and prediction of preeclampsia. Hypertens Res 2005;46:1077-1085. Maynard S, Min J, Merchan J, Lim K. Excess placental soluble fms-like tyrosine kinase-1 (sFlt-1) may contribute to endometrial dysfunction, hypertension and proteinuria in preeclampsia. J Clin Invest 2003;111:649-658. Roberts JM, Bell MJ. If we know so much about preeclampsia, why haven´t we cured the disease? J Reprod Immunol 2013; 99:1–9.  Shibata E, Rajakumar A, Roberts RW. Soluble fms-like tyrosine kinase 1 is increased in preeclampsia but not in normotensive pregnancies with small-for-gestational-age neonates: relationship to circulating placental growth factor. J Clin Endocrinol Metab 2005;90:4895-4903.  Wang A, Rana S, Karumanchi SA. Preeclampsia: the role of angiogenic factors in its pathogenesis. Physiology 2009;24:147-158.   Yelliffe-Pawlowsky L, Shaw G, Currier R. Association of early preterm birth with abnormal levels of routinely collected first and second-trimester biomarkers. Am J Obstet Gynecol 2013;208:128-140.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareMicrowave-Assisted Solvothermal Synthesis of Tungsten Oxide (WO3) Nanoparticles for Microbial Inhibition English7679Harini SEnglish Aswini AEnglish S.C. KaleEnglish Jayashri NarawaneEnglish Jayant PawarEnglish Snehal MasurkarEnglish Shilpa RuikarEnglishIntroduction: Tungsten oxide is an n-type semiconductor which possesses the bandgap of 2.6 – 2.8 eV at room temperature. Additionally, tungsten oxide has the absorption capacity of 480 nm in the visible region resulted from its photocatalytic property. Objective: To synthesize and evaluate tungsten oxide nanoparticles for microbial inhibition. Methods: Microwave-assisted synthesis of tungsten oxide nanoparticles was carried out by solvothermal route for the development of antibacterial agent. 1 M Sodium Tungstate Dihydrate was dissolved in 100 mL distilled water which was then mixed with 20 mL of 0.1 M NaOH and the Conc. HCL was added into the reaction mixture. The precipitation of yellow colour was collected and rinsed with purified water three times. During 8 hours at 60oC and 4 hours, the precipitate having undergone drying and calcination to get tungsten oxide powder. Results: The yellow colour precipitate was obtained after the reaction, which was characterized by UV- Vis Spectroscopy and Scanning Electron Microscopy (SEM). The λmax was found to be at 364 nm and bandgap calculated as 3.41 eV. Conclusion: Antibacterial efficacy was determined by anti-well diffusion assay against E. coli and Pseudomonas Aeruginosa. The bacterial cultures were found to be sensitive for WO3 NPs at a concentration of 1000 µg/mL. The E. coli was more sensitive for WO3 NPs compared to Pseudomonas Aeruginosa. EnglishMicrowave-assisted method, Solvothermal synthesis, Tungsten oxide, E. coli, Pseudomonas Aeruginosa, Microbial inhibitionINTRODUCTION Metal oxide nanoparticles which have unique physical and chemical properties due to change in morphology under the range of 1-100nm. Metal oxide nanoparticles are important in many areas in physics, chemistry, and material science.1 There are various semiconductor oxides among these tungsten oxides is an important transition metal oxide semiconductor.2 Tungsten oxide is an n-type semiconductor which possesses the bandgap of 2.6 – 2.8 eV at room temperature.3,4 In addition to that tungsten oxide is having the absorption capacity of 480 nm in the visible region resulted from its photocatalytic property.5 Based on high photocatalytic property tungsten oxide has strong antibacterial activities.2 The properties of tungsten oxide (WO3) are electrochromic, photochromic, gas chromic, Photocatalytic, Ferroelectric properties, optical properties and chromic.6,7 Tungsten oxide (WO3) has obtained multiple industrial applications especially in the field of metallurgy, material science, electronic displays and optical modulators8,9 smart windows 2, dye-sensitized solar cell.7 There are several methods to synthesize tungsten oxide nanoparticles. Among these methods, microwave irradiation method is most preferable due to less time and uniformity.10 The synthesized nanoparticle was studied on bacterial cultures such as Escherichia. coli and Pseudomonas aeruginosa. Thus experimental work was studied on the UV-Visible Spectroscopy, Scanning Electron Microscopy MATERIALS AND METHODS Materials Sodium tungstate (WO3) with the purity of 98% was purchased from LobaChemiePvt.Ltd, Mumbai. Sodium hydroxide pellets (NaOH) with the purity of 98% was purchased from Sisco Research Laboratories Pvt Ltd, Mumbai. Hydrochloric acid (HCl) with the purity of 35% was purchased from Loba Chemie Pvt Ltd Mumbai. Synthesis of WO3 NPs 0.1 M sodium tungstate was dissolved in 0.1 M sodium hydroxide. The concentrated Hydrochloric acid added dropwise into the reaction mixture with continuous stirring until it reaches pH 1 (Fig. 1). The yellow colour precipitate was obtained and washed for three times using distilled water. The precipitate underwent drying and calcination for 8 hours at 60ºC and 4 hours at 300 ºC respectively, to get tungsten oxide powder.7,8 Characterization of Tungsten Oxide Nanoparticles      Tungsten oxide was characterized by UV-Visible spectroscopy and Scanning Electron Microscopy (SEM) to analyze absorption spectra of nanomaterial, the structural and morphological properties.4,5 Determination of Antibacterial Activity of tungsten oxide nanoparticles      Tungsten oxide was tested for its antibacterial efficacy against bacterial culture. coli and Pseudomonas aeruginosa by Anti Well Diffusion Assay (AWDA). The bacterial inoculum was prepared to a final concentration of approximately 1 X105 CFU/mL for the selected bacterial cultures. The synthesized WO3NPs of concentration 10, 100 and 1000 µg/mL were dispersed in 0.5 % DMSO by ultra-sonication to make the colloidal solution of nanomaterials. On the surface of agar plates, wells of 5 mm in diameter and of 18 µL in capacity were formed by using sterile gel borer. The 15 µL of WO3 NPs suspension was placed in each well and was incubated at 37 °C ± 2 °C for 24 hours and zone of inhibition were recorded to understand antibacterial efficacy of WO3 NPs. 9,10 result and discussion Synthesis of tungsten oxide nanoparticles             The yellow-coloured precipitate of Tungsten oxide nanoparticles was obtained. The resultant powder was dried and used for further characterization. UV-Visible spectroscopy The synthesized tungsten oxide nanoparticles were characterized in UV-Visible Spectroscopy which was shown in fig.2. In the current work, the λmax was found at 364 nm. The same experiment was done by Wei Hao Lai et al.,6,7 by chemical deposition method the change in nanoparticles UV-Visible absorbance λmax at 300 to 900 nm. The optical band gap was calculated by the equation (1), and the calculated bandgap is 3.41 eV. E =  h*c/λ……(1) Scanning Electron Microscope Tungsten oxide nanoparticles obtained was characterized by SEM to understand its size and morphology. Fig. 3(a) showed a bunch of nanostructures at low magnification and at high magnification, the flakes ofWO3 NPs was observed and overall size was found in the range of 200-1000nm. 4,5 Antibacterial efficacy of tungsten oxide Tungsten oxide nanoparticles were tested against the bacteria E. coli and Pseudomonas Aeruginosa. Both bacterial cultures were found sensitive for tungsten oxide nanoparticles and got inhibited effectively at 1000 µg/mL concentration of WO3 NPs. At different concentration, tungsten oxide nanoparticles tested against bacteria are shown in Table 1 and Figure 4. Conclusion Tungsten oxide nanoparticles were synthesized successfully which have the maximum absorbance λmax at 364 nm. Nanoparticles of tungsten oxide have been synthesised and characterised by U.V. Vis. spectroscopy and distinguished by SEM. It was observed that the expansion of biofilm formation of Pseudomonas sp. and E. coli was greatly reduced by tungsten oxide nanoparticles. The solvothermal tungsten oxide nanoparticles have demonstrated substantial antibacterial action against Pseudomonas sp. and E. Coli. Thus, it shows positive activity on E. coli and Pseudomonas Aeruginosa bacteria. Moreover, from the evaluative analysis, it was deduced that the WO3 NPS has significant antibacterial potential that can be used in medicine and food industries. The MIC needed to minimize the biofilm formation as observed in microbial studies was 8 wt% of tungsten oxide NPs. Future experiments will explore how tungsten oxide nanoparticle sizes impact on antibacterial activities. ETHICAL ISSUE: Ethical clearance was taken from institutional ethical committee, KIMSDU, Karad. FUNDING SOURCES: Krishna Institute of Medical Sciences Deemed To Be University, Karad. CONFLICT OF INTEREST: Nil. ACKNOWLEDGEMENT: We acknowledge the contribution and support as being provided by the Department of Electronics and Communication Engineering, Nanotechnology Division, Periyar Maniammai Institute of Science and Technology, Thanjavur, India, Department of Allied Sciences, Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India, Directorate of Research, Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra, India. Englishhttp://ijcrr.com/abstract.php?article_id=3314http://ijcrr.com/article_html.php?did=3314 Dizaj SM, Lotfipour F, Barzegar-Jalali M, Zarrintan MH, Adibkia K. Antimicrobial activity of the metals and metal oxide nanoparticles. Mat Sci Engg: C 2014;44:278-284. Khan I, Abdalla A, Qurashi A. Synthesis of hierarchical WO3 and Bi2O3/WO3 nanocomposite for solar-driven water splitting applications. Int J Hydrogen Energy 2017;42(5):3431-3439. Ahmadi M, Younesi R, Guinel MJ. Synthesis of tungsten oxide nanoparticles using a hydrothermal method at ambient pressure. J Materials Res 2014;29(13):1424-1430. Ahmadi M, Younesi R, Guinel MJ. Synthesis of tungsten oxide nanoparticles using a hydrothermal method at ambient pressure. J Materials Res 2014;29(13):1424-1430. Rezaee O, Chenari HM, Ghodsi FE. Precipitation synthesis of tungsten oxide nanoparticles: X-ray line broadening analysis and photocatalytic efficiency study. J Sol-Gel Sci Tech 2016;80(1):109-18. Wasmi BA, Al-Amiery AA, Kadhum AA, Mohamad AB. Novel approach: tungsten oxide nanoparticle as a catalyst for malonic acid ester synthesis via ozonolysis. J Nanomat 2014;2014. Zheng H, Ou JZ, Strano MS, Kaner RB, Mitchell A, Kalantar?Zadeh K. Nanostructured tungsten oxide–properties, synthesis, and applications. Adv Func Mater 2011;21(12):2175-2196. Ghasemi L, Jafari H. Morphological characterization of tungsten trioxide nanopowders synthesized by sol-gel modified Pechini&#39;s method. Mat Res 2017;20(6):1713-1721. Popov AL, Zholobak NM, Balko OI, Balko OB, Shcherbakov AB, Popova NR, et al. Photo-induced toxicity of tungsten oxide photochromic nanoparticles. J Photochem Photobio B: Biology. 2018;178:395-403. Jain N, Bhosale P, Tale V, Henry R, Pawar J. Hydrothermal assisted biological synthesis of silver nanoparticles by using honey and gomutra (Cow Urine) for qualitative determination of its antibacterial efficacy against Pseudomonas sp. isolated from contact lenses. Eur Asian J Bio Sci 2019;13(1):27-33.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareStudy of Bipolar Hemiarthroplasty of Hip Joint in Rural Teaching Set Up English8084Jainish PatelEnglish Munir UpadhyayEnglish Aditya K. AgrawalEnglish Prasanna ShahEnglish Yash MuthaEnglish Paresh GolwalaEnglishBackground: With increasing orthopaedic expertise in the rural centres, there has been the development of tertiary care centres in rural areas wherein a high-end surgery such as hip joint replacement can be done. Bipolar hemiarthroplasties, performed at rural teaching set up are evaluated for comparison of similar surgeries performed at sophisticated, high-end corporate hospitals. Objective: To compare outcome at the rural teaching setup, with large series at a high-end teaching or corporate hospitals from published literature. It also would enable us to recognize short-comings at tertiary teaching set up in rural areas, and innovation to circumvent these shortcomings and evaluate and access the benefits of these alternative resources and innovation for a better bipolar hip arthroplasty outcome. Methods: In the present study 30 cases of bipolar hemiarthroplasty were taken. Clinical outcome and functional results were evaluated by using the Harris hip score. Results: Out of 30 cases 11 were females and 19 males. With most common indicators are fracture neck femur and avascular necrosis of femoral head where the acetabular surface was not involved. We have evaluated the functional outcome by Harris hip score at the final follow up period. We have achieved 80% of excellent results as the functional outcome of the patient. Conclusion: The clinical and functional outcome of Bipolar hemiarthroplasty done at our rural teaching set up, with experienced surgeons, adequate manpower etc. are comparable to the high end sophisticated established urban teaching centres and corporate hospitals. We have used Harris Hip Score to analyze the results and 90% had good results. English Bipolar Hemiarthroplasty, Harris Hip Score, Fracture neck femur, Avascular necrosis of femoral head, Clinical and functional outcomes, Hip prosthesisINTRODUCTION The incidence of a Joint Replacement Surgery has increased exponentially over the past few decades. There is a surge in joint replacement surgery in the last few decades across all developing countries due to increased longevity of life and an increasingly ageing population. India the second-most populous country in the world can be broadly divided into two groups, one residing in urban and the other in rural areas. Till recent times, hip joint replacement surgeries were restricted to urban areas with well-equipped state of the art hospitals and experienced trained surgeons. However, with increasing orthopaedic expertise in rural centres, there has been the development of tertiary care centres in rural areas wherein such a high-end surgery can be done. These tertiary care teaching centres where good manpower is available but still improving in development of high-end infrastructure like modular operating units. The literature has shown predictable, consistent, and reproducible results following replacement surgeries, but all these studies were done in highly sophisticated and well-equipped hospitals. Not all the patients have the extensive deformities of both the femoral head and acetabulum, for which a dual-assembly total hip prosthesis is required. In some patients, then, it would appear appropriate to make use of a system that embraces the low friction principle, but yet does not require removing or distorting the acetabulum, which, in a good number of cases does not need to have a total hip replacement. This led to the development of "bipolar" type of hip replacement, the credit for which goes to James E. Bateman.1 Modular hip systems provide not only for the selection of the various sizes of the stem but now also allow independent sizing of various portions of the head and neck. This single assembly type of unit is well tolerated within the body, and clinical progress has been most encouraging. Patients walk early and without pain and a high degree of stability has been maintained. Therefore, this study of hip replacement surgeries which is bipolar hemiarthroplasty, performed at our teaching hospital in a rural setup was undertaken. This would enable us to compare outcomes at the rural teaching setup, with large series at high-end teaching or corporate hospitals from published literature. This will allow us to rectify short-comings at tertiary teaching set up in rural areas, and innovation to circumvent these shortcomings and evaluate and access the benefits of these alternative resources and innovation for a better outcome of bipolar hip arthroplasty.  MATERIAL AND METHODS The present study was carried out in the department of orthopaedics with approval obtained before the study from the Ethical Committee of the institute (SVIEC/ON/MEDI/BNPG13/14507). This study includes patients who underwent bipolar hip joint hemiarthroplasty surgery at the Department of  Orthopedic Surgery. The inclusion criteria included patients with fracture neck femur and avascular necrosis of femoral head willing to participate in the study, all cases of bipolar hemiarthroplasty surgery irrespective of gender and medical condition of the patient. The exclusion criteria included short term follow-up cases of surgery less than six months and patients not willing for study. The statistical analysis was done using SPSS software (Illinois, Chicago) and p-value less than 0.05 was considered statistically significant. All the patients in our study were admitted in the outpatient department or casualty. A detailed history is taken and specific evaluation was done regarding life expectancy, incurable disease, general condition to tolerate the elective procedure. X-rays of the pelvis with both hips was done. In AVN patients MRI was done. After all preoperative investigations and pre-anaesthetic check-up, the patient was taken to OT. All surgeries were performed under full aseptic condition and in laminar airflow theatre. The patients were kept in the lateral position and surgery was performed by posterior Moore’s approach. Patients were followed up for a longer duration from 6 months up to 3 years. On follow up the patient was evaluated according to Harris hip score for clinical and functional outcome. Under normal circumstances, static and active quadriceps exercise and ankle pump were begun on the same day within the comfort followed by high sitting on the second postoperative day. Patients were mobilized depending upon the advice of the surgeon and compliance of the patient to follow our advice. Patients who underwent cemented hemiarthroplasty were advised weight bearing as soon as pain permits whereas in uncemented hemiarthroplasty we initiated weight-bearing between 4 weeks to 5 weeks. Patients were instructed not to squat,  sit cross-legged or indulge in active sports and advised to use western-style toilets. RESULTS In the present study, we studied 30 cases of operated bipolar hemiarthroplasty (24 uncemented + 6 cemented). The primary aim of the study was to critically evaluate the results regarding clinical, radiological and functional parameters. In our study, the age group ranges from 25 – 81 years, among them 8 patients were among 35 – 44 years age group and second common age group were 65 – 74 years. In our study male to female ratio was 2:1.In this study, we included 15 patients of fracture neck femur and 15 patients of AVN (3 patients grade2 & 12 patients grade3FicatArlet). In our study 43.4% of patients were heavy worker which were mainly farmers and labourers, 30% were moderate worker mostly females (housewife), 26.6% were lightworker (shop keeper).In our study, 1 superficial infection and 1 dislocation were noticed which was managed by debridement and close reduction respectively. We had started weight-bearing walking among 6 patients of cemented bipolar within a week of surgery according to patients’ compliance. 26 patients of uncemented bipolar were made to walk after 1 month of surgery and 2 patients were made to walk after 45 days of surgery due to complication and persistent pain, both of them were walking with limp. Among all patients, 28 patients could walk more than 1 km without pain. 2 patients had limb length discrepancy (one with shortening of one cm compensated with shoe raise on the affected side and one with lengthening of one cm compensated with shoe raise of the unaffected side). On a series of X-ray evaluation, it was found that three patients had trochanteric osteoporosis on long term follow up while 27 patients did not show any limb length discrepancy. The outcome was evaluated according to Harris hip score and results were with good to excellent results in 93.32 % cases as shown in Table 1. So, 28 patients had satisfactory outcome and 2 patients had a fair outcome. All patients were able to return to work except one. DISCUSSION The joint replacement surgeries have surged exponentially over the past decade due to increased longevity of life and increasing ageing population. Most of the patient who underwent this surgery belonged to urban and economically well of population. However with an increase in economic development and penetration of insurance facilitates in the rural area and increased longevity of life, there is a sharp increase in the incidence of joint replacement surgeries in rural population. Generally, good clinical results have been reported with the use of bipolar prosthesis and its current indications have expanded to include: The primary surgical management of non-infective hip joint arthritis secondary to avascular necrosis, rheumatoid arthritis, ankylosing spondylitis, osteoarthritis and in fresh, pathological, iatrogenic, and non-union femoral neck fractures. Bipolar prosthesis confers following advantages over a conventional Austin Moore&#39;s prosthesis like wide range of movements, intrinsic stability at two bearing interfaces thus, reducing the chances of dislocation of the hip, decreased incidence of complications like acetabular erosion, protrusion acetabuli, femoral stems loosening, increased longevity of the prosthesis.  However, there are certain shortcomings in rural areas like no high tech hospitals, lack of expertise (super specialist joint replacement surgeons are not available). These joint replacement surgeries are limited to urban corporate hospitals and patient need to travel a long distance from their residence to urban area for surgery. This lead to infrequent, inadequate follows up due to the long distance of travel and expense involved for a visit to the urban centre. But with increasing orthopaedic expertise there has been the development of tertiary care teaching centres in rural areas wherein such a high-end surgery can be done. These centres have the infrastructure and technically skilled manpower with experienced surgeons. We have studied 30 cases of bipolar hemiarthroplasty at tertiary care hospital. These cases were compared with studies conducted by other authors done at sophisticated urban centres, where there is no constrain of material and money. Various aspects of the procedure have been observed and discussed in detail. The average age of the patients was 52.76 ± 8.5 years, with a range of 25 to 85 (CI 95%). Majority of the patients were in the age group 35 – 44 years & the second common group was 65-74 years. The average age varies from 54 to 80 years in varius studies conducted previously.1-5 The common age incidence in my study is less as compared to the reported series probably due to the young patients suffering from  AVN of the femoral head (acetabulum is not involved), we did bipolar hemiarthroplasty as the life expectancy of these patients are not that high as they are having sickle cell disease. This will give them good functional hip throughout their lifetime. As common age group in AVN cases is 35-44years with the average age of 39.4yrs. In fracture neck of femur, the average age is 66 years ranging between 65-74 years. In this series, it was observed that out of the 30 patients 11 were female (36.7%)  and 19 were male (63.3%). In the literature, a lot of variation is reported, female being more common than male. Percentagen of females in diferent studies was in the range of 80-90%.3-5 Fracture neck is common in older females due to hormonal imbalance in the postmenopausal age and associated osteoporosis. However, in this study males were predominant as compared to females. This is probably due to the high incidence of younger patients with AVN and more males are venerable to RTA. Out of thirty patients, fifteen cases were of avascular necrosis of femoral head, of which three were due to sickle cell disease, one was due to long term use of steroid (asthmatic), three were alcohol-induced and in rest eight cause of AVN  could not be detected. All cases were grade 2 or 3 according to Ficat Arlet classification. We did bipolar arthroplasty in some grade 2 because of less possibility of reversal of AVN by other methods or surgery as in sickle disease and a case of steroid-induced AVN where the patient can’t discontinue steroid due to severe asthma. The majority of patients had no complication that was 28 patients (93.33%).  One patient was noticed with the infection that was treated with debridement and appropriate antibiotics given according to the culture and sensitivity of discharge. And 1 patient (3.3%) had dislocation which was treated by close reduction and traction in abduction and de-rotation bar for 3 months.  In the published series, the infection rates were 2.8% and 2.1%.3,5. Nottage and McMaster reported wound breakdown in 3.9%, deep wound infection was 3.9% and superficial in 3.33% which is comparable to our series.6 A dislocation rate of 2.4% si also observed by Lesrange, 1900. Our results are quite similar to the published series. In Nottage and Mc Master6 one patient (3.33%) developed deep vein thrombosis after 7th day, which was treated successfully with S/C heparin after monitoring PT and PTT.  Even though we have not used prophylactic anticoagulants, we have not encountered any thromboembolic phenomena like deep vein thrombosis probably due to the early mobilization of the patients. In this series study the average Harris Hip Score is 89.43 outcome was an excellent result in 24 (80%) patients, a good result in three cases(10%), fair in one case (3.3 %)  and poor in two cases 6.6%. In the reported series of Giliberty7 had 92% satisfactory results with a mean Harris hip score of 84.81 points, Mannarino et al.8 had mean Harris hip score of 84.7 points, Lausten et al.9 found 75% excellent to good results, Lestrange5 had 70.8% excellent to good results. Nottage and Mc Master (1990)6 had a mean Harris hip score of 83 in the bipolar group and Amite et al11 had 90.6% excellent to good results in bipolar and Marya et al.2 had excellent to good results in 85% while We have got 90% satisfactory results ( excellent results in 80% and good result in 10% of the cases) with an average Harris Hip Score of 89.43, which is quite similar to the above-mentioned series. CONCLUSION The clinical and functional outcome of Bipolar hemiarthroplasty done at our rural teaching set up, with experienced surgeons and adequate manpower are comparable to the high end sophisticated established urban teaching centres and corporate hospitals, which are very costly. The results of the present series were achieved with strict adherence to operation theatre discipline at all time like a team. We have used Harris Hip Score to analyze the results and 90% had good results. As this study was time-bound, the sample size was small, which will not reflective of the entire rural population. Despite these limitations in our study, we have several unique strengths like cost is meagre as compared to urban centres. Patients feel homely in the rural setup, as our set up and have no problem in follow up and travel as and when required. However, more studies in larger groups need to be done to establish the above facts and may reduce the cost with much better results. Conflict of interest – None. Source of funding – None. Ethical Approval – Taken from an institutional ethics committee. Acknowledgement – We would like to thank the patients and clinical & administrative staff of the hospital for their contribution to the study.     Englishhttp://ijcrr.com/abstract.php?article_id=3315http://ijcrr.com/article_html.php?did=33151.      Garrahan WF, Madden EJ. The long-stem bipolar prosthesis in surgery of the hip. Clin Ortho  Related Res. 1990 Feb (251):31-7. 2.      Marya SK, Thukral R, Hasan R, Tripathi M. Cementless bipolar hemiarthroplasty in femoral neck fractures in the elderly. Ind J Orth. 2011 Jun; 45: 236-42. 3.      LaBelle LW, Colwill JC, Swanson AB. Bateman bipolar hip arthroplasty for femoral neck fractures. A five-to ten-year follow-up study. Clin Ortho Related Res. 1990 Feb (251):20-5. 4.      Gallinaro P, Tabasso GI, Negretto RE, del Prever Brach EM. Experience with bipolar prosthesis in femoral neck fractures in the elderly and debilitated. Clin Orthopaed Related Res. 1990 Feb (251):26-30. 5.      Lestrange NR. Bipolar arthroplasty for 496 hip fractures. Clin Orthopaed Related Res. 1990 Feb 1; 251:7-19. 6.      Nottage WM, McMaster WC. Comparison of bipolar implants with fixed-neck prostheses in femoral-neck fractures. Clin Orth Related Res. 1990 Feb (251):38-43. Dudani B, Shyam AK, Arora P, Veigus A. Bipolar hip arthroplasty for avascular necrosis of femoral head in young adults. Ind J Orth. 2015 Jun;49:329-35. 7.      Giliberty RP. Bipolar endoprosthesis minimizes protrusio acetabuli, loose stems. Orthop Rev. 1985; 14:27. 8.      Mannarino F, Maples D, Colwill JC, Swanson AB. Bateman bipolar hip arthroplasty: A review of 44 cases. Orthopaedics. 1986 Mar 1;9(3):357-60. 9.      Lausten GS, Vedel PE, Nielsen PM. Fractures of the femoral neck treated with a bipolar endoprosthesis. Clin Orthopaed Related Res. 1987 May (218):63-7. 11.    Amite P, Malhotra R, Bhan S. Conversion of failed hemiarthroplasty to total hip arthroplasty: a short to a mid-term follow-up study. Indian journal of orthopaedics. 2008 Jul; 42(3):294.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareThe Study of Anti-inflammatory and Analgesic Effects of Oral Serratiopeptidasein Postoperative Patients in a Tertiary Care Hospital English8589C. KhanwelkarEnglish Kartik PeethambaranEnglish S. A. JadhavEnglishIntroduction: Oral proteolytic enzymes like serratiopeptidase are very commonly used by clinicians either alone or in combination with non-steroidal anti-inflammatory drugs for analgesia and anti-inflammatory and wound healing purpose in postoperative patients. Objective: To study the effect of serratiopeptidase and diclofenac in postoperative patients. Methods: Three groups (n= 20) of postoperative patients having clean surgical wound were treated with diclofenac 50 mg twice a day (BID) and serratiopeptidase 10mg three times a day (TID) + Diclofenac 50 mg BID for one week. The third group was not given any analgesic- anti-inflammatory drug. The pain and inflammation at the site of the wound were assessed by VAS and Asepsis score on 1st and 7th day. Results: No difference in analgesic and anti-inflammatory effects were found in both treatment groups (p> 0.05). Patients in the no-treatment group had relief of inflammation comparable to both treatment groups. Patients from no treatment group did not require analgesic for pain relief. Conclusion: Addition of serratiopeptidase did not potentiate the analgesic and anti-inflammatory effects of diclofenac. In clean surgical wounds, use of analgesic anti-inflammatory drugs should be as per need and not on regular basis. EnglishSerratiopeptidase, Diclofenac, Analgesic, Anti-inflammatory, Postoperative, Surgical wound.Introduction Oral preparations of proteolytic enzyme serratiopeptidase are routinely marketed in India, either isolated or as a fixed-dose combination with non-steroidal anti-inflammatory drugs (NSAID) like aceclofenac, diclofenac. They are widely prescribed by physicians and surgeons for producing analgesia and anti-inflammatory effect and to reduce oedema associated with trauma, surgery, dental procedures, respiratory tract infection, parotitis, arthritis, etc.1,2 Serratiopeptidase is a proteolytic enzyme obtained from non-pathogenic bacteria Serratia E-15 species belonging to Enterobacteriaceae family. It is produced in the intestine of silkworm which causes a breakdown of cocoon walls. It has a very large molecular weight, 45000-60000 daltons.3,4 Naturally large molecular weight proteins, when given orally, are degraded by proteolytic enzymes in the gastrointestinal tract and not absorbed intact. Therefore, it is doubtful that serratiopeptidase retains its structure after absorption and enters the plasma intact. There are very few studies suggesting oral bio-availability of serratiopeptidase.5 Only one study has shown the presence of this enzyme in high concentration in the abscess, in carrageenin induced paw oedema in rodents.6 Thus though the pharmacokinetic data of serratiopeptidase is still unproven but many studies have suggested its very good analgesic and anti-inflammatory role in dental surgeries.7,8 Serratiopeptidase like other oral enzymes were shown to have a good effect in osteoarthritis.9 Serratiopeptidase is not yet listed in any official drug compendium, pharmacopoeia.10 Therefore, it was worthwhile to study the analgesic and anti-inflammatory effect on the surgical wound in postoperative patients in surgery wards in a tertiary care hospital. Material and Methods The study was conducted in the general surgery ward of Krishna Hospital, Karad, Maharashtra. Approval of protocol and permission of Ethics Committee of Krishna Institute of Medical Sciences, Karad, was taken before starting the study (Ref. No. KIMSDU/IEC/09/20188). Total 60 adult postoperative patients of either sex, having clean surgical wound were enrolled after they gave volunteer informed consent. All patients were given all information of study protocol when surgery was planned and consent was taken before the surgery. Patients who had emergency surgery, complication during surgery, malignancies, uncontrolled diabetes mellitus or any serious co-morbidity were not included in the study. Pregnant, lactating women were also excluded. Patients already receiving corticosteroids, NSAIDs or any oral enzyme preparation were excluded from the study. The patients were assigned randomly to either of the three study groups on their first postoperative day (Table 1). Each group had 20 participants. Following the treatment, the schedule was given to the respective group for 7 days. Statistical Methods The recorded data was processed and analyzed utilizing the Social Sciences Statistical Package (SPSS) for ANOVA and students paired ‘t’ tests. The expectation threshold of the analysis was held at 95 per cent, which suggested that the "p" will be less than 0.05 level of significance. A 10 point Visual Analog Scale (VAS) for the pain analysis was used to evaluate the intensity of pain10. A wound assessment method, ASEPSIS, was used that enhances the outcomes including reproducibility of the wound&#39;s sepsis evaluation by assigning points especially within the 1st week of wound development as well as clinical implications of infections. In Group C no treatment with any analgesic or anti-inflammatory drug was given for 7 postoperative days, but if the patient needs rescue NSAID treatment was decided to be given. The severity of pain was assessed by asking the patient to mark the level of pain on the visual analogue scale (VAS), for 1st and 7th postoperative day11. The inflammation and status of healing of surgical wound were assessed by measuring, Asepsis Wound Score as given in Table 2 12. Asepsis score was calculated for each patient on 1st and 7th postoperative days. Mean of asepsis scores of each group was calculated for day 1 and 7. The difference between asepsis scores on 1st and 7th day was taken as a measure of wound healing and reduction in inflammation. The mean values of VAS score and Asepsis score of each group on day 1 and day 7 were compared by applying student’s paired ‘t’ test, and significance was calculated. The differences in VAS score and differences in Asepsis scores of all three groups were compared by applying ANOVA.  Comparison of reduction in pain and reduction in inflammation between Group A & B, Group A & C and Group B & C was done by using student’s paired ‘t’ test. Results The two scales VAS and Asepsis used for the scoring of pain and sepsis of wound were statistically analyzed. The mean visual analogue scale (VAS) was correlated according to age in Groups. The mean VAS score was decreased very highly significantly (p 0.05). The reduction in asepsis score of group A, as well as that of B, was not statistically different from that of group C (No treatment group) and p> 0.05. The reduction in pain indicated by the reduction in VAS score was statistically significantly higher in group A(Diclofenac) and group B (Diclofenac+ Serratiopeptidase) as compared to that in group C (No treatment group). Discussion The present study was aimed to evaluate the efficacy of serratiopeptidase and diclofenac in reducing pain and inflammation at the surgical wound site in postoperative patients. Total of 60 patients was distributed in three groups: A, B, C (n= 20). Group A patients received oral diclofenac 50 mg BID, group B patients received oral diclofenac 50 mg BID and oral serratiopeptidase 10 mg TID. In both these groups, treatment with respective drug was started on the first postoperative day and was continued till 7th postoperative day. The group C was not given any analgesic or anti-inflammatory treatment unless needed. No patient in this group required rescue analgesia or anti-inflammatory drug, though diclofenac 50 mg BID was kept as a rescue if the patient complains of intolerable pain.               Our results indicate that there was no added analgesic or effect produced by serratiopeptidase when it was combined with diclofenac. Isolated diclofenac treatment produced equivalent analgesic activity as that produced by diclofenac and serratiopeptidase combined treatment (p> 0.05).  No patient in the no-treatment group (Group C) demanded analgesia during 7 postoperative days, that shows pain in clean surgical wounds is tolerable most times. In our study, it was very much obvious that in both the treatment groups, the reduction in VAS score was significantly more than the no-treatment group. Therefore, we suggest that analgesic should be given in postoperative patients having clean surgical wound as per need and if the pain is intolerable for the patients and not regularly.                    The reduction in asepsis score was comparable in all three groups and there was no significant statistical difference, p>0.05 (Table 6). In no-treatment group i.e. group C, also reduction of asepsis score was similar to treatment groups, i.e. groups B and C. These results suggest that addition of serratiopeptidase has not enhanced the anti-inflammatory effect of diclofenac. It is also suggested that in clean surgical wounds neither diclofenac nor serratiopeptidase can enhance wound healing, and anti-inflammatory drugs should be given if there is excessive inflammation at the wound site.                    Many studies, particularly involving dental procedures, have suggested that serratiopeptidase reduces inflammation, pain and trismus following dental procedures2,7,13,14. Many studies, particularly involving dental procedures, have suggested that serratiopeptidase reduces inflammation, pain and trismus following dental procedures. In a study including postoperative orthopaedic patients anti-inflammatory, analgesic and wound healing effects of trypsin–chymotrypsin combination was found to be significantly higher than serratiopeptidase.15 Serratiopeptidase have shown significant anti-inflammatory effect and mild analgesic effect of in patients with upper and lower limb trauma.16 Our results are not in agreement with the results of these studies. In the study of Rath et al.17, they have shown improvement in wound healing by topical application of serratiopeptidase – metronidazole in full-thickness wounds in rabbits. Thus serratiopeptidase may be beneficial by topical application. In a case report, serratiopeptidase was reported to increase the spread of infection after dental surgery.18 In a study in hysterectomy, caesarian section and episiotomy wounds, much-delayed healing was seen in patients treated with serratiopeptidase 10 mg TID. In this study, patients treated with the only serratiopeptidase required more NSAIDs for getting pain relief.19 In a study in rabbits it was concluded that serratiopeptidase could not improve and rather caused the delay in oral wound healing.20               There is a lack of pharmacokinetic data about oral administration of serratiopeptidase. Only a few studies show the presence of serratiopeptidase in serum after oral administration in human and animals.2,5 One questionnaire-based study has shown that the use of serratiopeptidase and other oral proteolytic enzymes with or without NSAIDs is influenced by marketing skills of medical representatives and pharmaceutical companies. The same study has shown that the cost of treatment using a combination of serratiopeptidase and NSAID is approximately 5 times more than compared to isolated NSAID treatment.21                Thus looking towards these facts and results of our and many other clinical studies, we suggest that use of oral proteolytic enzymes for analgesic, anti-inflammatory and wound healing purpose in clinical practice should be avoided until it is included by official drug compendia. Use and availability of such drugs having unproven efficacy should be regulated by strict actions by the drug controlling authorities. Conclusion The results suggested that the addition of serratiopeptidase has not enhanced the anti-inflammatory effect of diclofenac. It is also suggested that in clean surgical wounds neither diclofenac nor serratiopeptidase can enhance wound healing, and anti-inflammatory drugs should be given if there is excessive inflammation at the wound site. Addition of serratiopeptidase did not potentiate analgesic and anti-inflammatory effect of diclofenac. In clean surgical wounds, use of analgesic anti-inflammatory drugs should be as per need and not regularly. Funding source: Krishna Institute of Medical Sciences “Deemed To Be “University, Karad, Maharashtra. Conflict of Interest: None Acknowledgement: We are grateful for the support to the Department of Pharmacology, Krishna Institute of Medical Sciences, Karad-415339, Maharashtra, India. Englishhttp://ijcrr.com/abstract.php?article_id=3316http://ijcrr.com/article_html.php?did=3316 Moslemi N, Khorsand A, Torabi S, Shahnaz A, Shayesteh YS, Fekrazad R. Periosteal releasing incision with diode laser in guided bone regeneration procedure: a case series. J Lasers Med Sci 2016;7(4):259. Tiwari M. The role of serratiopeptidase in the resolution of inflammation. Asian J Pharma Sci 2017;12(3):209-215. Nakahama K, Yoshimura K, Marumoto R, Kikuchi M, Lee IS, Hase T, et al. Cloning and sequencing of Serratia protease gene. Nucleic Acids Res 1986;14(14):5843-5855. Nirale NM, Menon MD. Topical formulations of serratiopeptidase: development and pharmacodynamic evaluation. Ind J Pharm Sci 2010;72(1):65. Dallas P, Rekkas D, Choulis NH. HPLC determination of serratiopeptidase in biological fluids. Pharmazie 1989;44(4):297. Moriya N, Nakata M, Nakamura M, Takaoka M, Iwasa S, Kato K, et al. Intestinal absorption of serrapeptase (TSP) in rats. Biotech Appl Biochem 1994;20(1):101-108. Mouneshkumar CD, Suresh KV, Patil MR, Desai R, Tauro DP, Shiva Bharani KN, et al. Comparison of clinical efficacy of methylprednisolone and serratiopeptidase for reduction of postoperative sequelae after lower third molar surgery. J Clin Expt Dentistry 2015 Apr;7(2):e197. Santhoshkumar M. The emerging role of serratiopeptidase in oral surgery: literature update. Asian J Pharm Sci 2018;11(3):19-23. Klein G, Kullich W. Short-term treatment of painful osteoarthritis of the knee with oral enzymes. Clin Drug Invest 2000;19(1):15-23. Mathew JR, Sivasubramanian K. Letter to Editor-Use of oral enzyme preparations: Is there any evidence? Ind J Plastic Surg 2004;37(1):80. Collins SL, Moore RA, McQuay HJ. The visual analogue pain intensity scale: what is moderate pain in millimetres? Pain 1997;72(1-2):95-97.  Harish Patel BN, Kumar P, Kailas CT, Chandrasekhar RL. A study on wound asepsis score for skin closure in surgical procedures. Int J Surg 2019;3(1):61-64. Sivaramakrishnan G, Sridharan K. Role of Serratiopeptidase After Surgical Removal of Impacted Molar: A Systematic Review and Meta-analysis. J Maxillofac Oral Surg 2018;17(2):122-128. Basheer SA, Mohan GM, Vijayan S. Efficacy of medication on postoperative pain, swelling & Trismus after impaction of Mandibular third molar. Int J App Dental Sci 2017;3(3):96-99. Chandanwale A, Langade D, Sonawane D, Gavai P. A randomized, clinical trial to evaluate efficacy and tolerability of trypsin: chymotrypsin as compared to serratiopeptidase and trypsin: bromelain: rutoside in wound management. Adv Therap 2017;34(1):180-198. Garg R, Aslam S, Garg A, Walia R. A prospective comparative study of serratiopeptidase and aceclofenac in upper and lower limb soft tissue trauma cases. Int J Pharmacol Pharm Technol 2012;1(2):11-16. Rath G, Johal ES, Goyal AK. Development of serratiopeptidase and metronidazole based alginate microspheres for wound healing. Artif Cells Blood Substit Immobil Biotechnol 2011;39(1):44-50. Rajaram P, Bhattacharjee A, Ticku S. Serratiopeptidase–A cause for spread of infection. J Clin Diag Res 2016;10(8):ZD31. Koltsakidou Α, Katsiloulis C, Εvgenidou Ε, Lambropoulou DA. Photolysis and photocatalysis of the non-steroidal anti-inflammatory drug Nimesulide under simulated solar irradiation: Kinetic studies, transformation products and toxicity assessment. Sci Total Env 2019;689:245-257. Garg S, Garg A, Shukla A, Dev SK, Kumar M. A review on Nano-therapeutic drug delivery carriers for effective wound treatment strategies. Asi J Pharm Pharmac 2018;4(2):90-101. Shah SA, Nerurkar RP. Evaluation of prescribing trends and rationality of the use of oral proteolytic enzymes. Ind J Pharm 2013;45(3):309.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareLipid Peroxidation and Hepatoprotective Activity of Bauhinia Vahli Against Carbon Tetra Chloride Induced Toxicity English9094Amit Kumar NigamEnglish Phool ChandraEnglish Zeashan HussainEnglish Neetu SachanEnglishIntroduction: Liver cirrhosis has become a serious health problem because of the wider use of prescribed medications with adverse reactions in the modern life of today or drug misuse. Objective: In the present study, the hepatoprotective activity of the aerial part of Bauhinia vahlii was investigated against the carbon tetrachloride-induced hepatotoxicity model in Wistar albino mice. Methods: Glutathione (GSH), Glutathione Peroxidase (GPx), Glutathione S-transferase (GST), Superoxide dismutase (SOD), Multiple Organ Dysfunction Syndrom (MOD) were measured in liver and blood samples. The acute toxicity study of the selected plant showed that there is no mortality or adverse reaction at the fixed dose of 2000 mg/kg. The methanolic extract at 200 and 400 mg/kg body weight respectively were administered daily to study the hepatoprotective effect in carbon tetrachloride-induced hepatotoxic model for 7 days. Results: A remarkable decrease was observed in bilirubin, alkaline phosphatase (ALP), serum glutamic-oxaloacetic transaminase (SGOT), and serum glutamic-pyruvic transaminase (SGPT) levels in the treatment group as compared to the hepatotoxic group. In a histopathological study, hepatocytic necrosis and inflammation in the centrilobular region with portal triaditis was found in hepatotoxicity induced group whereas minimal inflammation with moderate portal triaditis and normal lobular architecture observed in extract treated groups. Conclusion: From the observation, it can be concluded that the methanolic extract of Bauhinia vahlii has the potential to revert the hepatic injury induced by carbon tetrachloride. Comparatively, the methanolic extract at 400 mg/kg w/w resulted in a significant hepatoprotective effect. The standard drug silymarin was used for comparison. EnglishHepatoprotective activity, Lipid peroxidation, Bauhinia vahlii, Silymarin, Carbon tetrachlorideINTRODUCTION The liver is the largest organ in the body weighing 1400-1600 gm. in males and 1200-1400 gm. in females. There are two main anatomical lobes right lobe and left lobe, the right is being about six times the size of the left lobe. It produces bile, an alkaline compound which aids in digestion, via the emulsification of lipids. Besides, it aids the metabolism of carbohydrate, protein and fat, detoxification, secretion of bile, and storage of vitamins.1,2 The primary function of this organ in the removal of substances from the portal circulation makes it susceptible to first and persistent attacks by offending foreign compounds, culminating in liver dysfunction.3 Liver cirrhosis has become a serious health problem because of the wider use of prescribed medications with adverse reactions in the modern life of today or drug misuse. The current research has targeted on finding new therapeutic alternatives and analyzing their mechanism to get rid of the signalling routes and reduce the loss induced on the liver.4 The numbers of compounds of natural origin are generally used as possible health care options and they are being experimented on various animal models.5,6 Many medicinal plants with hepatoprotective activity have been reported by several researchers.7,8 In continuation of the search of hepatoprotective agents, Malu Creeper was undertaken to investigate the active constituents and its medicinal value. Bauhunia vahlii (Malu Creeper) is a tree of large family Leguminosaceae (subfamily- Caesalpiniaceae); it is traditionally used to treat the liver cirrhosis.9  Bauhinia genus of family Caesalpiniaceae consists of about 15 species that occur in India. Some of them are shrubs or trees, while a few are climbers.10 Bauhinia vahlii is a giant climber shrub and one of the most common Indian Bauhinia species. The species is distributed in the Sub-Himalayan region and also found in Assam, Central India, Bihar, Eastern, and the Western Ghats.11 Bauhinia vahlii Wight and Arn belonging to family Caesalpiniaceae is a giant evergreen shrub having white flowers. Various part of Bauhinia vahlii is used, as the seeds possess tonic and aphrodisiac properties and leaves are demulcent and mucilaginous. The plant is reported to possess antibacterial,12 anti-inflammatory, anti-diabetic13,14,15 antioxidant16 and anti-hyperlipidemic activity.17 It is also used for the treatment of dysentery, diarrhoea, haemorrhoids, piles, oedema, laxative, anthelmintic, astringent, antileprotic, wound healing, antigoitrogenic, antitumor, the antidote for snake poisoning, dyspepsia, carminative.18 Bauhinia vahlii is the largest creeper in India and is called adattige in Telugu and asamantaka in Sanskrit. It has been reported to contain amino acids, proteins,19 minerals,20 and flavonoids.21 They have various medicinal activity, Dried pods, without seeds, yielded 4 new constituents, viz. methyl 4-O-methyl gallate (0.08%), methyl gallate (0.26%), (+)-mopanol (0.07%) and (+)-catechin (0.11%).22 It has also contained betulinic acid, triterpene, campesterol, and steroid. Even though the plant was traditionally used to treat liver disease, but there is no such documented evidence of hepatoprotective activity. Because of this, it is of considerable interest to investigate the above-mentioned plant with the hope to obtain a safe and potent hepatoprotective agent. MATERIALS AND METHODS Collection and identification of plant sample The fresh aerial parts of Bauhinia vahlii were collected from surrounding of Chandi Devi Temple located in Haridwar, Uttarakhand, India. The selected plant was authenticated by CSIR Laboratory, National Botanical Research Institute, Lucknow (CSIR-NBRI). The authentication reference number is NBRI/CIF/530/2018. Preparation of Plant Extract The aerial parts were washed with running tap water, air-dried under the shade at room temperature, and then ground to a coarse powder and stored in an airtight container. The size of the dried parts was reduced, powdered and about 250 g of powder was continuously extracted with methanol and water by soxhlet extractor at room temperature for three days. The methanolic extract was filtered and concentrated to a dark viscous mass (Yield 21.7 % w/w) under reduced pressure at 45-50°C. The dried extract was suspended in distilled water and was further fractionated by using different polarity-based solvents such as n-hexane, ethyl acetate; the obtained dark brown to green colour crude extract was stored in an airtight container at 6-10°C for further studies.23 Animals Albino mice of weight ranges from 120-150 gm of female mice were used for the study. Female Mice were kept in the animal house of the pharmacy department at maintained room temperature of 22-25°C. During the whole experimental study animals kept in light and dark conditions. The experiments were carried according to guidelines of the Institutional Animal Ethics Committee approved the experimental protocol and animals were maintained under standard conditions in an animal house. Ref. no: 2014/PO/Re/S/18/CPCSEA. Acute toxicity study The acute toxicity study was done according to the Organization for Economic Cooperation and Development guidelines (OECD 423). In acute toxicity study, methanolic extract and aqueous extract were determined on Albino mice of weight ranges from 25-30 gm of female mice. Acute toxicity was calculated as per OECD 423 guidelines and LD50 of test compounds were found at 2000 mg/kg.w/w. Carbon tetrachloride-induced liver toxicity Animals were divided into five groups (each group contains 6 animals). Group, I served as vehicle control, which received liquid paraffin. Groups II-V were treated with CCl4 in liquid paraffin (1:2) at the dose of 1 ml/kg body weight intraperitoneal once in every 72 h for 14 days. Groups IV and V were treated with Bauhinia vahlii Methanolic extract (BBME) at the doses of 200 and 400 mg/kg body weight, respectively. Group III was administered with standard drug silymarin at a dose of 25 mg/kg body weight orally. BBME treatment was started 10 days before Carbon tetrachloride administration and continued until the end of the experiment.24 Evaluation of liver damage At the end of the experiment, after 72 hrs toxicity of CCl4, blood samples were collected from retro-orbital plexus from the overnight fasted animals, after anaesthetized with 100 mg/kg ketamine, i.p. The blood samples were taken with 20 μl Ethylene diamine tetraacetic acid  (EDTA) (5%) in each Eppendorf and centrifuged at 5000 rpm for 20 min (Sigma 3K30, UK). The supernatant (serum) was separated with the help of a micropipette and placed it in a new Eppendorf with well labelled and stored at -80°c for further analysis. The homogenate was centrifuged at 4°C for 5 min at 3000 r/min and the supernatant used for the estimation of viscous oxidative stress markers. (Biochemical and antioxidant estimation). The opposite liver tissue specimens were used for histopathological examination.25,26 Biochemical parameters like Serum glutamate oxaloacetate transferase (SGOT), Serum glutamate pyruvate transferase (SGPT), alkaline phosphatase (ALP) and Serum bilirubin were estimated by reported methods.27,28 Statistical analysis The results of the study were expressed as mean±SEM (Standard error of the mean). The student t-test and analysis of variance (ANOVA) were used followed by Newman-Keul’s multiple comparison tests to analyze the experimental data for its significance. RESULTS Histopathological Investigation Control (Group I): Hepatocytes of the normal control group showed normal lobular architecture of the liver (Figure 1A). Toxic Control Groups (II): Hepatocytic necrosis and inflammation region were observed in the liver treated with carbon tetrachloride (Figure 1B). Silymarin 25 mg/kg (Groups III): Silymarin pretreated group showed normal hepatocytes normal architecture (Figure 1C). Methanolic extract 200 mg/kg and 400 mg/kg (Groups IV & V): Methanolic extract 200 mg/kg and 400 mg/kg treated group showed recovery of hepatic parenchyma, mild congestion and microvesicular changes (Figure 1D & 1E). The phytochemical analysis of an extract of aerial parts of Bauhinia Vahli confirmed the presence of various phytoconstituents i.e. alkaloids, flavonoids, glycosides, terpenoids, and steroids. The extract is devoid of toxicity up to 2000 mg/kg in Wistar albino mice. In Carbon, tetrachloride treated mice, the levels of Bilirubin (Total & Direct), serum glutamic-oxaloacetic transaminase (SGOT), and serum glutamic-pyruvic transaminase (SGPT), and Alkaline phosphatase was significantly elevated. Silymarin (25 mg/kg) showed a significant decrease in Bilirubin (Total & Direct), SGOT, SGPT, and Alkaline phosphate level. Treatment with methanolic extract of Bauhinia Vahli at 200 mg/kg and 400 mg/kg showed a significant decrease in Bilirubin (Total & Direct), SGOT, SGPT, and Alkaline phosphatase level. Similarly, the treatment of aqueous extract at 200 and 400 mg/kg but 200 mg/kg showed a significant decrease in the above-mentioned biomarkers. However, 400 mg/kg w/w had shown a profound reduction of the above markers. The detailed result of the biochemical analysis is given in tables 1 & 2. The histopathological studies of the normal liver sections showed the hepatic cells with well-preserved cytoplasm, prominent nucleus, and central vein (Figure 1A). In rats treated with Carbon tetrachloride, the normal architecture of the liver was completely lost with the appearance of centrilobular necrosis, lymphocytes infiltration of the periportal area, and fatty changes were observed (Figure 1B). The mice administrated with silymarin (25 mg/kg) exhibited a significant reversal of the hepatic damage caused by Carbon tetrachloride (Figure. 1C). Methanolic extract at a dose of 200 mg/kg and 400 mg/kg had shown some improvement in damaged hepatocytes whereas the aqueous extract at 200 and 400 mg/kg had shown remarkable improvement in damaged hepatocyte which is evidenced from reversal of damaged hepatocytes to normal hepatic architectural pattern with mild hepatitis (Figure. 1D & 1E). Discussion CCl4 intoxication is a widely used experimental model for liver injury. The highly hepatotoxic metabolites, namely, trichloromethyl radicals (CCl3* and CCl3O2*) are generated during the metabolic activation of CCl4 by cytochrome P-450. These radicals have a central role in the initiation of lipid peroxidation, inflammation, and fatty changes of the liver.29,30 Moreover, CCl4 intoxication is associated with oxidative stress since theCCl3* and CCl3O2* radicals alter the antioxidant state of the liver by deactivating the hepatic antioxidant enzymes including SOD, GPx, GR, and GST. Trichloromethyl radicals also react with the sulfhydryl groups of GSH leading to its deactivation.31 In the present study, CCl4 treatment markedly increased the levels of AST, ALT, and ALP. The leakage of the marker enzymes into the blood was associated with marked necrosis, loss of hepatic architecture, hydropic degeneration, fatty changes, Kupffer cell hyperplasia, central vein congestion, and infiltration of the liver by lymphocytes. The MDA level in the liver tissue was markedly increased in response to CCl4 intoxication, indicating oxidative damage of the liver. CCl4 administration also reduced the levels of GPx, SOD, GST, GSH, and GR in the liver tissue compared to the normal mice. The results of the present study demonstrated that treatment with BBME returned the increased MDA to its normal level. The inhibitory effect against lipid peroxidation suggested that BBME could prevent the liver injury induced by free radicals along with the subsequent pathological changes in the liver.33 The marked reduction in the leakage of liver enzymes into the serum also confirmed the inhibitory effect of BBME against lipid peroxidation. In contrast, the GSH, GPx, SOD, GST, and GR levels were markedly improved compared to the silymarin-treated group. Modulation of these antioxidant defences contributed to the antioxidant and hepatoprotective activity of BBME. The remarkable hepatoprotective and antioxidant effect of Bauhinia vahlii Methanolic extract (BBME) may be attributed to a synergistic effect between these compounds.32, 34 Conclusion Based on the results of this study, the hepatoprotective effect of BBME is attributed to its ability to reduce the rate of lipid peroxidation, to enhance the antioxidant defence status, and to guard against the pathological changes of the liver induced by CCl4 intoxication. The hepatoprotective activity of BBME is concluded to be partly mediated by the antioxidant effect of the extract. Advanced tools and equipment are needed for identification, isolation, and purification of the active ingredients of the hepatoprotective activity and to examine their efficacy and safety through controlled clinical trials. There should be a motivation plan to Medicinal Plants Research Centre in Sudan to create cooperative collaborative research activities among the involved institutions. ABBREVIATIONS ALP, Alkaline phosphatase; BBME, Bauhinia vahlii Methanolic extract, CCl4, Carbon tetrachloride; GPx, Glutathione Peroxidase; GSH, Glutathione; GST, Glutathione S-transferase; MOD, Multiple Organ Dysfunction Syndrom; SGOT, Serum Glutamic Oxaloacetic Transaminase; SGPT, Serum Glutamic Pyruvic Transaminase; SOD, Superoxide dismutase. ETHICS APPROVAL AND CONSENT TO PARTICIPATE Not applicable. HUMAN AND ANIMAL RIGHTS Animals were used for studies that are the basis of this research. ACKNOWLEDGMENTS Authors are thankful to CSIR-National Botanical Research Institute, Lucknow, Uttar Pradesh, India for authentication of selected Indian medicinal plant. Authors are also thankful to Er. Mahesh Goel, Chairman, Goel Group of Institutions, Lucknow, India for providing the research facilities to the compilation of present study. CONFLICT OF INTEREST The authors declare that they have no financial conflict of interest. FUNDING SOURCES Nil Englishhttp://ijcrr.com/abstract.php?article_id=3317http://ijcrr.com/article_html.php?did=3317 Afolayan AJ, Adewusi EA. A review of natural products with hepatoprotective activity. J Med Plant Res 2010;4: 1318-1334. Ahsan MR, Islam KM, Bulbul IJ. Hepatoprotective activity of Methanol Extract of some medicinal plants against carbon tetrachloride-induced hepatotoxicity in rats. Eur J Sci Res 2009;37:302-310. Banskota AH, Tezuka Y, Adnyana IK, Xiong Q, Hase K, Tran KQ, et al. Hepatoprotective effect of Combretum quadrangular and its constituents. Biol Pharm Bull 2003;23:456-460. Daly AK, Donaldson PT, Bhatnagar P, Shen Y, Peer I, Floratos A. HLA-B5701 genotype is a major determinant of drug-induced liver injury due to flucloxacillin. Nat Genet2009;41:816-819. Yang H, Sung SH, Kim YC. Two new hepatoprotective stilbene glycosides from Acer mono leaves. J Nat Prod 2005;68:101-103. Wang N, Li P, Wang Y, Peng W, Wu Z, Tan S. Hepatoprotective effect of Hypericum japonicum extract and its fractions. J Ethnopharmacol 2008;116:1-6. Alshawsh MA, Abdulla MA, Ismail S, Amin ZA. Hepatoprotective effects of Orthosiphon stamineus extract on thioacetamide-induced liver cirrhosis in rats. Evid Based Complement Alternat Med 2011;2011:1-6. Amin ZA, Bilgen M, Alshawsh MA, Ali HM, Hadi AHA, Abdulla MA. Protective role of Phyllanthus niruri extract against thioacetamide-induced liver cirrhosis in the rat model. Evid Based Complement Alternat Med 2012;2012:1-9. Garudapuran, Geeta press book, 2013, path 187. Krishnamurthi A, Manjunath BL, Sastri BN, Deshaprabhu SB, Chadha YR. The Wealth of India. Dictionary of Indian Raw Materials & Industrial Products, First supplement series (Raw Materials). NISCAIR New Delhi 2004;1:119-119. Chauhan R, Saklani S. Bauhinia vahlii: plant to be explored. Int Res J Pharma 2013;4:5-9. Pritipadma P, Sikha S, Abhishek P, Priyanka D Goutam G. Antimicrobial and Immunomodulatory Activities of Methanolic Extract of Bauhinia vahlii. Res J Pharm Biol Chem Sci 2015;6:655-660. M Nirmala M, Girija K,  Lakshman K, Divya T. Hepatoprotective activity of Musa paradisiaca on experimental animal models. Asian Pac J Trop Biomed 2012;2:1383-1387. Elbanna AH, Nooh MM, Mahrous EA, Khaleel AE, Elalfy TS. Extract of Bauhinia vahlii Shows Antihyperglycemic Activity, Reverses Oxidative Stress, and Protects Against Liver Damage in Streptozotocin-induced Diabetic Rats. Pharmacogn Mag 2017;3:607-612. Saravanan KS, Madhavan V. Antidiabetic activity of Bauhinia vahlii wt. and arn. (Caesalpiniaceae) root a botanical source for the Ayurveda drug murva.  Asian J Pharm Clin Res 2019;12:359-362. Singh KL, Singh DK, Singh VK. Multidimensional uses of Bauhinia variegate. Am J Phytomed Clin Therap 2016;4:58-72. Rajani GP, Ashok P. In vitro antioxidant and antihyperlipidemic activities of Bauhinia variegata Linn. Int J Pharmacol 2009;41:227-232. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareStudy of Fracture Patella with Tension Band Wiring English9599Mahendra GuptaEnglish Manish R ShahEnglish Aditya K. AgrawalEnglish Malkesh ShahEnglish Sarvang M DesaiEnglish Jagdish J PatwaEnglish Paresh GolwalaEnglishIntroduction: It is the study of patella fractures treated with tension band wiring. Objective: We wanted to study the surgical management and to assess its functional outcome in patella fractures, to study the range of movements, functional outcomes, duration of union, complications and compare the results of operated cases with other studies. Methods: The study consists of 35 patients sustaining patella fracture operated with tension band wiring. Clinical & functional outcomes were assessed by the knee society scoring system. Results: We have operated a total of 35 cases with tension band wiring in patella fractures. The average union was achieved in 12 - 13 week. We have obtained 85.71 % of an excellent outcome. Conclusion: In the case of transverse fracture of patella pleasing results were obtained with tension band wiring technique that allows early motion and rehabilitation. This technique has the benefit of early mobilization & early return of independent function. With strict adherence to anatomical reduction, aseptic soft tissue handling & soft tissue repair & proper & in time physiotherapy protocol we can get satisfactory results in almost all the patients. EnglishPatella, Tension band wiring, Physiotherapy, Anatomical reduction, Rehabilitation, UnionThe patella is a sesamoid bone and serves several important functions. It protects the knee joint from direct trauma. The patella is part of an extensor component mechanism of the knee. It serves to increase the mechanical advantage of the quadriceps muscle. Patella fractures constitute approximately 1% of all fractures.1 These fractures are most commonly seen in active young individuals. Commonly patella fracture is transverse, comminuted, or chip avulsion. The most common mechanism is direct or indirect trauma. Direct trauma is during a fall onto the anterior aspect of the knee or because of hitting a hard object. An indirect fracture can be due to sudden jumping, or rapid flexion and twisting of the knee against fully contracted quadriceps.2 Patellar fracture from indirect forces occurs when the intrinsic strength of the patella is exceeded by the pull of musculotendinous units attaching to it. This typically occurs in the act of stumbling or partially falling. Combined direct/indirect injuries are characterized by evidence of direct trauma to the skin and considerable fragment separation. The association between fragmentations of the distal pole has been noted.3 Transverse fractures are the most common, constituting 50% to 80% of a patella fracture. Stellate and comminuted fractures account for 30% to 35%, whereas longitudinal or marginal vertical fractures make up 12% to 17%. Osteochondral fractures are usually observed in-patient of 15 to1 20 years of age. Anomalies of ossification usually are related to an accessory, ossification centre at the superolateral corner of the patella. This is called a bipartite patella. If a similar lesion is present in the opposite knee, the diagnosis is clear. A major complication when the treatment is not entirely successful is post-traumatic arthritis of the patellofemoral joint and reduction in the range of motion of the knee joint.3 There are various options available in the literature for the treatment of fractures of the patella. Non-operative treatment has been limited to fracture that shows intact quadriceps component, separation of the fragments for less than two centimetres, and no significant displacement of articular surface.4 Tension band wiring is a commonly used treatment for displaced transverse fractures of the patella. The principle of tension band wiring is distractive forces at the fracture site are converted to compressive forces. The implant absorbs the tension and bone compression5. We have studied 35 cases of displaced transverse fractures of patella treated with tension band wiring in the present series. The study is aimed to evaluate the result of tension band wiring technique in patella fractures and to compare the outcomes achieved by tension band wiring of our study with other studies.4,6 MATERIALS and METHODS The patients were operated at a tertiary care district hospital after approval from the institutional ethics committee (SVIEC/Medi/BNPG14/D15). It was a prospective study. Inclusion criteria included fractures of patella in all age groups. The exclusion criteria included open patella fractures, un-displaced patella fractures, pathological fractures, patients managed non-operatively. Patients were followed for every month for a minimum period of six months. Patients were treated and admitted in hospital and followed up in orthopaedics outpatient department. In the current study, only those cases which were treated with tension band wiring were included. The operation was performed with longitudinal skin incision over the affected knee. After approaching the patella by a midline incision, blood clots and small fragments were removed and fracture surface cleaned, the extent of extensor expansion tear explored and trochlear groove inspected for damages to the femur. Proximal and distal fragments reduced and held firmly with clamps, with special attention to restoring the smooth articular surface. Two K-wires were introduced longitudinally across the fracture, wire loop being passed behind the tips of Kirchner wires and over the anterior surface of the patella in the form of the figure of eight. The wire was anchored directly in bone and retinaculum was repaired (tension band wiring). The articular surface of patella checked by palpation in extended knee position. Both upper ends of K-wire were bent at acute angles and anteriorly, cut short, rotated 180 degrees and hammered in with an impactor. The tear in the extensor expansion was repaired with interrupted sutures using ethibond 2-0 (Merville, USA). The tension band wiring procedure was performed with twelve to thirty-six hours after admission. In stable fixation of simple transverse fracture achieved early rehabilitation of knee joint with partial weight-bearing should be started as soon as the patient became pain-free. Static quadriceps and hamstring strengthening exercises were started immediate post-op. An active extension was started on 4th week.7,8 Active flexion started from 2nd week. In cases with associated extensor expansion tear flexion exercises were started after 3 weeks and without extensor expansion tear after 2 weeks.  Non-weight-bearing walking with extension brace was done till 2nd day and in associated injuries at 8th or 10th week respectively. Partial weight-bearing was continued till 2nd week and in associated injury till 8th and 10th week. Full weight-bearing was started after 2nd week and in associated injury after signs of the union of associated fracture seen. After discharge patients were followed up on 2nd week, 4th week, 2 months, 4th month and 6th month and thereafter every 2months in outpatient clinics. X rays were repeated on 4th week, 2nd month, 4th month and 6th month and thereafter every 2 months till radiological union. At every follow-up movements of the knee, quadriceps strength was noted. All the patients were examined and interviewed for evaluation. We used knee society score to see the results of surgical treatment of patella fracture with tension band wiring each patient was scored according to knee Society score. Patients below the score of 60 were considered poor, score60-69 were considered fair, score 70-79 were considered good, and score 80-100 were considered excellent. The criteria for fracture union were free movements on walking and sitting and union was also assessed by radiographs as well as clinical examination. No case was declared united unless it was fit on criteria of assessment. Non-union has been defined as a lack of healing for short time as six months to as long as 18 months.9,10 Statistical Analysis Statistical analysis was done using SPSS software (Illinois Chicago, USA) with a p-value less than 0.01 considered as significant. RESULTS From January 2016 to September 2017 a total number of 35 patients with recent fracture of the patella were treated with tension band wiring technique. All patients were followed for 22 ± 3 months. Those patients were selected in which fracture displacement was more than two centimetres. The best results were in the patients. Out of 35 patients 21 (60 %) patients were between 20-40 years of age, 14 (40%) patients were above 45 years ago. Out of 35, 27 (77.14%) patients were male and 08 (22.85%) were female out of 35 patients. 20 (57.14 %) patients had left side involvement and 15 (42.86 %) patients had right-sided involvement. The main cause of injury in 27 patients out of 35 (77.14 %) was a road traffic accident. All cases of road traffic accident were from two-wheelers. Eight patients (22.85 %) had a direct injury due to slipping while walking or climbing up on the stairs. Most of the patients were having displaced mid-patellar transverse patella fracture (n= 25 out of 35, 71.42 %). Five patients out of 35 (14 %) were having associated injuries with the majority having ipsilateral shaft femur fracture.  Four patients out of 35 (11.42 %) had shaft femur fracture on the same limb and one (2.85 %) patient with an ipsilateral distal femur fracture. Extensor expansion tear was not possible to diagnose on clinical examination, but during surgery on exploration, extensor expansion tear was identified on palpation in seven (20%) patients out of 35 patients. 25 (71.43 %) patient were operated within 72 hours of injury while five (14.85 %) patients were operated between 72 hours to 1 week after injury and five (14.85 %) patients were operated one week after injury. Patients were advised ambulation on the walker with extension knee brace without bearing weight on the next day. Partial weight bearing was started as soon as patient tolerated. Patients having associated fracture were not subjected to weight bearing till fracture shows signs of healing. All patients with delayed weight bearing were due to associated secondary injuries. Average mobilization was started on 2-3 weeks postoperatively the patients with extensor expansion tear were advised knee motion after 3 weeks and in other patients, mobilization was started after two weeks. In none of the patients, CPM (continuous passive motion) was started. 26 patients (74.29 %) were discharged one week after surgery while seven (20 %) patients were discharged between 8-12 days after surgery and two (5.71 %) patients were discharged two weeks after surgery. Patients discharged after two weeks had longer hospital stay due to associated injuries to the femur and tibia. 20 patients came for follow up between 9-12 months for follow up, 13 patients came for follow up more than 12 months after surgery and only two (5.72 %) patients came for follow up for less than 9 months. Meantime of union was 12 – 13 weeks, no non-union occurred in any patient. Post-operative wound infection was seen in one patient (2.85%). One patient (2.85 %) had a postoperative infection and one case (2.85 %) had mal-union due to inaccurate reduction. Six patients (17.14 %) had hardware impingement which was removed after the union. Two patients (5.71 %) had extension lag which was due to inaccurate education and osteoarthritis. Five patients (14.28 %) had painful movements which were due to mal-union and osteoarthritis.  Thirty patients with early post-op rehabilitation were having excellent results, four patients (11.42 %) with late post-op rehabilitation had a good result and one patient (2.85 %) had the fair result. Out of 30 patients operated within one week of injury had excellent results in 27 (90 %), good in two patients (2.85 %), fair in one (2.85%) patient. Out of 5 patients operated more than 1 week after injury had excellent results in 03 (60%), and good in 2 (40%). Knee society score for 30 (85.14%) patients was excellent, four (11.42 %) was good and one patient (2.85 %) had the fair result. One patient had ten degree of extension lag which was due to improper reduction with significant step off. Osteoarthritic changes were in one patient (2.85 %) with no marked quadriceps weakness seen. Out of 35, 34 (97.14 %) patients were satisfied with treatment and outcome. One (2.85 %) patient was less satisfied. All the patients had returned to the full level of their daily activities all the patients had returned to their original job. DISCUSSION The treatment of fracture of the patella may be either operative or non-operative but in most reports, non-operative treatment has been limited to fracture that show intact quadriceps mechanism less than 2 millimetres of separation and without significant displacement of the articular surface.  If there is rupture of quadriceps mechanism and displacement of patellar fragments more than 3mm it should be openly reduced and internally fixed.6 There are many surgical techniques for open reduction and internal fixation of a transverse fracture of the patella. However, at 90° of flexion of knee joint articular surface was distracted by posterior angulation of fracture fragments.7 But after application of tension band, wiring technique changes in the articular surface distraction are reduced so that early mobilization can be started.8 Tensile forces of quadriceps are converted to compressive force by anteriorly placed tension band wires.  Surgical treatment of transverse fractures of patella can lead to favourable results after tension band wiring.9,10 As males are more prone to road traffic accidents there was more number of male patients presented with patella fracture. In this study total number of 35 patients were included out of which 27 were male and 8 patients were female as the most common cause of injury in 27 (77.14%) were due to road traffic accidents and  08 patients were due to direct fall. Out of 35 20 (57.14 %) had left-sided involvement and 15 (42.86 %) had right side involvement.11 All 27 (77.14%) patients who were injured during road traffic accident were below 45 years age and all 08 (22.85%) patients sustaining injury due to direct fall while walking or climbing stairs were above 45 years ago. This directly correlates the main cause behind the injury in elderly people was primary osteoporosis and the cause of injured patella in the young patient was due to road traffic accident as they are breadwinners for the family, remains outdoor and live more active lives they are more prone to road traffic accidents.11,12 Levack et al found that men are more prone to road traffic accident due to more outdoor activities.13,14 Srinivasulu et al in his study reported 10.5 % cases with restriction of movements more than 20 degrees and suggested early mobilization and physiotherapy protocol to get better results.15 Maini et al., 1986 in his study of 30 patients showed extensor lag in 8 (26.6%) patients.16 We recommend knot to be bent at the anterolateral edge of the superior pole of the patella and proper bending of wire ends. Also, sharp ends of k wires should be made blunt so that they do not impinge on soft tissues. We recommend hardware should be removed as early as possible after the clinical and radiological union is established to prevent complications such as implant breakage and impingement. Results are always better when supported with proper post-operative physiotherapy protocol, early mobilization, proper intraoperative surgical technique supported by pre-operative planning, gentle tissue handling and less soft tissue damage, and also the full co-operation of patients in the rehabilitation phase as shown in figures 1, 2 and 3. Knee society score was excellent in 30 (85.71%), good in four patients (11.42%), and fair in one (2.85%) patient. Two patients (5.4%) had mild rest pain, two patients (5.4%) had mild pain while walking and five patients had mild pain in staircase climbing. All such patients responded well to physiotherapy and had good results. Gosal et al., 2016 in his study showed knee society score excellent in 75 % patients good in 20 % patients and fair in 05 patients out of 30 patients17 as shown in table 1. CONCLUSION Out of 35 patients, 34 patients (97.14%) were happy and satisfied with the treatment and outcome. One patient was not fully satisfied with the outcome as he was advised revision surgery to correct articular step-off. All the patients (100%) had returned to the full level of their daily activities. All the patients (100%)   had returned to their original job. This was one of the most important and most satisfying criteria for our study as this was the single criteria which explain all the result. In case of fracture of patella in our study satisfactory results obtained with tension band wiring than allow early motion and rehabilitation. This technique has the advantage of early mobilization and early return of independent function. With strict adherence to anatomical reduction, aseptic soft tissue handling and soft tissue repair and proper and in time physiotherapy protocol we can get satisfactory results in almost all the patients. CONFLICT OF INTEREST: None SOURCE OF FUNDING: None ACKNOWLEDGEMENTS: Patients and nursing staff of our hospital. Englishhttp://ijcrr.com/abstract.php?article_id=3318http://ijcrr.com/article_html.php?did=33181. Son M, Kim B, Kang N, Choi T. Treatment of patellar Fractures with Modified Tension Band Wiring. J Korean Soc Fract 1999;12(4):872. 2. Ndiaye A, Sy MH, Dansokho AV. Early evaluation of surgical treatment for patella fractures. Dakar Med J 1996; 41(2): 119-123. 3. Hung L, Chan K, Chow Y, Leung P. Fractured patella: operative treatment using the tension band principle. Injury 1985; 16(5):343-347. 4. Benjamin J, Bried J, Dohm M, McMurtry M. Biomechanical Evaluation of Various Forms of Fixation of Transverse Patellar Fractures. J Orthop Trauma 1987;1(3):219-222. 5. Burvant J, Thomas K, Alexander R, Harris M. Evaluation of Methods of Internal Fixation of Transverse Patella Fractures. J Orthop Trauma 1994; 8(2):147-153. 6. Berg E. Open Reduction Internal Fixation of Displaced Transverse Patella Fractures with Figure-Eight Wiring through Parallel Cannulated Compression Screws. J Orthop Trauma 1997; 11(8):573-576. 7. Jones D. Rockwood and Green’s Fractures in Adults (7th ed, 2 volume. J Bone Joint Surg 2010;92-B(10):1480-1480. 8. John J, Wagner W, Kuiper J. Tension-band wiring of transverse fractures of patella. The effect of site of wire twists and orientation of stainless steel wire loop: a biomechanical investigation. Int Orthop 2006; 31(5):703-707. 9. Della Rocca G. Displaced Patella Fractures. J Knee Surg 2013; 26(05):293-300. 10. Kim J, Lee Y, Gong H, Lee S, Lee S, Baek G. Use of Kirschner Wires With Eyelets for Tension Band Wiring of Olecranon Fractures. J Hand Surg 2013; 38(9):1762-1767. 11. Gardner M, Griffith M, Lawrence B, Lorich D. Complete Exposure of the Articular Surface for Fixation of Patellar Fractures. J Orthop Trauma. 2005; 19(2):118-123. 12. Yang K, Byun Y. Separate vertical wiring for the fixation of comminuted fractures of the inferior pole of the patella. J Bone Joint Surg 2003;85-B(8):1155-1160. 13. Gosal H, Singh P, Field R. Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester- a study of 37 cases. Injury 2001;32(2):129-135. 14. Chen A, Hou C, Bao J, Guo S. Comparison of biodegradable and metallic tension-band fixation for patella fractures: 38 patients followed for 2 years. Acta Orthopaedica Scandinavica 1998; 69(1):39-42. 15. Chatakondu S, Abhaykumar S, Elliott D. The use of non-absorbable suture in the fixation of patellar fractures: a preliminary report. Injury 1998;29(1):23-27. 16.       Chen C, Huang H, Wu T, Lin J. Transosseous suturing of patellar fractures with braided polyester—a prospective cohort with a matched historical control study. Injury 2013; 44:1309–1313.  17. Gosal H, Singh P, Field R. Clinical experience of patellar fracture fixation using metal wire or non-absorbable polyester — a study of 37 cases. Injury 2001; 32(2):129-135.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareHypoglycemic Effects of Apigenin from Morus Indica in Streptozotocin Induced Diabetic Rats English100105Satish AnandanEnglish Asna UroojEnglishIntroduction: Morus Indica L occupies an important position in the holistic system of Indian medicine ‘Ayurveda’ which has its roots in antiquity and has been followed for centuries. Objective: Methods: The hypoglycemic potential of apigenin isolated from MI leaves in streptozotocin (STZ) induced diabetic rats was studied. The rats were divided into four groups (n=6 animals in each group) viz. Group I- Normal healthy control rats (NC); Group II- STZ-induced diabetic control (DC) rats without treatment; Group III- STZ-induced diabetic rats treated with Aminoguanidine (AG) (30 mg kg-1 body weight by intraperitoneal); Group IV- STZ-induced diabetic rats treated with Apigenin (API) (50 mg kg-1 body weight was given by orally). The protective effect of API was evaluated by determining the biochemical parameters (lipid profile, liver, and kidney) and by studying the histopathological alterations in liver and kidney. Results: Diabetic control group had altered biochemical values (lipid profile, liver and kidney) when compared with the NC group. However, treatment with API showed significant improvement in the biochemical parameters and values are comparable to the NC group. Histopathological data revealed destruction of the kidney and liver architecture in DC, which was reverted in the group treated with API. Conclusions: The present findings suggest that API might be useful in the management of diabetes mellitus. English Hyperglycemic, Mulberry, Flavonoids, Streptozotocin, Oxidative stressINTRODUCTION Diabetes mellitus (DM) is a metabolic disorder characterized by insulin resistance and pancreatic β-cell dysfunction as a consequence of unsettled hyperglycemia.1 Prolonged hyperglycaemia may lead to a variety of secondary complications such as retinopathy, nephropathy, neuropathy and cardiovascular disease.2 Type 2 diabetes mellitus (T2DM) is one of the most common forms of diabetes in worldwide. In India, around 69.2 million people are prone to T2DM and it has the second-highest number of people living with DM worldwide following China.3 Even though powerful anti-diabetic drugs are offered for the management of diabetes, there has been no drug developed which has no side effect(s) with low cost-effective.4 Therefore, natural products have stimulated a new wave of research to look for more ef?cacious agents with lesser side effects.5, 6 Traditional knowledge with its holistic and systematic approach supported by scientific documentation can serve as a novel, affordable medicine with minimum side effects.7,8 Morus Indica L. is used as traditional medicine for its hypoglycemic and diuretic properties.8In our laboratory, Morus Indica (MI) has been screened for various biological properties such as antioxidant, toxicological studies, anti-hypercholesterolemic, and anti-diabetic effect in in-vitro, ex-vivo and in-vivo models.9-12 In our previous study, Morus Indica-G4 (MI-G4) variety exhibited the highest AGEs inhibition in BSA-glucose model which could be due to the presence of polyphenols and phenolic compounds.13 Further, we isolated the bioactive compound of apigenin (API) and showed potential AGEs inhibition in all stages of protein glycation.14 Besides, API is also proved to inhibit Aldose reductase (ALR) activity, one of the major complications of diabetes (cataract) in the lens.15 Literature reports research studies carried out in the crude extract of MI and very limited studies have investigated the role of active ingredients from MI of G4 variety for their bene?cial effects on DM. Therefore, the present study was undertaken to assess the role of isolated API from MI for anti-diabetic efficacy in STZ-induced diabetic rats. MATERIALS AND METHODS  Chemicals and reagents Clinical diagnostics kits were purchased from M/s. Agappe Diagnostics Ltd, Kerala, India. All the chemical reagents used in this experiment were of analytical grade. Collection of Plant material Morus Indica G4 leaves ((ISGR Reg. No.: 050564) were collected from Centre for Sericulture Research and Technical Institute (CSRTI), Mysore district of Karnataka, India. Apigenin was isolated from 80% methanol extract of leaves by preparative HPLC and characterized through Ultra performance liquid chromatography-mass spectra (UP-LCMS), Nuclear magnetic resonance (NMR), Fourier transform infrared spectroscopy (FTIR) and Scanning electron microscope (SEM).14 Experimental rats In this experimental study, twenty-four healthy adult male Wistar Strain rats (140-190 g), were procured from the animal house facility of the University of Mysore (UoM), Mysuru. The obtained animals were kept in polyacrylic cages. The animals were maintained under standard conditions, with a temperature of 22 ± 2?C, a regular 12/12 hour light-dark cycle. The animals were fed with pellet diet and water ad libitum. The animal experimental protocol was approved by the Ethics Committee of the UoM, Manasagangotri, Mysuru. (Animal Sanction Order No: UOM/IAEC/05/2017). Induction of diabetes and treatment Diabetes was induced by a single intraperitoneal injection of streptozotocin (STZ) to animals fasted overnight at a dose of 45 mg kg-1 body weight citrate buffer (pH 4.5) and the normal control rats received freshly prepared citrate buffer (pH 4.5) alone.16 Diabetic condition in rats was confirmed by measuring the altered fasting blood glucose level (by Glucometer) after 72 h of STZ injection. The rats with fasting blood glucose above 250 mg dL-1 were considered to be hyperglycemic and used for the experiment. Based on their weights using randomized block design, the rats were divided into four groups (consisting of 6 rats in each group) viz. Group I- Normal healthy control rat (NC), Group II- STZ-induced hyperglycemic rats without treatment (DC), Group III- STZ-induced hyperglycemic rats treated with Aminoguanidine (30 mg kg-1 body weight by intraperitoneal) as a positive control, Group IV- STZ-induced hyperglycemic rats treated with Apigenin (API) (50 mg kg-1 body weight was given by orally) and treated accordingly for 45 days. At the end of the study, the rats were made to fast for 12 h before blood collection. For ease of handling, before blood sampling, the rats were anaesthetized with diethyl ether. The blood samples were collected by cardiac puncture using 25 G, 1" needle. Approximately 5 ml of blood was taken and dispensed into labelled plain tubes. The blood samples were then centrifuged at 3000 rpm at 4 °C for 15 min to separate the serum. The serum was stored at -40°C until biochemical assays were carried out. Estimation of body weight During the experimental period, the body weights of the experimental rats were recorded on alternate weeks, i.e on day 0, 14, 28 and 45 by using a digital balance. These weights were determined at the fixed time in the morning session throughout the experimental period. Estimation of blood glucose Blood glucose levels of experimental rats were measured using a glucometer (Roche, Germany) by taking 0.5 µL blood from lateral tail vain onto the test strip on days of bodyweight determination. Biochemical studies Blood serum was used for the evaluation of lipid profile [total cholesterol (TC), triglyceride (TG) and high-density lipoprotein (HDL)],  renal function test [Creatinine (CR), bilirubin (BIL), blood urea nitrogen (BUN)] and liver function test [alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) including, total protein (TP), albumin (ALB)], using commercial kits from (Agappe Diagnostics Ltd., India), according to the manufacturer’s protocol. Histopathological studies Small portions of the kidney and liver were fixed in 10% formaldehyde and were dehydrated with graded ethanol series (50-100%) and were embedded in paraffin. The paraffin blocks were subsequently cut into (4-5 ????m) and stained with haematoxylin and eosin (HE) dyes. The slides were examined under a microscope for histopathological changes. Statistical analysis The values are expressed as mean ± SD. The data were subjected to one-way ANOVA followed by Tukey&#39;s multiple comparisons test for significant difference (≤0.05) using SPSS16.0 software. RESULTS Changes in blood glucose level and body weight of experimental rats The blood glucose level and body weight of all the groups of experimental rats are shown in Table 1. There was a significant elevation in the blood glucose level and a significant decrease in the body weight in diabetic control compared with normal rats. The daily administration of API  for 45 days tended to decrease the blood glucose level, while the mean body weight was comparable with that of the control group. Serum lipid profiles, renal and liver function test of experimental rats The serum level of lipid profile [total cholesterol (TC), triglyceride (TG) and high-density lipoprotein (HDL)],  renal function test [Creatinine (CR), bilirubin (BIL), blood urea nitrogen (BUN)] and liver function test [alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) including, albumin (ALB)] and total protein (TP) activities in all groups are shown in Table 2. The serum TC, TG, CR, BIL, BUN, ALT, AST and  ALP levels were significantly increased in diabetic control when compared to normal control. Signi?cant (PEnglishhttp://ijcrr.com/abstract.php?article_id=3319http://ijcrr.com/article_html.php?did=3319 American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2014 Jan 1;37(1): S81-90. Fowler MJ. Microvascular and macrovascular complications of diabetes. Clin Diabetes 2008 Apr 1;26 (2):77-82. Sen A. Health: perception versus observation: self-reported morbidity has severe limitations and can be extremely misleading. BMJ 2002;324(7342): 860–861. Chaudhury A, Dufour C, Dendi R, Sena V, Kraleti S, Chada A, et al. Clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. Front Endocrinol 2017;8:6. Rey-Ladino J, Ross AG, Cripps AW, McManus DP, Quinn R. Natural products and the search for novel vaccine adjuvants. Vaccine 2011;29(38):6464-6471. Katiyar C, Gupta A, Kanjilal S, Katiyar S. Drug discovery from plant sources: An integrated approach. Ayurveda 2012;33(1):10-9. Patwardhan B, Vaidya AD, Chorghade M. Ayurveda and natural products drug discovery. Curr Sci 2004 Mar 25:789-799. da Silva Almeida JR, Souza GR, da Cruz Araújo EC, Silva FS, de Lima JT, de Araújo Ribeiro LA, et al. Medicinal plants and natural compounds from the genus Morus (Moraceae) with hypoglycemic activity: a review. Glucose Toler 2012:189. Arabshahi-Delouee S, Urooj A. Antioxidant properties of various solvent extracts of mulberry (Morus Indica L.) leaves. Food Chem 2007;102(4):1233-1240. Reddy PV, Urooj A. Inhibition of 3-hydroxy-3-methylglutaryl coenzyme A reductase (ex vivo) by Morus Indica (Mulberry). Chinese J Biol 2014; 2014. Devi DV, Urooj A. Antihyperglycemic and hypolipidemic effect of Morus Indica L. in streptozotocin-induced diabetic rats. Ann Phytomed 2014;3(2):55-59. Reddy PV, Sreenivas N, Urooj A. Acute toxicological studies of leaf extracts of Morus Indica L. in rats. Ann Phytomed 2016;5(2):108-102. Anandan S, Kotebagilu NP, Shivanna LM, Urooj A. Inhibitory potency of C-glycosyl flavonoids from morus sp. on advanced glycation end products. J Biol Active Prod 2017;7(5):391-400. Anandan S, Urooj A. Bioactive Compounds from Morus Indica as Inhibitors of Advanced Glycation End Products. Ind J Pharm Sci 2019;81(2):282-292. Anandan S, Mahadevamurthy M, Urooj A. Ex vivo and in silico Molecular Docking Studies of Aldose Reductase Inhibitory Activity of Apigenin from Morus Indica L. J Young Pharm 2019;11(1):483-486. Furman BL. Streptozotocin?induced diabetic models in mice and rats. Curr Protoc Pharmacol 2015;70(1): 5.47.1-5.47.20. Ward DT, Yau SK, Mee AP, Mawer EB, Miller CA, Garland HO, Riccardi D. Functional, molecular, and biochemical characterization of streptozotocin-induced diabetes. J Am Soc Nephrol 2001;12(4):779-790. Wei M, Ong L, Smith MT, Ross FB, Schmid K, Hoey AJ, et al. The streptozotocin-diabetic rat as a model of the chronic complications of human diabetes. Heart Lung Circ 2003;12(1):44-50. Wilcox G. Insulin and insulin resistance. Clin Biochem Rev. 2005 May;26(2):19-39. Salem MY, El-Azab NE. The possible protective role of aloe vera extracts in pancreatic β cells of experimentally induced diabetic rats: a histological and immune histochemical study. Egyptian J Histol 2014 Sep 1;37(3):571-578. Fernstrom MH, Fernstrom JD. Large changes in serum free tryptophan levels do not alter brain tryptophan levels: studies in streptozotocin-diabetic rats. Life Sci 1993;52(11):907-916. Aguirre L, Arias N, Teresa Macarulla M, Gracia A, P Portillo M. Beneficial effects of quercetin on obesity and diabetes. Open Nutraceu J 2011;4(1):189-198. Shah SS, Shah GB, Singh SD, Gohil PV, Chauhan K, Shah KA, Chorawala M. Effect of piperine in the regulation of obesity-induced dyslipidemia in high-fat diet rats. Ind J Pharmacol 2011;43(3):296-299. Andallu B, Kumar AV, Varadacharyulu NC. Lipid abnormalities in streptozotocin-diabetes: amelioration by Morus indica L. cv Suguna leaves. Int J Diabetes Dev 2009 Jul;29(3):123-128. Jain D, Saha S. Antioxidant and antihyperglycaemic effects of naringenin arrest the progression of diabetic nephropathy in diabetic rats.  Egypt pharmaceut J 2017;16 (3):144-151. Niedowicz DM, Daleke DL. The role of oxidative stress in diabetic complications. Cell Biochem Biophys 2005;43(2):289-330. Anandan S, Siddiqi S, Siraj SF, Asna U. Protective Effect of Apigenin from Morus indica. L against Methylglyoxal Induced Oxidative DNA Damage. Int J Pharm Biol Sci. 2019.9(20):173-178. Ghanbari E, Nejati V, Khazaei M. Improvement in serum biochemical alterations and oxidative stress of liver and pancreas following use of royal jelly in streptozotocin-induced diabetic rats. Cell J 2016;18(3):362-370. Nithiya T, Udayakumar R. Hepato and renal protective effect of phloretin on streptozotocin-induced diabetic rats. J Biomed Pharm Sci 2018;1(105):3-6. Patel DK, Prasad SK, Kumar R, Hemalatha S. An overview on antidiabetic medicinal plants having insulin mimetic property. Asian Pac J Trop Biomed 2012;2(4):320-330. Rajesh R, Arunchandra SS, Anandraj KV, Manimekalai K, Dhananjay K, Rajasekar. The effect of Mucuna pruriens seed extract on pancreas and liver of diabetic Swistar rats. Int J Curr Res Rev 2016;8(4):61-67.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareAn overview of the Implant Therapy: The Esthetic Approach English106112Kashish MangalEnglish Mithilesh M. DhamandeEnglish Seema SatheEnglish Surekha GodboleEnglish Rupali M. PatelEnglishMany have mastered the skills of implant placement, but the art of rehabilitating the patient with anaesthetic prosthesis is the most important aspect of the treatment. While dealing with implants placed in the anterior region of the oral cavity in patients which in a way can be termed as the limelight area for esthetics, incorporating various factors for esthetics become imperative. This article aims to concise the majority of these factors under one umbrella. For this article, a thorough online search on this topic was carried out for collection and evaluation of available data. Before the surgery, the patient should be thoroughly evaluated using appropriate records like study models and necessary investigations like radiographs and CBCT scan should be obtained to assist in appropriate planning of the case. The patient’s soft and hard tissue profile has to be evaluated, any discrepancy in which should be suitably addressed. After the pre-surgical evaluation, the technique of implant placement should be finalised by the patient’s clinical conditions and requirements. The implant should be placed in an ideal manner to create near to natural esthetic profile. Any aberrations in the soft tissue occurring should also be anticipated and managed to reduce the number of surgeries required in the creation of the esthetic appearance. Once the placement has been done a suitable abutment should be selected and the entire focus should be given to creating a natural emergence profile for the future implant prosthesis. The result should be a natural life-like esthetic profile of the patient. English Implant esthetics, Provisionalization, Emergence profile, Implant positionIntroduction With the increase in technological advancement, a good number of population has now become more aware regarding the available dental treatments and its importance. Not only this but the significance of teeth in the esthetics and appearance of a person has also been more accepted and understood by people. When a patient loses their anterior teeth, the most preferred option by patients has been fixed prosthesis because of various reasons out of which esthetics is prime. Esthetics can be defined as “the theory and philosophy that deal with beauty and the beautiful, especially concerning the appearance of a dental restoration, as achieved through its form and/or colour; those subjective and objective elements and principles underlying the beauty and attractiveness of an object, design, or principle.1 This becomes truer when the clinician is dealing with the anterior zone which is the prime esthetic focal point of any person. Dental implants were first introduced by Brånemark in the 1900s.2 Since then there have been countless advancements in this treatment modality ranging from its type, design, material as well as associated techniques. Currently, the market is flooded with a huge array of options available.3 A few of these have specifically been designed keeping the esthetic demands of the treatment.4-6 Though awareness in the population about implants as the preferred treatment is limited but the willingness to know more has been reported.9 Many have mastered the skills of implant placement, but the art of rehabilitating the patient with anaesthetic prosthesis is the most important aspect of the treatment. Detailed information regarding managing the anterior esthetics specifically for implant-retained fixed dental prosthesis [FDP] is relatively less. The existent difference between natural teeth and a dental implant governs various factors which need an additional consideration of anterior implant-retained FDP.2,10,11 This article deals with the implant esthetics and factors associated with it while specifically dealing with the anterior zone. For ease of clinical correlation and understanding, three different phases of the treatment have been identified with their respective imperative factors to be considered for optimum implant esthetics (Table 1). Pre-Surgical Phase When a patient enters the clinic with the expectation of rehabilitating his lost anterior teeth, the best treatment that can be given to him starts with an impeccable treatment planning before implant placement. It includes – Study Model Evaluation Radiographic Evaluation Soft & Hard Tissue Evaluation7,8 Study Model Evaluation The study models in any and every prosthodontic treatment are indispensable. These important diagnostic tools enhance the predictability of the treatment & enabling proper treatment planning with a 3D working representation of the patient to the clinician.13 This overall visualization of the patient’s oral cavity helps in planning a holistic treatment for the patient. The analysis of obtained models can give the clinician a wide range of information including the occlusal & arch relation, interarch space, number & position of adjacent teeth, appreciation of the edentulous ridge as well as planning of future implant placements to be done. Radiographic Evaluation Bone quality governs the success of implants. It is a primary factor in successful osseointegration of implants. Before the decision of implant placement is made, it is always imperative to assess the bone condition in which the said treatment is planned to estimate the prognosis. This bone quality is assessed with the help of roentgenographs or radiographs. With the help of Cone Beam Computed Tomography (CBCT), we can now have a very accurate idea of the bony conditions which the clinician might encounter.14,15Software these days come along with additional features of assessing the Hounsfield units of the imaged bone which when compared with the Mischclassification for bone can give a precise idea for the prognosis of the treatment.9,10 Soft & Hard Tissue Evaluation Esthetics is a harmony which exists between the teeth and its surrounding hard and soft tissues. Therefore, assessment of the adjacent structures is also necessary. Firstly, the gingival biotype i.e. thickness of the gingiva in faciopalatal/ faciolingual direction is to be assessed. It can be divided into two types- thin and scalloped or thick and flat. When the gingiva measures less than 1.5mm it is deemed as thin and scalloped biotype and when it has a dimension more than 2mm it is called thick and flat. Normal thickness of gingiva ranges from 1.5-2 mm. An unfortunate chance of visibility of an unesthetic titanium ‘shadow’ may be seen with thin biotype along with increased vulnerability for gingival recession. Thus, various esthetic prosthetic implant options like esthetic abutments or different implant placement technique or varied implant design might be considered. Secondly, an assessment of the keratinized band of gingiva has to be made. A minimum requirement of 2 mm has been suggested for optimum peri-implant esthetics. Thirdly, the available bone height and width has to be checked in absence of which various grafting and augmentation techniques like vertical augmentation, en bloc grafting, particulate grafting, distraction osteogenesis. might have to be employed.16,17 Surgical Phase Under this head, first comes the evaluation of best possible esthetic implant placement modality. After it, the ideal implant placement has to be ensured by the implantologist following which comes the management of soft tissue.11,12 Available Treatment Modalities The ultimate aim of a treatment offered by any dentist is to give the patient the best possible results. With the inputs of various creative and great minds over the years, now we have a variety of treatment modalities to choose from as per the patient’s requirement. The two modalities which stand out in this are – Guided implant surgery and Immediate implant placement. These both techniques have been advised and reported with better results when dealing with implant placement in the patient’s esthetic zone. Both of these techniques work best when applied together but can also be employed separately. Guided implant surgery refers to implant placement with the help of a custom made surgical stent for the patient with the help of their CBCT scans and respective analysis made on the scan. The data is then processed via computer-aided designing and computer-aided manufacturing (CAD-CAM) machinery to fabricate a replica of the image assessment and planned implant. The most important advantage that this technique offers is the precise implant placement in the patient and thus optimum esthetics.18-20 Immediate implant placement works best when we are dealing with the anterior zone provided the appropriate method of temporization is used. This provides the patient with not only an immediate replacement and thus protect them from any social or personal awkwardness regarding edentulousness but also the extracted tooth provides optimum guidance for optimum implant placement.21,22 Ideal Implant Positioning Another important factor to consider while ensuring the best possible esthetics for a patient is the appropriate implant placement. A faulty placement may not only lead to esthetic but also prosthetic complications. Mesio-distal positioning The implant should be placed with at least 1.5mm of the distance between the implant and adjacent teeth on each side. In cases of multiple implant placement, a minimum of 3mm inter-implant distance should be maintained (Figure 1).23  Labio-palatal positioning This dictates the angulation at which the implant will be placed in the alveolar bone. The labio-palatal positioning holds utmost importance when dealing with anterior zone since it helps in developing the emergence profile of future implant prosthesis. The ideal positioning of the implant in this direction is advised to be following the facial contours of the adjacent teeth. A minimum of 1-1.5mm of buccal bone and 0.8mm of palatal bone should be spared while placing the implant (Figure 2). 24 Not only the amount of bone but the type of future implant prosthesis which is planned also dictates the labio-palatal positioning of the implant. It has been advised that if the prosthesis has to be cement-retained then the placement has to exactly in the centre of the long axis of the said prosthesis. When a screw-retained prosthesis is planned, the implant may have to be positioned slightly palatal to the long axis of the prosthesis to ensure palatal access to the screw channel. An improper implant placement or a too buccal placement may lead to inadequate buccal bone present to envelope the implant. This may further result in severe complications like dehiscence or fenestrations.11 Apico-incisal Positioning An implant placed rightly in the axial or apical-incisal direction will give the clinician sufficient space to develop an adequate emergence profile for the future implant prosthesis. It has been suggested that the implant ideally should be placed 2-3mm apically to an imaginary line connecting the deepest portions or the zenith of gingival contours of the adjacent teeth. When the natural adjacent landmarks are missing and multiple implants are to be placed then the implant head can be positioned at the alveolar crest within the circumference of the tooth to be restored. The 2-3mm of pico-incisal distance will give the clinician sufficient space around the implant, otherwise called a running room, within which the contours of restoration can be developed (Figure 3).12-14 It is an obvious fact that the cross-sectional diameter of a natural tooth and the head of an implant has a huge variation. To compensate this & provide the patient with a near to natural esthetics, this running room is essential. In this, the clinician can gradually increase the bulk of material to create optimum peri-implant esthetics.15 Soft Tissue Management As rightly said by Professor Dr. Jan Lindhe “The bone sets the tone, the soft tissue is the issue”, dealing with the peri-implant soft tissue for a complete esthetic appearance is of great significance. The major value here has to be given to the development of suitable interdental papilla, the absence of which may lead to the highly unesthetic black triangles. If the implant were to be placed appropriately in its apical-coronal direction, then according to Tarnow, with 5mm of the distance between the crest of the bone and contact point of teeth and prosthesis should observe a 100% papilla fill. As the distance increases a reduction in papillary fill is observed which may further complicate the situation and require surgical or prosthetic intervention for correction.25–28 Post-surgical Phase After the implant has been placed, and it is the time for restoration, the post-surgical management of implant esthetics come into the picture. In this, the primary focus will be on professionalization, development of emergence profile, abutment selection followed by the definitive prosthesis and follow-up. Provisionalization Provisionalization or temporisation refers to rehabilitating the patient with a short-lived treatment option until definitive restoration can be put into its place.29 They help not only in improving the quality of life for the patient undergoing implant therapy by enhancing his esthetics but also serves as a template for designing the definitive prosthesis. The provisional prosthesis can be given soon after the tooth extraction or during the socket healing and site development. It can also be utilized before implant placement or during the phases of osseointegrationor after the second stage surgery. In such case, the provisional prosthesis will help in supporting the soft tissue to build an appropriate emergence profile and help in assessment of esthetics and phonetics prior to fabrication of the definitive restoration.30 Broadly, provisional restorations can be classified as removable or fixed. Under the umbrella of temporary prosthesis, the clinician has various options like an existing prosthesis that the patient already uses or a removable partial denture, a vacuum formed retainer, a chairside or laboratory made resin bonded bridge,conventional FDP, provisional prosthesis supported by immediately loaded transitional implants or implant-supported provisional prosthesis. The choice of provisional prosthesis should be made considering the type of treatment modality planned. For example, in cases where the surgical site has been modified with augmentation or grafting which necessitated a longer unhindered healing period, a provisional prosthesis which can withstand for the prescribed duration without hampering the healing and also enable modifications as and when required should be preferred. In cases of immediate implant placement, if an immediate temporary restoration/ prosthesis is planned, then it should be constructed such that support to the peri-implant tissue is provided. With this, the provisional prosthesis would help in preserving the already existing soft tissue curtain of the extracted natural tooth.4,30-31 Development of Emergence Profile Emergence profile is the contour of the implant restoration as it emerges from the gingiva. Creating a natural emergence profile holds utmost importance in implant esthetics. This can be done with ideal/ optimum implant placement and usage of proper temporary restoration for the patient.32-33 In optimal intraoral conditions where no major corrective procedures are required, the provisional prosthesis can be employed for the creation of an almost natural emergence profile.30The temporary restoration aids by the virtue of its diameter which is gradually increased beneath the gingival envelope, in other words within the running room. If the apical-incisal positioning of the implant is faulty resulting in an inadequate running room, the emergence profile of the restoration may be compromised. Every restoration within this running room should possess sub-critical and critical contours (Figure 4). These contours have to be incorporated in the prosthesis as per the requirement of the patient’s peri-implant conditions. Critical contour refers to the area of implant prosthesis and an underlying abutment which is immediately apical to the gingival margin of the restoration. The facial/labial profile of the critical contour plays a significant role in the location of the zenith of the associated gingival curtain which directly affects the apparent clinical length of the crown. Also, the interproximal profile of critical contour governs the shape of the prosthesis (triangular/ square). Modification in critical contour can affect the level of gingival zenithlabially.34 The second is sub-critical contour which exists only when an optimum running room has been given. This is the area of implant prosthesis which lies immediately coronal to the implant-abutment interface. Modification in the profile of this contour [convex, concave or flat] can have a significant effect on the overlying gingival envelope. If made convex it will support the gingival curtain, the concave profile may help in gaining increased tissue volume and in ideal conditions it can be maintained flat. The interproximal modification of this subcritical contour is said to help in enhancing the papilla fill inter proximally up to 0.5 –  1 mm.35 Abutment Selection The future of the prosthesis depends on the type of abutment selected. Currently, numerous options are available for the clinician ranging from different materials to different angulations and types of retention. Based on the type of retention, screw or cement-retained abutments may be chosen. Both of them have respective pros and cons, but their selection is also relative to the implant placement and vice-versa as stated earlier. If the abutment screw channel arises on the labial aspect of the prosthesis, then it will require further management to create an esthetic appearance which may not be completely acceptable to the patient. In cases where prior soft tissue evaluation was done and the patient had a thin gingival biotype with a high probability of a titanium shadow display, esthetic implant options will have to be considered.36 This is also true in cases whereas a result of improper implant placement titanium hue is visible. With the recent advances in biomaterials, there are diverse options available to handle such situations. These include Zirconia abutments, hybrid abutments, polyetheretherketone (PEEK) abutments etc.37-39 If the patient presents with an improperly placed implant or an implant with abnormal angulations, then utilization of angulated abutments or customized abutments may be required to fulfil the esthetic requirements of the patient. Variety of pre-angulated abutments are available with manufacturers these days ranging from 17 degrees to 35 degrees. But when the favourable esthetic profile cannot be established with the angulated abutments as well, the clinician might have to opt for customized abutments. Here, the options include castable abutments as well as the newer CAD-CAM abutments which widens the horizons with different biomaterials to be milled using various types of machinery for accurate fit and esthetics.34,40 Definitive prosthesis and Follow-up The task of construction of anaesthetic definitive or final restoration for anterior implants becomes much easier when appropriate temporization has already been employed. This provisional restoration, after thorough assessment for esthetics which includes the creation of emergence profile, phonetics and function, could directly be replicated to form the definitive restoration. With the technological benefit of CAD-CAM, this provisional restoration can directly be scanned and a replica of the same can be obtained. This helps the clinician by eliminating the errors which might occur due to multiple impression, duplication and laboratory procedures.26 After the definitive prosthesis has been delivered, the patient can be evaluated for the esthetics and function imparted by the restoration by using various scales and indices available. With the help of such indices along with patient satisfaction and clinician’s evaluation, the success of prosthesis and thus the treatment can be verified and justified. Conclusion The rehabilitation of the esthetic zone by implant-retained FDP is one of the most demanding and complex treatments due to the necessity to obtain an optimum esthetic result. Through osseointegration, restoration of function and soft and hard tissue esthetics dictate implant success, the patient&#39;s satisfaction is a key element of the success of implant therapy. With the concurrent paradigm shift in the approach of dental implantology making it more prosthetically driven, the necessity of a synergistic harmonious interdisciplinary approach between implant placement, soft tissue management and the prosthetic rehabilitation holds the key towards a happy and satisfied patient and clinician. To achieve this, a treatment governed by the guidelines for esthetic rehabilitation, specifically designed for implant rehabilitation should be imparted to the patient. This article outlines these guidelines with details about their clinical implication to help clinicians decide the best treatment course for the patient. Conflict of interest: Nil Acknowledgment: 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. Figure 1 : Illustration showing mesiodistal positioning of implant. a= 1.5mm distance between implant and adjacent teeth; b= 3 mm inter-implant distance. Figure 2: Illustration showing labio-palatal positioning of the implant. The green line denotes the level of implant head, the blue line represents the natural labial contour of natural teeth. a) Optimum space is present between the implant head and tooth contour whereas in b) implant is placed too close to the buccal contour and c) too much distance exists between the labial contour and implant making it difficult to rehabilitate with good esthetics. Figure 3 : Illustration depicting correct apico-coronal implant position. Ideally it should be placed 2-3mm beneath the gingival zenith to allow for adequate running room for prosthetic build-up. Englishhttp://ijcrr.com/abstract.php?article_id=3320http://ijcrr.com/article_html.php?did=33201.         Ferro KJ. The Glossary of Prosthodontic Terms 9. J Prosthodont 2017 May; 2.         Rajput R, Chouhan Z, Sindhu M, Sundararajan S, Chouhan RRS. A Brief Chronological Review of Dental Implant History. Int Dent J Stud Res 2016 Oct;4(3):105-107. 3.         Hong DGK, Oh J. Recent advances in dental implants. Maxillofac Plast Reconstr Surg. 2017 Dec;39(1):33. 4.         Kan JYK, Rungcharassaeng K, Liddelow G, Henry P, Goodacre CJ. Peri-implant tissue response following the immediate provisional restoration of scalloped implants in the esthetic zone: A one-year pilot prospective multicenter study. J Prosthet Dent 2007 Jun;97(6): S109–118. 5.         Starch-Jensen T, Christensen AE, Lorenzen H. Scalloped Implant-Abutment Connection Compared to Conventional Flat Implant-Abutment Connection: a Systematic Review and Meta-Analysis. J Oral Maxillofac Res 2017;8(1). 6.         Wöhrle PS. Nobel Perfect? Esthetic Scalloped Implant: Rationale for a New Design. Clin Implant Dent Relat Res 2003;5(s1):64-73. 7.         McAllister BS. Scalloped Implant Designs Enhance Interproximal Bone Levels. Int J Periodontics Restorative Dent 2007;27(1):9-15. 8.         Gadhia MH, Holt RL. A New Implant Design For Optimal Esthetics and Retention of Interproximal Papillae. Implant Dent 2003 Jun;12(2):164-169. 9.         Revankar RP, Sathe S, Borle AB, Godbole S, Pande S, Khungar P. Evaluation of Knowledge, Attitude and Awareness of patients regarding dental implants in Central India. Int J Dent Sci Innov Res 2019 Jun;2(3):285–291. 10.       Misch CE. Dental Implant Prosthetics. 2nd ed. Elsevier Mosby; 2015:46–65. 11.       El Askary AES. Advances in Esthetic Implant Dentistry. 3rd ed. Wiley Blackwell; 2019. 12.       Prem R, Acharya BG, Mathews J, Ambadas, Jagtap P, Bhavsar B. Indications for dental implant treatment- A clinician’s point of view. Int J Curr Res Rev 2014 Nov;6(21):29–33. 13.       Hupp JR. Introduction to Implant dentistry?: A student guide. J Oral Maxillofac Surg 2017 Feb;75(Supplement 2):106. 14.       Diwakar NR, Kamakshi SS. Recent advancements in dental digital radiography. Nagaraj T, editor. J Med Radiol Pathol Surg 2015;1:11-6. 15.       Jayachandran S. Digital imaging in dentistry: A review. Contemp Clin Dent 2017;8(2):193. 16.       Ferrari M, Carrabba M, Vichi A, Goracci C, Cagidiaco M. Influence of Abutment Color and Mucosal Thickness on Soft Tissue Color. Int J Oral Maxillofac Implants 2017 Mar;32(2):393–399. 17.       Agrawal DR, Jaiswal P. Different Techniques of Harvesting Connective Tissue Graft: An Update. Int J Curr Res Rev 2020 Aug;12(15):16–25. 18.       Motta M, Monsano R, Velloso GR, de Oliveira Silva JC, Luvizuto ER, Margonar R, et al. Guided Surgery in Esthetic Region: J Craniofac Surg 2016 May;27(3):e262–265. 19.       Fürhauser R, Mailath-Pokorny G, Haas R, Busenlechner D, Watzek G, Pommer B. Esthetics of Flapless Single-Tooth Implants in the Anterior Maxilla Using Guided Surgery: Association of Three-Dimensional Accuracy and Pink Esthetic Score: Esthetics of Guided Flapless Single-Tooth Implants. Clin Implant Dent Relat Res 2015;17:e427–433. 20.       Kulkarni PN, Bulbule NS, Kakade DM, Hakepatil NV. Radiographic Stents and Surgical Stents in Implant Placements: An Overview. Int J Curr Res Rev 2019 Jun;11(2):11–5. 21.       Agarwal DS, Devkar ND, Vibhute AR, Walke PD. Immediate Placement of Dental Implants: An Overview. J Dent Allied Sci 2018;7(2):5. 22.       Bhola M, Jacobs L, Kolhatkar S. Immediate implants for aesthetic success: New guidelines. J Int Clin Dent Res Organ 2015;7(3):138. 23.       Higginbottom F, Belser U, Jones JD, Keith SE. Prosthetic Management of Implants in the Esthetic Zone. Int J Oral Maxillofac Implants 2004;19 Suppl:62-72. 24.       Batra R, Kalra S, Batra H. Implant esthetics. Indian J Dent 2012 Jan;3(1):15–20. 25.       Ishikawa T, Salama M, Funato A, Kitajima H, Moroi H, Salama H, et al. Three-Dimensional Bone and Soft Tissue Requirements for Optimizing Esthetic Results in Compromised Cases with Multiple Implants. Int J Periodon Restor Dent 2010;30(5): 23-26. 26.       Tarnow D, Elian N, Fletcher P, Froum S, Magner A, Cho SC, et al. Vertical Distance from the Crest of Bone to the Height of the Interproximal Papilla Between Adjacent Implants. J Periodontol 2003 Dec;74(12):1785–1788. 27.       Tarnow DP, Magner AW, Fletcher P. The Effect of the Distance From the Contact Point to the Crest of Bone on the Presence or Absence of the Interproximal Dental Papilla. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareCharacteristic of Hemopoetic Microelemental Status in Conditionally Healthy Elderly Men and Women Depending on the Age Range English113117Boltaev Kamol ZhumaevichEnglishIntroduction: Hypomicroelementosis is currently a significant problem for modern haematology. Objective: The purpose of this study is to carry out a comparative analysis of hematopoietic trace elements - iron, copper and zinc - in apparently healthy elderly men and women, depending on the age range. Methods: For these purposes, all surveyed men and women living both in urban and rural conditions were divided into two age ranges - surveyed - up to and over 70 years. Results: The results of the analysis showed that there is no statistically significant difference between the indicators of blood haemoglobin and hematopoietic microelements - iron, copper and zinc in the whole group of examined elderly men and the group of examined elderly men and examined elderly women in old age. Conclusion: The study did not reveal differences in the indices of hematopoietic microelements - iron, copper, and zinc in the examined conditionally healthy urban and rural elderly men, depending on the conditions of permanent residence. English Hematopoiesis, Trace elements, Blood serum, Haemoglobin, AgeIntroduction Disturbances in the balance of trace elements in the human body lead to the development of diseases called microelementosis.1,2 It should be noted that the violation of the normal balance of trace elements in the body can be due to several reasons, namely deficiency, excess (overload), or imbalance.3,4 Studies indicate a wide spread of various forms of vitamin and microelement deficiency, in particular, among children, adolescents, women of fertile age, pregnant and lactating mothers, athletes, elderly people, the so-called polyhypovitamins and hypomicroelementosis.5 Among these nutritional deficiencies, hypomicroelementosis is currently a significant problem for modern haematology due to the significant frequency of these deficiencies and the variety and severity of their manifestations.3,6,7 Materials and Methods We examined elderly persons (the age of the surveyed was from 61 to 75 years) and 65 elderly persons (the age of the surveyed was 75 to 90 years). All subjects were selected for study by the method of random selection. In the study, haematological, morphological, and biochemical methods of analysis were used to verify the diagnosis of anaemia. The results of the study were processed by the methods of variation statistics with the determination of the reliability of the compared values ??of the analyzed indicators. Results and Discussion We carried out in a comparative aspect the study of indicators of hematopoietic microelements - nutrients and iron metabolism in the examined conditionally healthy elderly men who permanently live in urban and rural conditions of the Bukhara region to find out whether the conditions of permanent residence affect certain indicators reflecting the state of various functional body systems. As can be seen from the presented Table 1 there is no statistically significant difference between the haemoglobin values ??of blood and hematopoietic microelements - iron, copper, and zinc in the entire group of examined elderly men and the group of examined elderly men under the age of 70 - 133.5 ± 0.49 g/Land 132.6 ± 0.50 g/L, 14.9 ± 0.76 μmol/L and 17.5 ± 0.92 μmol/L, 12.1 ± 0.5 μmol/Land 14.0 ± 1.16 μmol/L and 16.8 ± 0.82 μmol/L and 18.9 ± 0.95 μmol/L, respectively. Note: p1-reliability between the indicators of trace elements in the surveyed under the age of 70 and the entire group of surveyed elderly men; p2-reliability between the indicators of microelements in those surveyed over the age of 70 and the entire group of surveyed elderly men; p3-reliability between the indicators of trace elements in those surveyed over the age of 70 and up to 70 years. At the same time, a statistically significant difference is revealed between the studied indicators between the entire group of examined elderly men and men over the age of 70 - 133.5 ± 0.49 g/Land 130.5 ± 0.78 g / l; 14.9 ± 0.76 μmol/L and 12.5 ± 0.61 μmol/L; 12.1 ± 0.50 μmol/L and 11.1 ± 0.84 μmol/L; and 16.8 ± 0.82 μmol/L and 14.2 ± 0.92 μmol/L, respectively. Similarly, we found a statistically significant difference in the studied indicators in the examined elderly men between older men under the age of 70 and over 70 years - 132.6 ± 0.50 g/l and 130.5 ± 0.78 g/l; 17.5 ± 0.92 μmol/L and 12.5 ± 0.61 μmol/L; 14.0 ± 1.16 μmol/L and 11.1 ± 0.84 μmol/L; and 18.9 ± 0.95 μmol/L and 14.2 ± 0.92 μmol/L, respectively. Table 2 also presents comparative data on indicators of hematopoietic trace elements studied by us in elderly women, depending on the age range. Note: p1 is the reliability between the parameters of haemoglobin and trace elements in the surveyed elderly women (the whole group) and surveyed elderly women under 70 years old; p2 - reliability between the parameters of haemoglobin and trace elements in all surveyed women and elderly women over the age of 70; ?3 - reliability between the surveyed elderly women under the age of 70 and over. As can be seen from the data presented, we did not find significant differences between the studied indicators of blood haemoglobin and trace elements in the entire group of examined elderly women and elderly women under the age of 70 - 122.3 ± 0.26 g/l and 123.0 ± 0, 23 g/L and 12.2 ± 0.36 μmol/L and 13.1 ± 0.52 μmol/L; 10.8 ± 0.34 μmol/L and 11.7 ± 0.46 μmol/L and 16.6 ± 0.54 μmol/L and 17.1 ± 0.50 μmol/L. At the same time, there is a statistically significant difference between the studied parameters of hemoglobin and trace elements in all surveyed elderly women and elderly women over the age of 70 - 122.3 ± 0.26 g/l and 121.0 ± 0.38 g/l; 12.2 ± 0.36 μmol/L and 10.2 ± 0.31 μmol/L; 10.8 ± 0.34 μmol/L and 8.59 ± 0.34 μmol/L; and 16.6 ± 0.54 μmol/L and 12.6 ± 0.32 μmol/L, respectively. A significant difference between the studied indicators was also revealed between the indicators typical for the group of surveyed elderly women aged up to 70 years and the group of elderly women aged over 70 years - 123.0 ± 0.23 g/l and 121.0 ± 0.38 g/l; 13.1 ± 0.52 μmol/L and 10.2 ± 0.31 μmol/L; 11.7 ± 0.46 μmol/L and 8.59 ± 0.34 μmol/L; and 17.1 ± 0.50 μmol/L and 12.6 ± 0.32 μmol/L, respectively. Thus, the study of the dependence of the indicators of total haemoglobin in blood and indicators of hematopoietic trace elements in the examined elderly men and women with different age ranges shows that there is a direct dependence of these indicators on age - in older people, there is a decrease in all studied indicators, which indicates a decreasing adaptive potential of an ageing organism. We also carried out in a comparative aspect the study of indicators of hematopoietic microelements - nutrients and iron metabolism in the examined conditionally healthy senile men, permanently residing in urban and rural conditions of the Bukhara region. The distribution of the surveyed conventionally healthy elderly men shows that they are distributed approximately the same in a rather narrow age range of 81-84 years, and thus, the indices of hematopoietic microelement status and iron metabolism derived by us in the surveyed can also be extrapolated with a high degree of reliability to the entire sample of those examined old men. This circumstance is of interest in connection with the existing in the literature ideas about the relationship between the age of a person and the biological variability of certain studied indicators, defined for these age groups as reference or reference. The results of a comparative study of indicators of iron metabolism in conditionally healthy urban and rural senile men are presented in Table 3. As can be seen from the table, the average total haemoglobin of blood in the examined urban men of old age is 133.2 ± 0.1 g / l with a reference interval of this indicator from 130.0 g / l (min) to 136.7 g/l ( max). In the surveyed rural men of old age, the average value of this indicator is 130.5 ± 0.2 g/l with a reference interval of this indicator from 130.0 g/l (min) to 132.1 g/l (max). As can be seen in the indicators of total haemoglobin in conditionally healthy men permanently living in urban and rural conditions, there is a statistically significant difference - 133.2 ± 0.1 g/l and 130.5 ± 0.2 g/l, respectively (p 0.05). The indicator of total transferrin in blood serum in the examined urban, conventionally healthy elderly men, on average, according to our data, is 2.82 ± 0.1 g/l with a reference interval of this indicator from 2.88 g/l (min) to 3.00 g/l (max) and in rural conditionally healthy elderly men, according to our data, this indicator averages - 2.80 ± 0.1 g/l with a reference interval of this indicator from 2.44 g/l (min) to 2.95 g/l (max). It can be seen that this indicator, on average, also does not differ statistically significantly - 2.82 ± 0.1 g/l and 2.80 ± 0.1 g/l, respectively (p> 0.05) in the surveyed conventionally healthy urban and rural men old age. At the same time, it should be noted that in both urban and rural conventionally healthy senile men, the average level of serum transferrin is reduced compared to the similar content of transferrin in young people, in whom this indicator is normally distributed within the reference interval - 3.00- 3.50 g/l. This can be associated with the phenomenon of a general decrease in the protein-synthetic function of the liver with age. At the same time, our comparative analysis of the serum isotransferrin spectrum, i.e. quantitative analysis of various molecular isoformtransferrin, showed that the isotransferrin spectrum of blood serum in conventionally healthy elderly men has its characteristics. Thus, as a percentage of the total pool of serum transferrin, the share of transferrin completely saturated with iron - cholotrans-Ferrin is 60% or more, while in conventionally healthy young people, the share of cholotransferrin in the total pool of serum transferrin averages 36-45%. This indicates that although the total amount of serum transferrin in conventionally healthy elderly men is less than in young people, due to the higher content of functionally active molecules of cholotransferrin, the circulating pool of transferrin in the blood serum of elderly people can provide the bone marrow with the necessary amount of iron for the needs of haemoglobin formation. According to our data, the CST in the surveyed urban conditionally healthy elderly men averaged 23.1 ± 1.1%, with the reference interval of this indicator from 16.1% (min) to 27.8% (max), in the surveyed rural men of senile age, the average CST is - 22.2 ± 0.6% with the reference interval of this indicator from 16.8% (min) to 27.2% (max). A comparative study of indicators reflecting the saturation of the total pool of transferrin with iron (the coefficient of saturation of transferrin with iron) in conventionally healthy urban and rural elderly men shows that there are also no significant differences - 23.1 ± 1.1% and 22.2 ± 0.6 % respectively. Such a degree of saturation of the total pool of transferrin with iron, apparently, fully provides physiological erythropoiesis in elderly people. The study of such an important indicator of iron metabolism as the indicator of serum ferritin shows that, on average, the level of ferritin in the blood serum in the examined healthy urban senile men age is 42.6 ± 1.1 ng/ml with a reference interval of this indicator from 24.8 ng/ml (min) to 70.90 ng/ml (max). In the surveyed rural, conventionally healthy elderly men, the level of serum ferritin averaged 36.99 ± 1.2 ng/ml, with a reference interval of this indicator from 22.20 ng/ml (min) to 60.4 ng/ml (max). At the same time, a comparative analysis of such an important indicator of iron metabolism as the content of ferritin in the blood serum, which reflects the state of the iron depot in the body, unambiguously indicates that iron stores in conventionally healthy senile men who constantly live in urban conditions are significantly higher than in conventionally healthy senile men permanently residing in rural conditions - 42.6 ± 1.1 ng/ml and 36.99 ± 1.2 ng/ml, respectively (p 0,05). In Table 4, we present in a comparative aspect the indices of hematopoietic microelements - iron, copper, and zinc in conventionally healthy senile men permanently living in urban and rural conditions of the Bukhara region in a comparative aspect. As can be seen from the presented table, the hematopoietic microelement status in the examined conditionally healthy urban and rural elderly men is characterized as follows - the average level of such an important essential microelement as copper in urban elderly men is 11.7 ± 0.44 μmol/Lwith the reference interval of this indicator from 9.00 μmol/L (min) to 12.5 μmol/L(max), in rural areas it is 11.0 ± 0.36 μmol/L with a reference interval of this indicator from 8.11 μmol/L (min ) up to 11.6 And the average level of another important hematopoietic essential microelement zinc in the blood serum of the examined urban elderly men is 15.6 ± 0.60 μmol/L with a reference interval of this indicator from 14.3 μmol/L (min) to 25.3 μmol/L (max) and in rural elderly men, the average level of zinc in the blood serum was 15.0 ± 0.31 μmol/Lwith a reference interval of this indicator from 13.0 μmol/L (min) to 23.8 μmol/L (max). Conclusion Thus, as can be seen from the presented table, we did not reveal differences in the indices of hematopoietic microelements - iron, copper, and zinc in the examined conditionally healthy urban and rural elderly men, depending on the conditions of permanent residence. At the same time, certain correlations were noted in the content of these hematopoietic nutrients- microelements, and in both of those examined, the average content of iron in the blood serum prevails over the content of copper in the blood serum, and the level of zinc in the blood serum exceeds the content of iron and copper in the serum blood. Conflict of interest. We have no conflicts of interest. Acknowledgment. We thank the staff of the Bukhara Regional Multidisciplinary Medical Center. Funding information. None. Englishhttp://ijcrr.com/abstract.php?article_id=3321http://ijcrr.com/article_html.php?did=3321 Bakhramov SM, Boltaev KZ, Zharylkasynova Z, Kalmenov GT, Kazakbaeva KM. Analysis of the incidence of various forms of anaemia among adolescents and adults. Uzbekiston tibiyot zhurnal 2001;4:53–54. Skalny AV, Kaminskaya GA, Krekesheva TI, Abikenova SK, Skalnaya MG, Berezkina ES, et al. The level of toxic and essential trace elements in the hair of petrochemical workers involved in different technological processes. Envir Sci Poll Res 2017;24(6):5576-5584. Boltaev KZh, Akhmedova NSh. Characteristics of the phenomenon of the development of polydeficiency states during aging. Probl Biol Med 2020;1:24-26. Buglanov AA, Mamatkhonov OA. Exchange of hematopoietic nutrients in healthy women of fertile age in Uzbekistan. Hematol Blood Transf 2005;3:25-27. Fofana IY, Prilepskaya VN. The content of folic acid, zinc and copper in blood serum in pregnant women with urogenital mycoplasma infection. Med Advice 2015;11:39-45. Skalnaya, M.G. Establishing the boundaries of the physiological (normal) content of some chemical elements in the hair of residents of Moscow using centile scales. Bulletin of the St. Petersburg State Med Acad 2004;4:82-88. Skalnaya, M. Involvement of macro-and trace elements in dysregulation mechanisms of obesity and type II diabetes pathogenesis in pre-and postmenopausal women. Cell Biol  Toxicol 2008;24(1):39-46.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareTo Study the Impact of Allergic Rhinitis on Quality of Life in a Tertiary Care Hospital English118120R. AruthraEnglish Manoj KumarEnglishIntroduction: Chronic diseases because of their prolonged and enervating nature can influence the quality of life (QOL) of the individual1. Allergic rhinitis (AR) is a common long-standing medical condition. If not treated, it can result in considerable healthrelated and economic consequences. Quality of life, while referring to an individuals’ health is known as Health-Related Quality of Life (HRQL). The aim of this study was to evaluate the effect of AR on an individual’s quality of life. Objective: The objective of our study was to study the effect of allergic rhinitis on an individual’s quality of life. Methods: A specific questionnaire called the Rhino conjunctivitis Quality of Life Questionnaire (RQLQ) was used to study HRQL in allergic rhinitis in the ENT OP of Saveetha Medical College and Hospital from January 2020 to March 2020. RQLQ covers 7 domains and has a scale from 0 to 6. Results: Out of 40 patients, 24 (60%) were male and 16 (40%) were female. Out of 40 patients analysed the most common symptom was rhinorrhea. Out of the total 40 patients, the QOL was mildly affected in 13 (32.5%) and severely affected in 27 (67.5%) patients. Conclusion: It was observed that allergic rhinitis did have a notable impact on the quality of life. English Allergic rhinitis (AR), Quality of Life (QOL), Quality of Life Questionnaire (RQLQ), Rhino conjunctivitisINTRODUCTION Allergic rhinitis (AR) is a diagnosis associated with a group of symptoms affecting the nose and is induced after allergen exposure by an immunoglobulin E (IgE)-mediated inflammation of the membranes in the lining of the nose.1,2 Sneezing, itchy nose, rhinorrhea and nasal congestion are the general nasal symptoms for AR, it may be classified by the pattern of exposure to a triggering allergen (seasonal, perennial, episodic), recurrence (intermittent or persistent) and gravity of symptoms (mild or severe).3 Many causative agents have been linked to AR including pollens, moulds, dust mites and dander of animals.4 Although AR is not a serious condition, it is clinically relevant because it has many underlying complications, is a vital risk factor for asthma and affects the productive capacity at work or school.5 Quality Of Life (QOL) signifies the wellbeing and satisfaction of life.6 Quality Of Life (QOL) includes psychological, social and physical functioning and incorporating the positive aspects of well being and also the negative aspects of the disease. This is the definition of Quality Of Life (QOL) given by the World Health Organisation. Health, as defined by the World Health Organisation is a state of complete physical, mental, and social well being and not only the absence of disease and Health-Related Quality Of Life (HRQOL) is a vast concept which is defined as the individual’s subjective perception of the effect of their disease and its treatment(s) on their daily life, social development, physical and psychological well being. The study was performed to study the effect of allergic rhinitis on an individual’s quality of life. MATERIALS AND METHODS This was a prospective study of  40  patients done at the ENT OP of Saveetha Medical College and Hospital. Specific questionnaires are more susceptive and are much more to detect clinically salient changes in patients impairments, hence a specific questionnaire called Rhino conjunctivitis Quality of Life Questionnaire (RQLQ) was used to conduct the study. RQLQ covers 7 aspects of health: sleep, non-nasal symptoms, nasal symptoms, ocular symptoms, specific activities, practical problems, specific activities limited by symptoms in the previous week, and emotional function. The patients rate each aspect of health item on a scale of 0 (not troubled) to 6 (extremely troubled). The mean value for each health aspect is calculated and the final HRQL is demonstrated as the average of the 7 dimension scores. RESULTS Demographic data: Out of  40  patients, 24 (60%) were male and 16 (40%) were female. The age group ranged from 12 to 71 years. The mean age calculated in the study group was 32 years. Clinical findings Runny nose (Rhinorrhea) (52%) was found to be the most common symptom among the studied participants. Other main symptoms included sneezing (17%), stuffy blocked nose (14%), itchy eyes(7%). Tiredness/fatigue, irritability was also observed in some participants (Figure 1). In our study which used RQLQ, the patients quality of life was divided into seven categories - not troubled (0), hardly troubled at all (1), somewhat troubled (2), moderately troubled (3), quite a bit troubled (4), very troubled (5), extremely troubled (6). Each category had a specific score from 0-6 respectively. In our study setting, we divided the patients quality of life into two different categories, a mildly-changed category (having scores 0,1,2,3) and a severely-changed category (having scores 4,5,6). Among the total 40 patients, the quality of life was mildly affected in 13 (32.5%) and severely affected in 27 (67.5%) patients (Figure 2). No significant relation was observed between gender and quality of life. It was also found that lower the quality of life, more is the severity of the disease.  DISCUSSION Allergic rhinitis is a multifactorial disease with genetics and also environmental factors. It is one of the most recurrent and common allergic problem affecting the population in general, with its prevalence increasing globally.  The population in our study (60% male and 40% female) was similar to the previous study conducted by Hubert Chen et al.5 in which 63% of the participants were male and 37% were female. In a study by Shariat et al4, 39% of the participants were male and 61% were female, which is different from the present study. Rhinorrhea was the most common symptom found in our study setting. In a study conducted by Mohammad et al.2 in Tehran, rhinorrhea was found to be the most common symptom of allergic rhinitis. Shariat et al.3 reported that nasal congestion was the most common symptom of allergic rhinitis and had found a significant relation between nasal congestion and quality of life impairment. CONCLUSION Allergic rhinitis can have a notable impact on the quality of life affecting daily activities, quality of sleep, mood. Symptoms of allergic rhinitis which may interfere with the quality of life may predispose the affected individual to various comorbid conditions which may further influence the quality of life. To overcome these, the first step to be taken is making an early diagnosis. After making the diagnosis, physicians should consider treatment interventions that provide efficacious ways to minimise the impact of this disease, also keeping in mind the effect of allergic rhinitis on the quality of life. Since AR is a part of a systemic disease process, its management requires a coordinated approach rather than a fragmented, organ-based approach10. Hence early diagnosis and better treatment can help to ease the patients affected by allergic rhinitis. Conflict of Interest: None Source of Funding: None   Englishhttp://ijcrr.com/abstract.php?article_id=3322http://ijcrr.com/article_html.php?did=3322REFERENCES 1)    Kalmarzi R, Khazaei Z, Shahsavar J, Gharibi F, Tavakol M, Khazaei S, et al. The impact of allergic rhinitis on quality of life: a study in western Iran. Biomed Res Ther 2017;4(9):1629-1637. 2)    Van Oene CM, Van Reij EJ, Sprangers MS, Fokkens WJ. Quality-assessment of disease-Specific quality of life questionnaires for rhinitis and rhinosinusitis: A systematic review. J Allergy 2007;62: 1359-1371.  3)    Camelo-Nunes IC, Solé D. Allergic rhinitis: Indicators of quality of life . J Brasileiro de  Pneumologia 2010;36(1):124-133.  4)    Shariat MZ, Pourpak M, Khalesi A, Kazemnejad L, Sharifi G. Souzanchi M Quality of life in the Iranian adults with allergic rhinitis. Iranian J Allergy Asthma Immuno 2012;11(4):324-328.  5)    Mohammadi KM, Movahedi GM. A single center study of clinical and paraclinical aspects in Iranian patients with allergic rhinitis. Iranian J Allergy Asthma Immuno 2008;7(3):163-167.  Acknowledgement: The authors express their sincere thanks to Dr Saveetha Rajesh, The Director of Saveetha Medical College and Hospital for their constant motivation and cooperation for this study. Source of support: Nil. Conflict of Interest: None declared.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareUnani Perspective of Nausea and Vomiting in Pregnancy: A Literary Research English121126Arshi AnjumEnglish Kouser Fathima FirdoseEnglishNausea and vomiting (Qay’al-haml) are considered atypical and almost inevitable feature of pregnancy. Concern about the harmful effect of medication on the fetus may cause many women not to seek treatment or to try alternative therapies for nausea and vomiting. The only medicine that is FDA-approved for Nausea and vomiting in pregnancy is doxylamine–pyridoxine combination; has reported side effects like somnolence, headache, dizziness, dry mouth, and hypersensitivity. According to Unani scholars, nausea and vomiting in pregnancy are mostly due to the accumulation of morbid material in the stomach. It is relatively uncommon in the male fetus. The objective of the study is to search classical literature of nausea and vomiting in pregnancy (Qay’al-haml) and to correlate with modern literature. The classical Unani sources viz., Al-Qanun fi’l Tibb (Canon of Medicine), Iksir-i-A‘zam, Al Hawi fi’l Tibb (Continens Liber), Tarjuma Kamil al-Sana‘a al-Tibbiyya, Dhakhira Khawarizm Shahi, and Tibbi-Akbar were reviewed. Further, different search engines were also browsed on the website to explore recent studies. Various Unani drugs are mentioned for the treatment of qay’al-haml including gulqand, sikanjabeen sada, sharbat anar sheerin, sikanjabeen lemooni, jawarish anarain, mastagi, ilaichi etc. In this literary research, an effort has been made to focus on the various causes, diagnosis and management of nausea and vomiting in pregnancy by Unani system of medicine. Some herbs and Unani compound formulations used in the treatment of qay’al-haml have also been highlighted. EnglishNausea, Fetus, Doxylamine-pyridoxine, Qay’al-hamlINTRODUCTION Pregnancy and childbirth are basic life events vital to the maintenance of humankind and thus are considered physiological processes. The most common complication affecting women in the first trimester is nausea and vomiting of pregnancy (NVP),1 occurring in 44% to 89% of pregnant women.2 Nausea and vomiting in pregnancy is defined as the symptom of nausea and/or vomiting during early pregnancy when no other cause is responsible for it,3 with an onset which often begins between the fourth and seventh week after the first missed menstrual period and resolves by the 20th week of gestation.4 It is a syndrome caused by the complex interaction of genetic and environmental factors beginning during a unique period: organogenesis.2 The risk factors of NVP include race, baby’s sex, young maternal age, multifetal gestation, low income, low education level, history of premenstrual syndrome, and unwanted pregnancy.5 The severity of NVP has a broad spectrum therefore it is critical to have a graded scale to track the severity of symptoms as a guide to determine the appropriate treatment and response to treatment. In 2002 Ebrahimi et al. introduced the Pregnancy-Unique Quantification of Emesis (PUQE) scoring system.  The updated PUQE score assesses the severity of NVP based on three physical symptoms: nausea, vomiting, and retching over the previous 24 hours.6 MATERIAL AND METHODS The classical Unani sources viz., Al-Qanun fi’l Tibb (Avicenna’s Canon of Medicine), Hakeem Azam khan’s Iksir-i-A‘zam, Al Hawi fi’l Tibb (Rhazes’s Continens Liber), Tarjuma Kamil al-Sana‘a al-Tibbiyya, Jurjani’s Dhakhira Khawarizm Shahi, Jamiul Hikmat, Khazainul advia, Afadae Kabeer and Ghana Muna etc  reviewed and searched for terms including qay’al-haml, qay, matli, hamila ke awarizat, su’i-mizaj-i-mida, zofe mida, zofe jigar etc. for aetiology, differential diagnosis, management. Major scientific databases namely Pubmed, Science Direct and Springer, Google scholar, Orchid, SCOPUS, Crossref, CAS Abstracts, Publons, CiteFactor, Open J-Gate, ROAD, Indian Citation Index (ICI), Indian Journals Index (IJINDEX), Internet Archive, IP Indexing, Scientific Indexing Services, Index Copernicus etc were searched for the most recent information regarding the modern concept of NVP, risk factors, aetiology and pharmacological management etc. using keywords nausea, vomiting, retching. Same databases were also searched for evidence of scientific work done on Unani drugs in NVP by using terms zanjabeel, limoo, na’na, behi, hel etc. Approximately 15 books and 100 papers were browsed, some of them based on prevalence and studies, other papers were based on contemporary treatment, the complementary and alternative treatment of nausea and vomiting in pregnancy. AETIOLOGY Aetiology of NVP remains unknown;7 however various theories have been proposed for the aetiology of NVP, but a combination of several factors are probably involved (Table 1). UNANI CONCEPT In Unani classical literature, the term coined for nausea and vomiting in pregnancy is Qay’al Haml. According to Unani scholars, the cause of NVP is morbid material which accumulates in the cavity of the stomach or the muscles or layers of the stomach.13,14 This material can be bilious, phlegmatic (often balgham-i- milh) 13, 15 or black bile.13 More often nausea in pregnancy is due to bile, although bile is not a morbid material.16 Bilious material causes irritation in the stomach and hence vomiting. Thick and viscous material firmly accumulated on the surface of the stomach produces nausea and retching not vomiting. Differential diagnosis of Qay’al-haml14 Non- obstetrical causes of vomiting are- Haida, Su’-i-hadm, Waja-al mi’da, Quruh al-Mari wa Litha, Inqilab al- mi’da, Waram al- jigar ,?Qulanj ,Waram al-tihal , Humma , Waram al- gurda , Deedan       If vomiting is not due to these diseases, then itself is a disease. 2. Enquire about diet before vomiting, improper food habit, rotten food then cause is attributed     to  fasad-i -ghidha. (food poisoning). 3. If vomiting is not persistent and is associated with disorders of the liver, gall bladder, spleen and uterus or any other organ of the body then the cause of vomiting is due to these disorders. 4. Su’-i-mizaj Su’-i-mizaj sa’da: If no other cause of vomiting is diagnosed then it indicates that it is solely due to su’-i-mizaj sa’da. In this vomitus contains food particles but no other khilt. Urine is clear and diluted. a. Su’-i-mizaj harr sa’da: Increase thirst, dry mouth, burning sensation in the stomach, hadam qawi, hot drinks are harmful. b. Su’-i-mizaj barid sa’da: Decrease thirst, weak digestion, pale face, soft stool, increase appetite, belching. c. Su’-i-mizaj ratb sa’da: Coldwater, wet and moist things are harmful. Dry food and a small quantity of food is beneficial, increase salivation, nausea. d. Su’-i-mizaj yabis: Dry tongue, constipation, dislikes dry foods. Su’-i-mizaj Maddi: If manifestations of any khilt (humour) are present, then the type of vomiting depends upon khilt (humour) present in vomitus. If vomitus contain food particles along with khilt, then the cause of vomiting is su’-i-mizaj maddi and urine is viscous, turbid. a. Su’-i-mizaj safravi: Bitterness in mouth, nausea, yellow urine, belching. b. Su’-i-mizaj saudawi: All signs of su’-i-mizaj yabis including increase appetite, improper digestion, dark yellow pigmentation of the face, urine is a viscous and dark colour. c. Su’-i-mizaj balghami: decreased appetite, fatigue, nausea, increased salivation, pale face, urine is white, vomitus contains phlegm. 5. With manifestations of cold temperament, there is tension in ribs and increased flatulence- then the cause is riyah. 6. Stretched ribs along with nausea, burning sensation in the stomach, stool with bad odour- the cause is then attributed to spoilt food. MANAGEMENT Pharmacological treatment17-19 The following table  2 shows the treatment of drug with their dose and mode of action. Unani management Usoole ilaj (Unani principles of treatment) may be divided into following sub headings: 20 1. Ilaj bi’l ghidha (Dieto-therapy) 2. Ilaj bi’l tadbeer ( Regimental therapy) 3. Ilaj bi’l Dawa ( Pharmacotherapy) 4. Ilaj bi’l yad (Surgery) 1. Ilaj bi’l ghidha (Dieto-therapy) 14,19,21 1. Light diet is advisable which provides strength to the stomach and stops vomiting example titar, chuza murg. 2. Advise empty stomach- rube reebas, rube hasram. 3. Eat a pomegranate in the early morning and lies on the bed for 1 hour. 4. Avoid hot and warm food. 5. Avoid sweet dishes. 2. Ilaj bi’l tadbeer (Regimental therapy) 21,22 1. Moderate walk, light exercise. 2. Dimad on the abdomen- badiyan alone or along with qinnab and sharab Rehani or grape flowers and gulnar or barge kiram, gulnar and karafs Roomi, tukhme razyana 3. Ilaj bi’l Dawa (Pharmacotherapy)16,19,21,22 Nausea and vomiting in pregnancy is usually self limiting, if it is not alleviated advice mullaiyanat, muqawwiyat -al- mi’da wa a’da ra’isa. 1g. Gule surkh 9g, gule gaozaban 9g, sapistan 10g seeds, unnab 7g, khubani 7g, aloo bukhara 11g. All these drugs are soaked overnight in gulab jal and kewda. To this maghze khyare shambar 72 g, sheere khisht, gulqand each 48 g are added, grind the mixture and filter and give orally with 7 g roghane badam. 2. Qurs- qaranphal, quste sheerin, jooz, sak, mastagi, agar, ilaichi, kababa each of equal weight mix with aabe-tursh or aabe-bihi and make qurs(tablet). This tablet is a very useful formulation for vomiting and craving for food. 3. Gulqand and sikanjabeen sada 24 g is beneficial or sikanjabeen lemooni or murabba leemu kaghzi. 4. Oral intake of sharab rehani asfar is beneficial. 5. Rewand chini before and after meal. 6. Gile armani , mix with sharbate meeba. 7. Joshanda of assiur ra’as( lal sa’ag) before and after meal. 8. Joshanda shibt alone and along with shahed musaffa is beneficial in NVP. 9. Mixture of oode kham and mastagi is also beneficial. 10. For pregnant women with harr mizaj – sharbate turanj, sharbate leemu, sharbate ghura and sharbate anar is beneficial. 11. Safoof barai mitli- loung, qust sheerin, mastagi, jaipal, choti ilaichi, agar, kabab chini, sak each of equal weight are finely powdered. Dose- four and half gram with aabe-saib sheerin. 12. If vomiting is due to fasad-i-ghidha or safra then oral intake of sikanjabeen 50 ml and salt 25 mg in water is effective as it helps in stomach wash, then drink arqe- gulab 120 g, and sharbate anar sheerin 25 ml. 13. If vomiting is due to gastric ulcers then dimad of radia’at and sandal safaid, kishneez khushk is effective 5.3 Mamoolate matab13 Tukhme khurfa, tukhme khyarain, zarishk, munaqqa each 3 g, aloo bukhara 5, make sheera of all these in arqe-gulab 60 ml, drink after adding sharbate tamar hindi 12 ml. Tabasheer, zareward, kishnnez khushk, post samaq, anar dana biryan each 1 g, after grinding and straining add sharbate ghura 25 ml, sikanjabeen lemooni 25 ml and take orally. Jawarish anarain 7 g with zarishk 3 g, sheera pudina 3 g, sheera dana ilaichi 3 g in arqe- gawzaban 150 ml with sharbate anar 25 ml orally in the morning and evening. Zarishk, samaq, anardana, dana heel finely grinded and given with sikanjabeen lemooni 25 ml half an hour after food. EVIDENCE BASED UNANI MEDICINAL PLANTS EFFECTIVE IN NVP 1. Punica granatum (Pomegranate) The pomegranate belongs to plant family Lyhraceae 23 it is known as “Anar”24 (Figure 1), it&#39;s said to be cold and wet. a way to treat NVP in Unani medicine is keeping pomegranate seeds and mint within the mouth25,26. One study evaluated the results of pomegranate and spearmint syrup on NVP. No health hazards are reported following the right administration of designated therapeutic dosages.27,28 Citrus Limon(Lemon) The lemon is a plant of the family Rutaceae. It is known as “Limoo” ( figure 2) and has been used as an efficacious remedy for NVP in unani system of medicine, cold and dry in temperament. Lemon is rich in phenolic compounds, vitamins, minerals, fiber, and carotenoid oil and has analgesic, antiseptic, anti?emetic, and diuretic properties. In a study lemon aromatherapy led to a significant reduction in NVP compared to placebo.29 Mentha Piperita (Mint)           Mint is a plant in the family Lamiaceae  (Figure 3). The leaves of mint known as “Na, na” in Unani have also been used in the treatment of NVP. It is said to be warm and dry in temperament. In a double-blind RCT, the effect of aromatherapy with pure mint essential oil versus placebo was evaluated in 60 pregnant women with NVP.2,24 Elletaria carda­momum (Cardamom) Cardamom is a member of the family Zin­giberaceae (Figure 4). Cardamom (Elletaria carda­momum), known as “Hil” or “Hel”, warm and dry. Aromatherapy with inhalation of cardamom oils is effective in relieving nausea caused by chemotherapy in patients with cancer. Ozgoli et al. (2015) demonstrated that intake of capsules containing 500 mg cardamom powder three times a day significantly reduced the severity of NVP.5 Cydonia oblonga (Quince) The quince is a plant of the family Rosace­ae. Cydonia oblonga, known as “Behi” ( Figure 5), is an important natural product used in the treatment of NVP.21,22 In addition, it protects the fe­tus from abortion and is used as an appetizer.  Wet and balanced in warm and cold in temperament . A clinical trial was carried out in Tehran, Iran on the effectiveness of Cydonia oblonga (quince) syrup for treat­ment of NVP. The results showed significantly decreased NVP in the group receiving quince syrup. No health risks or side effects are reported following the proper administra­tion of designated therapeutic dosages.24,30 CONCLUSION Unani scholars have tak­en rational steps based on the observations. They believed that three basic steps, i.e. life­style modification, nutrition and medicinal herbs, had great effects on NVP treatment. Therefore, this research can provide valuable information on the clinical use of herbal medicines in NVP and prepares the ground to investigate their potential medicinal use. Author’s view Long-term use of traditional medicines may indicate their efficacy, but it is recommend­ed to conduct scientific studies to confirm their efficacy and safety. Scientific stud­ies on these Unani medicines during preg­nancy are required to determine their safety. Englishhttp://ijcrr.com/abstract.php?article_id=3323http://ijcrr.com/article_html.php?did=33231. Balikova M, Buzgova R. Quality of women’s life with nausea and vomiting during pregnancy. Osetrovatelstvi a Porodni Asist 2014; 5(1): 29-35. 2. Niebyl NR. The pharmacologic management of nausea and vomiting during pregnancy. J Family Pract 2014; 63(02): S31-S38. 3. Anonymous. The management of nausea and vomiting of pregnancy and hyperemesis gravidarum. RCOG Green-top guideline No. 69. 2016:1-27. 4. Khresheh R. How women manage nausea and vomiting during pregnancy: a Jordian study. Midwifery 2011;27(1):42-45. 5. Ozgoli G, Naz MSG. Effects of complementary medicine on nausea and vomiting in pregnancy. A systematic review. Int J Prev Med 2018;9:75. 6. Bustos M, Venkataramanan R, Caritis S. Nausea and vomiting of pregnancy- What’s new? Auton Neurosci Basic Clin 2017;202:62-72. 7. Gill SK. Investigating sources of variability in pharmacological response in nausea and vomiting of pregnancy. Doctoral Thesis, Departmet of Pharmacology, University of Toronto. 2010:17-20. 8. Heitmann K. Treatment of nausea and vomiting during pregnancy. Eur J Clin Pharmacol 2016; 72:593–604. 9. Magee L, Shrim A, Koren G. Diagnosis and management of nausea and vomiting in pregnancy. Fetal Mater Med Rev 2006;17:145–167. 10. Lee N, Saha S. Nausea and vomiting of pregnancy. Gastroenterol Clin N Am 2011;42:309-334. 11. Chartatos A. Nausea and vomiting in pregnancy and the impact upon dietary intakes and birth outcomes – a study performed in the Norwegian Mother and child cohort study. Master Thesis, Department of Nutrition, University of Oslo. 2011:1-15. 12. Mylonas L, Gingelmaier A, Kainer F. Nausea and vomiting in pregnancy. Dtsch Arzteb l. 2007;104(25):A1821–1826. 13. Qurshi HKM. Jamiul Hikmat. New Delhi: Idara kitab-us- shifa; 2011; 1145:725-727. 14. Khan MA. Akseere Azam (Urdu translation by Kabeeruddin). New Delhi: Idara Kitab-us-Shifa; 2011.  15. Qamri AMH. Ghana Muna. New Delhi: Markazi council baraye tahqeeqat tibbe Unani; 2008. 16. Sina I. Al Qanoon fit tib. Vol 3. ( Urdu translation by Kantoori GH). New Delhi: Idara Kitab-us-Shifa; 2007. 17. Taylor T. Treatment of nausea and vomiting in pregnancy. Aus Prescr 2014;37:42-45. 18. Anderka M, Mitchell AA, Louik C, Werler MM, Diaz SH, Rasmussen SA. Medications used to treat nausea and vomiting of pregnancy and the risk of selected birth defects. Birth Defect Res A Clin Mol Teratol 2012;94:22-30. 19. Arsenoult AY, Lane CA. The management of nausea and vomiting of pregnancy. SOGC clinical practice guideline. J Obstet Gynaecol Can 2002;24(10):817-823. 20. Qarshi AA. Afada Kabeer majmal. Translated by Kabiruddin Hk. Deoband: Faisal publication Jamia masjid; YNM. 157. 21. Razi ABZ. Kitabul H. New Delhi: CCRUM, 2001;9. 22. Jurjani AH. Dakheera Khwarzam Shahi (trans: Khan HH). New Delhi: Idara kitab-us- shifa; 2010. 23. Batista ALA, Lins RDAU, de Souza Coelho R, do Nascimento Barbosa D, Belém NM, Celestino FJA. Clinical efficacy analysis of the mouth rinsing with pomegranate and chamomile plant extracts in the gingival bleeding reduction. Complement Ther Clin Pract 2014;20(1):93-98. 24. Ghani HN. Khazainul adviya. New Delhi: Idara kitab-us-shifa; YNM. 25. Aghili Khorasani M. Khulas?at al-h?ikmah. Qom: Esmailian publications 2006(2):147. 26. Arzani M. Mufarrih al-qulub. Tehran, Almaee publications 2012: 860. 27. Abdolhosseini S, Hashem-Dabaghian F, Mokaberinejad R, Sadeghpour O, Mehrabani M. Effects of Pomegranate and Spearmint Syrup on Nausea and Vomiting During Pregnancy: A Randomized Controlled Clinical Trial. Iranian Red Crescent Med J 2017;19(10):e13542. 28. Nazamuddin WA, Jahan A, Tanveer AM, Iqbal NM, Khan AM. Gulnar (flower of Punica granatum lin): precious medicinal herb of Unani medicine- an overview. Int J Curr Res Rev. 2013; 5(20):16-21 29. Yavari KP, Safajou F, Shahnazi M, Nazemiyeh H. The effect of lemon inhalation aromatherapy on nausea and vomiting of pregnancy: A double-blinded, randomized, controlled clinical trial. Iran Red Crescent Med J 2014;16:e14360. 30. Abdolhosseini S, Dabaghian FH, Mehrabani M, Mokaberinejad R. A Review of Herbal Medicines for Nausea and Vomiting of Pregnancy in Traditional Persian Medicine. GMJ. 2017;6(4):281-90.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareAnalysis of the Results of a Study on the Frequency of Occurrence and Prevalence of Risk Factors for Chronic Kidney Disease English127131Akhmedova Nilufar SharipovnaEnglish Sulaimonova Gulnoz TulkinzhanovnaEnglish Mukhammedzhanova Mastura HayatovnaEnglish Giyosova Nigora OdiljonovnaEnglishIntroduction: Numerous studies have shown that in patients with chronic kidney disease (CKD), the clinical manifestations of this pathology often appear in an advanced stage of the disease when the patient needs pathogenetic therapy or substitution therapy. One of the necessary and important tasks of the preventive direction of nephrology is the identification and stratification of risk factors for the development and progression of CKD. Objective: To survey the population permanently living in rural areas for the early detection of CKD. Methods: Patients with microalbuminuria (MAU >10 mg/L), which persisted for 3 months or more were examined. Results: It follows that screening studies for the detection of CKD in the rural population are justified. Besides, it seems to be the basis for primary prevention of CKD and the basis for the development of secondary prevention of CKD among rural residents. The next stage of research was clinical and laboratory studies in the identified contingent to establish an early diagnosis of CKD using simple, cheap, reliable, and effective laboratory diagnostic methods using urine analysis of the examined. Conclusion: The first feature was that with the increasing age of the surveyed, the incidence of CKD significantly increases. The second feature is a gender difference, where the incidence of CKD was 2.2 times higher in women (p EnglishChronic kidney disease, Microalbuminuria, Glomerular filtration rate, Nephropathy of pregnancy, Arterial hypertension of pregnant womenIntroduction Screening is a secondary prevention measure aimed at detecting a specific disease in the preclinical stage. During the screening, a mass examination of the contingent from certain risk groups is carried out, who do not consider themselves sick, do not seek medical help, and accordingly, do not receive a specific treatment. The main goal of screening is to detect the disease before specific clinical symptoms appear and to completely cure the pathology.1,2 It should be emphasized that the works provided by screening studies in rural areas of our republic are rare. In this regard, we considered it expedient to survey the population permanently living in rural areas for the early detection of CKD.3,4 One of the necessary and important tasks of the preventive direction of nephrology is the identification and stratification of risk factors for the development and progression of CKD. In the conceptual model of CKD, several risk factor groups are distinguished: • risk factors for the development and progression of CKD; • modifiable and non-modifiable factors; • traditional and non-traditional. However, the classification of factors seems to be controversial. It is especially difficult to draw the line between the factors of development and progression of CKD. It has now been proven that most of the traditional risk factors for cardiovascular disease are also risk factors for CKD. These include arterial hypertension, diabetes mellitus, dyslipoproteinemia, anaemia, metabolic syndrome, age, etc.5 Materials and Methods The main selection criterion was microalbuminuria (MAU> 10 mg/L), which persisted for 3 months or more, considering this parameter as a diagnostic predictor of CKD development. Among the surveyed, this criterion of CKD was detected in 317 persons (29.1 ± 1.6%) out of 1087, note that there were 2.8 times more women than men - 68.8 ± 4.6%, respectively (n = 218) and 31.2 ± 3.1% (n = 99). This fact indicates that our data differ from other authors who indicate that the risk factor for the development of CKD belongs to the male sex.6,7 Results and Discussion Based on clinical materials, parameters of laboratory and instrumental studies, a diagnosis was made in some of the subjects. The number of examined and identified nosological units differed in the same way as 1 examined person sometimes had 2 or 3 diagnoses of the disease. Thus, in 210 patients with diagnoses established based on data from outpatient records, there were 351 diseases (1.67 nosologies per 1 examined). The contingent with the diagnosis established after our survey (n = 107) had 167 nosologies - 1.56 per 1 examined, respectively, the data in Table 1 were calculated from the total number of identified nosological units.   Note: absolute in the numerator, relative (%) indicators in the denominator: *significant difference in the parameter; ↑ ↓ and ↔ - increase, decrease or no difference between the indicator and the compared group. Among the diagnoses established, both on the basis of outpatient records and after examination, diseases of the cardiovascular system were often encountered, with arterial hypertension, respectively, 42.17 ± 4.93% (n = 148) and 33.54 ± 4.72% (n = 56), ischemic heart disease, respectively 15.38 ± 3.60% (n = 54) and 15.57 ± 3.62% (n = 26), primary urinary tract disease, respectively, 14.53 ± 3.52% (n = 51) and 17.37 ± 3.78% (n = 29). Other established diagnoses were less common - diabetes mellitus, respectively, 8.83 ± 2.83% (n = 31) and 4.79 ± 2.13% (n = 8); rheumatic diseases, respectively 7.69 ± 2.66% (n = 27) and 4.19 ± 2.0% (n = 7); anemia, respectively, 7.12 ± 2.57% (n = 25) and 3.59 ± 1.86% (n = 6); endemic goiter, respectively 2.85 ± 1.66% (n = 10) and 2.40 ± 1.53% (n = 4); obesity, respectively, 1.42 ± 1.18% (n = 5) and 17.37 ± 3.78% (n = 31). We can say that among the above diseases, the level of obesity diagnosis as a nosological unit is very low - the difference between the groups is 6.2 times. This indicates that health professionals do not rate obesity as an unfavourable risk factor for the development and various pathological conditions, including CKD. Considering the importance of urinary tract diseases as risk factors for the development of CKD, we decided to cite the frequency of occurrence of these nosological units separately (Table 2). It should be noted that among the surveyed with an established diagnosis based on the data of outpatient cards, the establishment of the diagnosis of CKD as a nosological unit was not identified. After the survey, this diagnosis was made in 29.1% (n = 21) of the general surveyed respondents. In our studies, the role of each nosological unit listed in Table 2 as a risk factor for the development of CKD is insignificant, so we decided to use the general group of urinary tract diseases to determine the groups according to the risk of developing CKD. Conducted scientific studies prove that hypertension, diabetes mellitus, and obesity are traditional factors in the development of CKD 3. However, in the development of chronic kidney damage, non-traditional factors in the development of CKD are of great importance. The results of our research show that these factors include: the place of residence (city or village), ethnic customs of the people, lifestyle, and standard of living of the population, the effectiveness of preventive measures carried out by medical institutions for widespread non-infectious chronic diseases, the use of poor-quality drinking water, violation rules of rational nutrition, the constant use of high-calorie food by the population. According to Valerie and Kathrin (2017), studies were carried out in Switzerland, many of the factors we indicated were the main causes of the spread of CKD among the population. Thus, it was found that there is a significant difference between the diagnoses established based on outpatient cards of rural family polyclinics and after our examination. Besides, there were 1.67 nosologies for 1 patient with a diagnosis established based on outpatient cards, and after our studies, this figure was 1.56 nosologies. Among the frequently encountered diseases, there were also diseases of the urinary tract (pyelonephritis, cystitis, urolithiasis, glomerulonephritis) - 16.09% (51 out of 317 examined). It was revealed that each separately the role of these nosologies as risk factors for the development of CKD was insignificant. Arterial hypertension, diabetes mellitus, obesity, and diseases of the urinary tract, which were among the main risk factors for the development of CKD, were insufficiently identified in terms of the primary and repeated referral of patients for medical help. Based on this, to determine the frequency of occurrence of manageable risk factors affecting the development and progression of CKD, the following factors were analyzed by the integration method: ? abuse of nephrotoxic drugs that are usually sold without a prescription in our country - analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), some antibiotics; ? abuse of salty and bitter foods; ? bad habits - smoking, alcohol intake; ? not controlling pathological conditions and diseases with a burdened history (proteinuria, dysuria, nephropathy of pregnant women, hypertension of pregnant women, acute allergic reactions, acute bleeding with hypovolemia); ? chronic foci of infection - chronic tonsillitis, chronic otitis media, dental caries. When analyzing the frequency of occurrence of these factors, we paid attention to the level of identification and / or elimination of these factors as the cause of the development of other diseases (Table 3). Note: ˆindicators are calculated by the number of surveyed women in groups, respectively, n = 133 and n = 85; *significant difference in the parameter; ↑ ↓ and ↔ - increase, decrease or no difference between the indicator and the compared group. Among the controllable risk factors for the development of CKD, the abuse of nephrotoxic drugs (analgesics, NSAIDs, antibiotics), respectively, 58.57 ± 4.92% (n = 123) and 62.61 ± 4.83% (n = 67) were common; the presence of chronic foci of infection, of which a large number of dental caries were detected 58.57 ± 4.92% (n = 123) and 64.48 ± 4.78% (n = 69), followed by chronic tonsillitis 31.90 ± 4.66% (n = 67) and 38.31 ± 4.86% (n = 41); among the surveyed women permanently residing in rural areas from non-traditional factors in the development of CKD revealed a history of nephropathy of pregnant women, respectively 60.90 ± 4.87% (n = 81) and 60.0 ± 4.89% (n = 51). Analysis of the results shows that the above factors are underestimated as a risk factor for the development of CKD, and the effectiveness of preventive measures for non-communicable chronic diseases among the rural population is rather low. Other studied factors, such as: history of acute allergic reactions (2.38 ± 1.52%, n = 5 and 13.08 ± 3.37%, n = 14); chronic otitis media from non-infectious chronic foci of infection (1.90 ± 1.36%, n = 4 and 5.60 ± 2.29%, n = 6); history of acute bleeding or hypovolemic shock (2.85 ± 1.66%, n = 6 and 4.67 ± 2.10%, n = 5). Thus, the frequency of occurrence of controllable (modifying) risk factors for the development of CKD among the subjects is different, ranging from 1.90 ± 1.36% (chronic otitis media) to 58.57 ± 4.92% (abuse of nephrotic drugs). Of the 10 studied these risk factors, the most significant in the group of patients to establish a diagnosis based on data from outpatient cards were: abuse of nephrotoxic drugs (58.57%), dysuria of unknown aetiology (43.80%), abuse of salty and bitter foods (33.40 %), bad habits (21.42%), history of proteinuria (20.95%) and history of nephropathy of pregnant women among women (60.90%). Almost the same tendency in the occurrence of controlled risk factors was observed in the group with established diagnoses at screening examination. From the clarified, it follows: firstly, the population permanently residing in rural areas generally has the same non-traditional risk factors for the development of CKD; secondly, a sufficiently large number of unidentified pathological conditions associated with the kidneys with the same risk factors. For each identified patient, there are 0.51 not identified conditionally sick persons with the same manageable risk factors for the development of CKD. The detectability of controllable risk factors per patient is, respectively, from 3.40 to 4.58 risk factors. From the above, it follows that screening studies for the detection of CKD in the rural population are justified. Besides, it seems to be the basis for primary prevention of CKD and the basis for the development of secondary prevention of CKD among rural residents. The next stage of research was clinical and laboratory studies in the identified contingent to establish an early diagnosis of CKD using simple, cheap, reliable, and effective laboratory diagnostic methods using urine analysis of the examined. All subjects underwent urine analysis using Combina 13 test strips (Human GmbH, Germany). These diagnostic test strips are designed to measure the semi-quantitative concentration of microalbumin in the urine. The test for measuring microalbuminuria is based on the principle of the colour change of an indicator under the influence of proteins. Renal function was assessed in terms of the glomerular filtration rate (GFR). Normal GFR is ≥120 ml/min. The prevalence of CKD was assessed by MAU> 10 mg / L and GFR Englishhttp://ijcrr.com/abstract.php?article_id=3324http://ijcrr.com/article_html.php?did=33241. Akhmedova NSh. Features of screening of renal function in an outpatient setting. Int Med J 2019;2(26):17-21. 2. Akhmedova NSh. The importance of proteinuria as a predictor of diagnosis and a factor for the development of chronic kidney ddisease. Eur Sci Rev 2018;7(8):84-85. 3. Maksimov ZhI, Maksimov DM. Screening: a modern perspective on early diagnosis and prevention of chronic non-communicable diseases. Arch Inter Med 2014;23:52–56. 4. Statsenko ME, Turkina IA. Visceral obesity is a marker of the risk of multi-organ damage.  Bull Volgograd State Med Uni 2017;1:10-14. 5. James MT, Hemmelgarn BR, Tonelli M. Early recognition and prevention of chronic kidney disease. Lancet 2010;375:1296-1309. 6. Gulov MK, Abdullaev SM, Rafiev KhK. Quality of life in patients with chronic kidney disease. Russian Med Bio Bull 2018;4:493-499. 7. Shvetsov MYu. Chronic kidney disease as a general medical problem: modern principles of nephroprophylaxis and nephroprotective therapy. Zh Comsilium Med 2014;16(7):51-64.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcarePrevalence of Obesity Among Children, Their Parents and to Assess the Practices Related to Restraining and Promoting Factors for Childhood Obesity English132135Mahantesh Appanna NaganuriEnglish Yayathee SEnglishObjective: To assess the prevalence of obesity among children and parents and to assess the restraining and promoting factors for childhood obesity. Methods: A multi-method research study was carried out over two months on 100 children of Class VIII, IX and X and their parents. Results: Results of the study revealed that 10 (10%) children were underweight, 81 (81%) children were normal, 8 (8%)children were overweight and 1 (1%) child was obese. In parents 2 (2%) were underweight, 68 (68%) were normal, 25 (25%) were overweight and 5(1%) were obese. Regarding the children and parents practices about childhood obesity, it was found that only 4( 4%) children practices were satisfactory. 71(71%) children practices were moderately satisfactory and 25(25 %) children practices were not satisfactory and in parents 30(30%) were satisfactory, 62(62%) were moderately satisfactory and 8(8%) were not satisfactory. Conclusion: Prevalence of obesity is a major concern in children as well as parents. Awareness through Structured teaching program about restraining and promoting factors for childhood obesity is needed to prevent and control the effects of obesity. EnglishChildhood obesity, Prevalence, Underweight, Overweight, Restraining, Promoting factorsIntroduction[DM1] : The westernization of the life-style and eating pattern has become a solid reason for causing the metabolic disorder called ‘obesity’. It is defined as an abnormal accumulation of fat that causes health disorders. Unfortunately, obesity doesn’t take account of the age group; it is seen in all age groups and gender even in childhood with co-existing morbidity as the age advances. Despite all the advancements in clinical practices and recent developments in the pharmaceuticals, still obesity remains the global threat. Thus, present study focused on various factors that contribute to childhood obesity, as from the review of literature it was obtained that, obesity is not a single-factor disease rather it is multifactorial disorder. This study was conducted to address the problem in the selected urban school students at Gokak Karnataka. Study also includes the assessment of various childhood obesity factors, the effectiveness of the childhood obesity prevention interventions, and the imperative role of parents and teachers. Parents and teachers can play a vital role in regulating the repercussions in childhood obese individuals.1             BMI is used as a measure of crude population where an Individual’s weight (Kg) divided by the square of their height (m). In general an individual with a BMI, more than 30 is obese, while an individual with a BMI of 25 and more is termed as overweight 1. Studies suggest that bodyweight 20 percent more than the optimum tends to be associated with obesity 2.             School is a place where a major part of the time per day is spent learning. The children who obtain habits in school that leave a long term impact on one’s health, which is the direct reflection of their current well-being. Habits attained like consuming junk foods and gulping processed foods lead to putting on weight, which causes harmful effects on health. India treasures a superabundant amount of different cultures and food. It can also be said that India has a rich heritage of recipes and foods 3.             A study was centered on BMI and body fat percentage and was conducted among adolescent girls in Bangalore city. it was found that there were around 13.1% overweight cases and around 5.0% of obese adolescent school girls in Bangalore. The higher rate of BMI and body fat percent was observed during the pubertal period between the age group of 10-12 years old on average.4 A study on fast food consumption and snacks revealed that The most professed fried Indian snack is ‘Samosa’ most of them preferred samosa over pizza. pizza is least preferred. Chaat items are also preferred mostly by 99.2% population. But, 73.2% of them occasionally consume fast food. 32.5% of them had a favorable attitude towards fast food items. Around 20.3% of them were totally aware of the post-consumption consequences. A total of 63% had the opinion that these foods consumption has harmful effects. 3 The major stakeholders in reducing childhood obesity not only consist of children and adolescents. There is need of  contribution from parents, school, health care professions, community and business leaders, and state and local area officials and in terms of wholeness ‘society’. 5 Material[DM2], Methods and Results: This study was conducted in 4 schools of Gokak, Karnataka for a period of two months, Approval was taken respective head of schools and  The study was approved [DM3] by the institutional research committee (Ref.No. SVU/Ph.D/RDC/2017)             The tool used for the data collection consisted of self administered semi structured questionnaire to assess the practices in school children and parents regarding restraining and promoting factors for childhood obesity.             Tool was divided into two parts Section I and Section II Section  I: Demographic Data Section II: Self-administered semi-structured questionnaire on restraining and promoting factors related to childhood obesity The first stage which includes descriptive research which is designed to conduct a large-scale survey regarding childhood obesity among school children, parents and, teachers. A simple random sampling technique was used. Section –I : Findings of Demographic data of children             In relation to the age majority, 80(80%) were 13 years, 14(14%) were 12 years, 4(4%) were 14 years and 2(2%) were 11 years. With regard to the gender, 59(59%) were females and 41(41%) were males. Majority of 78(78%) children’s residence was in rural area and 22(22%) were from urban. In relation to the travel to school, 37(37%) used of them public transport, 23(23%) used bicycle, 20(20%) go to school by walking, 17(17%) travel by school bus and 3(3%) use bike or auto. Findings of Demographic data Parents: In relation to the age of parents, majority 75(75%) were above 40 years, 13(13%) were between 36-40 years, 9(9%) were of 30-35 years age and 3(3%) were less than 30 years. With regard to relation, 58(58%) were mothers, 42(42%) were fathers. In the aspect of education, 47(47%) had completed PUC, 27(27%) had completed S.S.L.C, 17(17%) were graduates and above and 9(9%) were uneducated. Majority of parents 49(49%) had jobs, 22(22%) were doing Business, 20(20%) were unemployed or housewives and 9(9%) were doing agriculture. In relation to the income per month, 44(44%) had income of  above Rs. 20000, 33(33%) parents income was between Rs. 10000-20000, 17(17%) parents income was between Rs. 5001-10000/- and 6(6%) parents had less than RS. 5000/- per month income. In relation to the source of information, 30(30%) got information from television, 29(29%) got it from newspaper, 19(19%) got from social media, 19(19%) got from friends and 03(03%) were not having any information. In relation to the diet, 74(74%) were vegetarian and 26(26%) non-vegetarian. With regard to number of children, 50(50%) parents had two children, 23(23%) had three children, 21(21%)  had one child and 6(6%) had four and above. Section –II: Findings related to BMI and Restraining, promoting factors -BMI With regard to the body mass index BMI, 81(81%) had normal BMI, 10(10%) were underweight, 08(08%) were overweight and 01(01%) was obese. Majority of the parents classified based on BMI, 68(68%) had normal weight, 25(25%) had overweight, 05(05%) were obese and 02(02%) had underweight. -Restraining and promoting factors: Questionnaire [DM4]  for children includes, Frequently consume Soft drinks                     9. Prefer playing games over watching TV Frequently consume Snacks/Crisps               10. Likes to play outdoor games Frequently consume sweets                            11. Limit meals outside home Watch TV while having food                         12. Monitor Height/Weight regularly Prefer Junk foods over fruits                          13. H/E is provided in school on obesity Play video games                                            14. Daily separate timing for exercises Time consuming home work Daily follow routine exercises Children were asked to respond Yes/No to the above questions Questionnaire for parents includes, Frequency of purchasing sweet beverages Frequency of purchasing crispy snacks Frequency of purchasing sweets (Parents were asked to choose between Never/Rarely/Frequently) Restrict child watch TV while meal time Did the meal routine set for child? Were the children encouraged to eat vegetables? Were limits set on the types of food they can snack on regularly? Were limits set on types of soft drinks children can drink regularly? Were the children reminded to drink water? Were the children encouraged to play outdoors? Were limits set on the amount of time children can watch TV Did adult family members walk/cycle to get to or from places? Parents were asked to respond Yes/No to No. 4-12 questions Table No.1.             According to the below table, When the questionnaire was administered to children, only 8 children&#39;s responses were satisfactory, 67 children&#39;s responses were moderately satisfactory and 25 children&#39;s responses were not satisfactory. In parents, 30 responses were satisfactory, 57 parent responses were moderately satisfactory and 13 children responses were not satisfactory. Discussion[DM1] : Prevalence of overweight/Obesity: In the present study overall prevalence of obesity in children was observed (1%) and overweight (8%) in total 100 children. BMI: When assessed for BMI in children only one (1%) was obese and 5 (5%) parents were obese.              A similar study conducted in Ahmedabad which revealed the Obesity and overweight prevalence of 14% in that overweight was (11.8%) and obesity (2.2%). Findings of similar study in Latur shows overall prevalence of overweight and obesity was 9.98% in that 8.54% were overweight and 1.44% were obese. A study in Karnataka shows 9.63% of overweight/obese children in that 4.50% were overweight and 5.13% were obese.6             A study in Tamilnadu revealed that prevalence of overweight/obesity was 27% in that 20% were overweight and 7% were obese. Prevalence of obesity and overweight was comparatively less in a study conducted in Dakshina kannada and Udupi districts, overall it was 5.60%in that 3% overweight and 2.60% were obese.6 Restraining and promoting factors: Majority (67%) of the children practices were moderately satisfactory, 25% children practices were not satisfactory and 8% children practices were satisfactory. In parents majority (57%) of them had moderately satisfactory practices, 30% of parents practices were not satisfactory and only 13% of parents practices were satisfactory.             Findings of similar study in School of central part of Bangalore shows that 87.78% of parents monitor the diet of their child, 81.78% parents feel that their child has adequate activity. Parents feel excessive academic activity and TV watching for lack of physical activity.7                     Similar study on Attitude of mother on Childhood obesity and its prevention was carried out in Pududcherry, India. Findings revealed that mothers agreed with faulty food habits (40.83%), unhealthy lifestyle practices (55.83%), and parent dietary behavior (39.17%) is associated with obesity. Mothers agreed with high intake of sweet (41.67%) and chocolates (49.17%) ice creams (50%), fried foods (53.33%) induces obesity. 35% of mother accepted that, media influence the child eating behavior .8 Conclusion[DM2] :             Findings of the study revealed that overweight and obesity is very prevalent in children as well as parents and its growing numbers is a major concern. Results of Practices related to childhood obesity in children as well as parents shows it is satisfactory in only few respondents. A teaching program on childhood obesity will be helpful to improve the practices in children and parents which will in turn prevent the consequences like coronary artery diseases, diabetes, hypertension and chronic illnesses in their later life. Collective efforts from leaders of the society, school teachers, health professionals and parents are must to achieve a normal BMI in children and help them lead normal healthy life. Government should include activities related obesity prevention in school health program. Acknowledgments: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors also thank the help received from school management, teachers and parents. The authors are also grateful to [jjuhthis article has been reviewed and discussed. Funding: No funding sources. Conflict of interest: None declared Ethical approval: Approved by the Institutional Ethics Committee ((Ref.No. SVU/Ph.D/RDC/2017) Englishhttp://ijcrr.com/abstract.php?article_id=3325http://ijcrr.com/article_html.php?did=3325 WHO consultation on obesity, World health organization. Obesity preventing and managing the global epidemic report of WHO consultation. 1999-2000. https://pubmed.ncbi.nlm.nih.gov/11234459/Access date: 7/05/20 2.    Brown P J, Konner M. An anthropological perspective on obesity. Ann N Y AcadSci. 1987; 499, 29?46. https://pubmed.ncbi.nlm.nih.gov/3300488/    Access date: 12/05/20 Kaushik, J S, Narang M, Parakh, A. Fast food consumption in children. Indian pediatrics. 2011; 48(2) : 97-101.https://link.springer.com/article/10.1007/s13312-011-0035-8 Access date: 7/05/20 4.     Sood A, Sundararaj P, Sharma S, Kurpad A V, Muthayya S. BMI and body fat percent:    affluent adolescent girls in Bangalore City. Indian pediatrics. 2007; 44(8), 587. https://www.ijcmph.com/index.php/ijcmph/article/view/333 Access date: 10/05/20 5 .     Jordan, A. B, Robinson, T. N. Children, television viewing, and weight status: summary and recommendations from an expert panel meeting. The ANNALS of the American Academy of Political and Social Science. 2008; 615(1), 119-132. https://www.researchgate.net/publication/240696057_Children_Television_Viewing_and_Weight_Status_Summary_and_Recommendations_from_an_Expert_Panel_Meeting. Access date: 12/5/20 6.      Shiv Lal Solanki, Bhagraj Choudhary, Bharat Meharda, Abhilasha Mali. An  Epidemiological Study of Overweight and Obesity in High School Children of Udaipur City, (Rajasthan). IJCR.2018; 10 (8). http://ijcrr.com/article_html.php?did=2476#:~:text= Our%20 findings%20 are%20 supported%20by,%25)%20at%20age%2015% 20years. Access date: 28/9/20 7. Hemavathi Dasappa, Farah Naaz Fathima, Krithika Ganesh, Shankar Prasad. Prevalence, risk factors, and attitude of parents towards childhood obesity among school children in Bangalore city. International Journal of Community Medicine and Public Health. 2018 Feb;5(2):749-753 https://www.ijcmph.com/index.php/ijcmph/article/view/2404 Access date: 28/9/20 8.Samundeeswari Arunachalam, Maheswari Kandasami. Mother&#39;s attitude on childhood obesity and its prevention. Allied Academics. 2019; 23(3). https://www.alliedacademies.org/articles/mothers-attitude-on-childhood-obesity-and-its-prevention-11546.html Access date: 28/9/20

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareManagement of Traumatic Wounds of Hand and Foot by Various Modalities: A Comparative Analysis English136142Venkatesh DasariEnglish Naresh Kumar DhaniwalaEnglish Sohael M. KhanEnglish Vrushabh U. KumbhareEnglishBackground: Hand and foot have lower blood supply as compared to face and scalp, leading to hindrance in wound healing. Delayed and/or inadequate treatment of these wounds may even lead to permanent disabilities. Despite the importance of this matter, there are no widely accepted protocols for the treatment of traumatic wounds of hand and foot which can provide the most optimal treatment to the patients. Objective: To study the outcome of management of traumatic wounds of hand and foot by various modalities and compare the results of the above modalities of wound management in terms of rate of healing, control of infection, and functional outcome. Methods: A total of 30 patients were enrolled in this study and divided into 3 groups with 3 different treatment modalities: A- Regular sterile dressings, B- Infiltration of platelet-rich plasma (PRP) at wound edges, and C - Split thickness skin grafting. Wounds were assessed serially by Bates Jensen Wound Assessment Tool (BJWAT) and skin grafting wounds were assessed by clinical points of graft acceptance, exudation, infection, contractures, etc. The functional outcome was quantified by the QuickDASH score for hand injuries, and the Foot and Ankle Ability Measure (FAAM) score for foot injuries. Results: Pre-treatment, the majority of the wounds were in the size range of 6-10 cm2. The pre-treatment mean BJWAT scores were 31.2 ±4.26, 33.2 ±4.80, and 32.2 ±4.52, in dressing group, PRP group, and Skin grafting group, respectively and it was not statistically significant. There was a statistically significant decrease in BJWAT scores in groups A and B by 9 weeks of treatment, but the PRP group showed a faster rate of healing. 80% of patients in the skin grafting group showed ‘excellent’ results. Most superior functional outcome scores of QuickDASH and FAAM were observed in the PRP group, followed by dressing and skin grafting groups. Conclusion: Platelet-rich plasma infiltration at wound edges provides a safe and effective treatment modality for the treatment of traumatic wounds of hand and foot. EnglishManagement of Traumatic Wounds of Hand and Foot by Various Modalities: A Comparative AnalysisIntroduction Traumatic wounds are one of the most common problems seen in day to day life leading people to the hospital.1, 2 Amongst various age groups, children are prone to these injuries while playing outdoors or by household tools. Youth and adults are more likely to get injuries as occupational hazards during working with heavy machinery, as a result of assaults, railway accidents, and road traffic accidents(RTA) involving motorized vehicles leading the list.3 WHO reported 12 lakhs deaths around the world which were related to road traffic accidents in the year 2015, leaving millions more with an array of injuries and many with life-long adverse health consequences.4 India ranks fourth on the list of countries with the highest number of road traffic accidents.5 Trauma and its consequences lead to a heavy burden on the national economy and its individuals. In low- or moderate economy countries, the most affected age group is the one earning the bread in the family and contributing significantly to the working force of the society. With a huge population already below the poverty line in our country, trauma to the breadwinner of the family further worsens their poverty. This is due to loss of income to the family added with the burden of prolonged and costly medical care. Despite this being a large and preventable burden to human life, medical services, and the country’s economy, the measures to minimize the overall trouble have proved inadequate.4 The hands and feet are two very important structures of the human body that are highly functional and useful in activities of daily living (ADL). The hand and foot are the most functional part of the limbs, and hence more prone to traumatic injuries. They are the first, and sometimes the only body part in contact with the surrounding environment during trauma. Face and scalp have high vascularity and hence there are fewer chances of infection secondary to trauma. Relatively low vascularity in hand and foot makes them more prone to post-traumatic infections.6 All these factors make the hand and foot more prone to injury, its complications, long-standing disease, and even permanent deformity in some cases. Correct diagnosis and efficient management are essential to avoid complications.7 Traumatic wound management has had an unsettled history for centuries. The general approach to wound management involves local hemostasis, debridement, and primary closure. On failure or non-applicability of primary suturing, other modalities used are (i) regular dressing and healing of a wound by secondary epithelialization, (ii) infiltration of platelet-rich plasma at wound edges to help epithelization, and (iii) skin grafting. The most appropriate way to accomplish wound healing with a maximum functional and cosmetic gain is still debatable. The hand and foot are a common site of traumatic wounds and the most functional and important parts of human limbs, yet there are not many studies focusing on their wound management. In light of this paucity, the present work was undertaken with the aim of ‘studying the outcome of management of traumatic wounds of hand and foot by various modalities.’   Materials and Methods This prospective study was conducted in the Department of Orthopaedics, Jawaharlal Nehru Medical College, and Acharya Vinoba Bhave Rural Hospital, Sawangi (Meghe), Wardha (MH), India. The material of the study was constituted by the patients presenting to the Orthopaedics outdoor department or Emergency Medicine department with traumatic injuries of hand and foot. Institutional ethics committee approval was obtained before proceeding with the research work. Inclusion Criteria: All traumatic wounds on hand and foot with or without tendon, muscles and bony injuries Patients willing to participate in the study Exclusion Criteria: Traumatic wounds older than 1week from time of injury Patients with uncontrolled diabetes mellitus Patients not willing to participate in the study On presentation, patients were submitted to a detailed history and clinical examination. A clinical diagnosis was made and necessary emergency medical& primary management was provided. On stabilization of a general condition, advised investigations were done. All patients were taken up for wound debridement at the earliest possible opportunity after stabilizing the general condition. Primary closure was attempted, wherever possible. Associated musculoskeletal injuries were managed as per established protocols. A single dose of Injection Ceftriaxone 1gm intravenously (IV) was given to every patient at the time of admission and was continued bis in die for 3 days followed by tablet Cefixime 200mg orally twice daily for the next 5 days. Injection Metronidazole 400mg 8 hourly was given in selected patients having gross crushing and contamination to preventing anaerobic infections. Other necessary medical management for analgesia and supplementation was provided. Thirty patients were enrolled in this research. An informed written consent, in the regional language, was obtained from the patients before enrolment. Systemic randomization of patients was done into 3 groups, each of 10 subjects. In group A, patients received conservative management in the form of regular sterile dressings, group B patients received infiltration of platelet-rich plasma (PRP) at wound edges and in group C patients received surgical management of wound in form of split-thickness skin grafting. Details of treatment methodology in each group are as follows: Group A: Debridement and Dressing: After debridement, patients under this group were managed with the regular sterile dressing of the wound. The wound and surrounding skin were cleaned with a povidone-iodine solution followed by normal saline. After dry mopping, the area, a thin layer of povidone-iodine ointment was applied over the wound and covered with sterile gauze pieces. Specialized dressing materials were not used in this study. The frequency of dressing change varied, depending on the requirement of individual wounds. Most wounds required a more frequent dressing change in the initial period of 1-2 days, which would later be sufficed with alternate day dressing changed regime. Group B: Platelet-Rich Plasma infiltration: Autologous Platelet-Rich Plasma (PRP) was prepared in the Centre for Autologous Platelet Biotechnological Intervention (CAP_BI) at the Department of Orthopaedics, AVBRH. The preparation of PRP was done as per the protocol developed by the centre, STARS therapy. [8] 20ml of venous blood was collected from the antecubital vein of the patient and divided equally into 4 Ethylene-diamine-tetra-acetic acids (EDTA) bulbs. These samples were centrifuged by the standard double spin method. The first spin of 10 minutes at 1200 rpm would separate the RBCs at a bottom layer and plasma at the top layer. This plasma was extracted into separate bulbs and a second spin for 10 minutes at 2000 rpm was performed. This separates plasma into the upper buffy coat containing Platelet-Poor Plasma (PPP) and the lower Platelet-Rich Plasma (PRP) layer. This lower layer (normally 2-4 ml) was collected in 2 ml syringes. This whole preparation was done at a room temperature of 22–24°C. Haemoglobin level of 10gm% and above was kept as a requirement for PRP treatment (Figure 1). Meanwhile, the patient was taken on the table, in the sterile minor procedure room. The wound and surrounding area were cleaned with cetrimide-chlorhexidine (Savlon) solution and normal saline and draping were done using an eye towel. The prepared platelet-rich plasma (PRP) was infiltrated in the wound edges in a pattern similar to giving local anaesthesia, using a 24G gauge needle, followed by the sterile dressing of the wound. This process was repeated every 4th day, till satisfactory wound healing was achieved. A: Blood collected in EDTA bulb, B: After 1st spin of 10 minutes at 1200 RPM. Upper buffy layer and lower layer of settled RBCs and C: Buffy layer transferred to another bulb and undergone 2nd spin of 10 minutes at 2000 RPM Group C: Split thickness skin grafting: Patients in this group were initially managed with regular sterile dressings, similar to Group A, till a healthy granulation tissue bed was formed at the recipient site. The patients were then taken up for surgery after fulfilling the pre-operative requirements and obtaining the necessary consent. Pre-operative check-list: Haemoglobin >= 10gm% Control of other co-morbidities like systemic hypertension Donor site – Should be free of infections, wounds Recipient site – Healthy granulation bed, no exposed bones, tendons, ligaments                                        - No signs of infection                                        - Skin margins healthy The site used for harvesting graft was the anterolateral aspect of the thigh. The split-thickness skin graft was harvested using a Humby’s knife. Multiple slits were made in the graft using a knife to give it a ‘mesh-like’ appearance. Skin grafting was done as per the standard method. The grafted area was covered with saline-soaked gauze and an adequately tight dressing with sufficient padding was done (Figure 2A, B and C) and Figure 3A, B and C). Evaluation of wound healing For group A and group B patients, the wound assessment was done using “Bates Jensen Wound Assessment Tool (BJWAT)”.9, 10 This tool assesses the wound based on 13 points, namely: size, depth, exudation, necrosis, skin discolouration, granulation tissue, epithelium formation, etc. The wounds are scored between 13 and 65, where a decrease in the score means healing. A score of 13 indicates the complete healing of the wound. The wounds in these two groups (A & B) were evaluated using BJWAT on enrolment (Week 0) and then on 1st, 3rd, 5th, 7th, and 9th week of the intervention (Table1). Group C patients were evaluated initially (Week 0) using BJWAT. After skin grafting the wounds were assessed clinically for graft acceptance, signs of infection, exudation, graft contracture, or any other complications. The below-mentioned table was created for this purpose. The evaluation was done on enrolment (Week 0), on the 5th day (Week 1), followed by 3rd, 5th, 7th, and 9th-week post-graft. Evaluation of Functional and Cosmetic Outcome Functional outcome evaluation was done using the QuickDASH score 11 for hand injuries and Foot and Ankle Ability Measure (FAAM) score12 for foot injuries, at 3 and 6 months. Both these scales are well recognized and accepted internationally with a high-reliability index for evaluation of functional outcomes in traumatic injuries of hand and foot, respectively. The scales consist of a subjective questionnaire with graded responses. Patients have to select the most appropriate response as per their recent past experiences of day to day activities. All statistical analysis was done by Statistical Package for Social Sciences (SPSS) version 26. Results In the present study, the mean age in dressing group (A), PRP group (B), and skin grafting group (C) was 33.4 ±15.26, 29.8 ±17.07, and 34.5 ±16.33 years respectively. There was no significant difference in age distribution in all three groups. (p>0.05) Out of a total of 30 patients, 26 were male while 04 were female, making the male: female ratio 6.5:1. The majority of the patients in this study were students: 10 (33.33%) followed by employees in industrial setups: 8 (26.3%) and farmers: 8 (26.3%). On evaluating the mode of injury amongst patients, road traffic accidents were found to be the major mode of trauma, with 12 patients (40%), followed by industrial accidents in 8 patients (26.6%) and farming accidents in 8 patients (26.6%). As per side involvement, predominantly the injuries were on the right hand or right foot: 19 (63.3%) In associated local injuries, a majority of the cases had fractures of metatarsals, metacarpals, or phalanx: 22 (73.3%). Associated injuries elsewhere in the body included fractures of radius-ulna in 10 (33.3%) patients, followed by fractures of tibia-fibula in 7 (23.3%) patients. Wound size pre-treatment, in the majority of the wounds, was in the range of 6-10 cm2. The pre-treatment mean BJWAT scores were 31.2 ±4.26, 33.2 ±4.80, and 32.2 ±4.52, in dressing group, PRP group, and skin grafting group, respectively. The mean BJWAT score in dressing group (A) pre-treatment was 31.2 ±4.26 and at 9-week post-treatment was 13.3 ±0.94. There was a statically significant reduction in BJWAT score pre-treatment to 9 weeks post-treatment. (p0.05) With a male: female ratio of 6.5:1, the lower number of females in this study may be attributed to the fact that males are still the predominant bread earning and outgoing members of the rural and sub-urban society, where the study is based.21 This causes males more exposure to road traffic accidents and workplace hazards related to industrial and agricultural types of machinery. El-Sayed et al. 13 worked on the usefulness of platelet-rich plasma (PRP) (study) in treating foot wounds, in comparison to regular dressings (control). They noted the age range of 31 to 66 years (mean = 49±5.06 years). Soumya Ghosh et al.14 assessed wound healing in open hand injuries and found 31.13 years as the mean age with a range of 18-45 years. Predominantly, males were more affected (male: female = 2.3:1), similar to the finding of this present study. There was no difference when the three groups were compared statistically concerning the occupation.  (p>0.05) The majority of the patients in this study were students: 10 (33.33%)followed by industrial setup employees: 8 (26.6%). The fact that the majority of patients in both these groups had to travel for work or studies, combined with the poor traffic control might be a contributing factor towards more injuries due to road traffic accidents. An important part of the study group was formed by farmers: 8 (26.6%). On evaluating the mode of injury, road traffic accidents were found to be the major mode with 12 patients (40%), followed by industrial accidents in 8 patients (26.6%) and farming accidents in 8 patients (26.6%). Two third of road traffic accidents occurring in India have victims within the age range of 15-44 years. 15 This is similar to the age groups found in our study. An official report states that a total of 46044 road traffic accident cases were noted in India in the year 2018, with the highest number of road accident-related deaths in the world.16 The industrial employees’ work with heavy types of machinery, came with a work hazard of industrial accidents and injuries to hand and foot. Farmers use types of machinery like thresher machines, sharp farming tools, and knives, making them prone to traumatic injuries. There was no significant difference in the mode of injury amongst the three groups (p>0.05). As per the side involved in the current study, predominantly the injuries were on the right hand or right foot: 19 (63.3%). Since the dominant extremity is more prone to injuries, the majority of right-sided dominance can be observed from the study. But on comparing the three treatment groups, there was no statistically significant difference observed (p>0.05). Wound characteristics& healing The majority of the wounds in patients, 5 (50%) in dressing group(A), 6 (60%) in PRP group (B), and 6 (60%) in skin grafting group (C), were in the size range of 6-10 cm2, indicating no significant statistical difference amongst three groups. (p>0.05)The mean BJWAT scores before treatment in dressing group (A), PRP group (B), and Skin grafting group (C) were 31.2 ±4.26, 33.2 ±4.80, and 32.2 ±4.52respectively. There was no significant difference in BJWAT scores on the distribution of patients in all three groups indicating similar nature of wound characters in all 3 groups (p>0.05). The comparison of mean BJWAT score in the PRP group (B) and dressing group (A) at different intervals shows no significant difference in the two groups till 5 weeks. (p>0.05) But after 5 weeks, wounds in Group B heal quickly as compared to Group A with statistical significance up till 9 weeks. (pEnglishhttp://ijcrr.com/abstract.php?article_id=3326http://ijcrr.com/article_html.php?did=3326 Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999 Sep 1;34(3):356-367. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Engl J Med 1997 Oct;337(16):1142-1148. Park K. Park&#39;s textbook of preventive and social medicine. Bhanot Publishers, 2015. 23rd edition. World Health Organization. Global status report on road safety 2015. WHO; 2015 Dec 17. Singh J, Gupta G, Garg R, Gupta A. Evaluation of trauma and prediction of outcome using TRISS method. J Emerg Trauma Shock 2011 Oct;4(4):446. Notley DA, Martin DR, Hill M. Evaluation and management of traumatic wounds. Relias Media. 2015 March 1. Available at https://www.reliasmedia.com/articles/134664-evaluation-and-management-of-traumatic-wounds Werner SL, Plancher KD. Biomechanics of wrist injuries in sports.  Clin Sports Med 1998 Jul;17(3):407-20. Shrivastava S, Mahakalkar C, Tayde S, Mehmood M, Gupta A. Developing ideal solution for acute wound treatment by regenerative medicine. J Regen Med 2016;5:2: 21-24. Bolton L, McNees P, van Rijswijk L, de Leon J, Lyder C, Kobza L, et al. Wound outcomes study group, Wound-healing outcomes using standardized assessment and care in clinical practice. J Wound Ostomy Continence 2004;31(2):65-71. Harris C, Bates-Jensen B, Parslow N. Development of a pictorial guide for training nurses. Wound Care Canada 2009;7(2):34. Wong JY, Fung BK, Chu MM, Chan RK. The use of Disabilities of the Arm, Shoulder, and Hand Questionnaire in rehabilitation after acute traumatic hand injuries. J Hand Ther 2007;20(1):49-56. Goldstein CL, Schemitsch E, Bhandari M, Mathew G, Petrisor BA. Comparison of different outcome instruments following foot and ankle trauma.  Int J Foot Ankle 2010 Dec;31(12):1075-80. Abd El-Mabood ES, Ali HE. Platelet-rich plasma versus conventional dressing: does this really affect diabetic foot wound-healing outcomes? Egypt J Surg 2018;37(1):16. Ghosh S, Sinha RK, Datta S, Chaudhuri A, Dey C, Singh A. A study of hand injury and emergency management in a developing country. Int J Crit Illn Inj 2013 Oct;3(4):229. Sharma N, Kumar AA. Road accidents in India: Dimensions and issues. [Accessed on 2018 Dec 14]. Available from: http://www.teriin.org/library/files/Road_Accidents_in_India.pdf  Road accidents in India. [online] [Accessed on 2020 Oct 10]. Available from: https://morth.nic.in/sites/default/files/Road_Accidednt.pdf Martinez-Zapata MJ, Martí-Carvajal AJ, Solà I, Expósito JA, Bolíbar I, Rodríguez L. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database Syst Rev 2012; 10:89–92.  De Leon MJ, Driver VR, Fylling CP, Carter MJ, Anderson C, Wilson J, et al. The clinical relevance of treating chronic wounds with an enhanced near-physiological concentration of PRP gel. Adv Skin Wound Care 2011; 24:357–368. Villela V, Falanga A, Brem H, Ennis W, Wolcott R, Gould L, Ayello E. Role of PRP and maintenance debridement in the treatment of difficult-to-heal Chronic wounds. Ostomy Wound Manage 2010; 6(3):2–13. Thimmanahalli GU, Kumar M. Efficacy of autologous platelet-rich plasma over conventional mechanical fixation methods in split-thickness skin grafting. Int Surg J 2018 Dec 27;6(1):108-13. Li H, Hamza T, Tidwell JE, Clovis N, Li B. Unique antimicrobial effects of platelet?rich plasma and its efficacy as a prophylaxis to prevent implant?associated spinal infection. Adv Healthc Mater 2013;2(9):1277-84.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareFoetal Anomalies: Correlative Study of Sonography and Autopsy English143147Aiswarya Lekshmi RVEnglish G RajuEnglish K ChandrakumariEnglishBackground: Sonography is performed without risk to mother or foetus for a scientific anatomical survey of the external features and all organs related to each system. Objectives: In this study by comparing Ultrasound and Autopsy of intrauterine congenitally anomalous foetuses contrasting findings were detected. Methods: The results of Limb anomalies, Palmar crease defect, Cleft palate and Cleft lip, Club foot, Diaphragmatic hernia, Gastrointestinal anomalies like Omphalocele, Imperforate Anal defects are considered. Results: Four categorizations of anomalies with the comparison of Ultrasound and Autopsy findings are done. Conclusion: Categorization plan shows that each Ultrasound and Autopsy findings are influenced by Socio-economic status and Dietary habits. Early diagnosis of malformations and awareness to parents can be helpful for Medical termination of pregnancy and prevention in subsequent pregnancies. English Autopsy, Categorization, SonographyINTRODUCTION The aim of this study is to analyse the potential use of Prenatal scan done throughout intrauterine life from 6-20 weeks for the assessment and diagnosis of defective embryological anomalies.Sonography is performed without risk to mother or foetus for a scientific anatomical survey of the  external features  and  all  organs related to each system.Two broad subsets of foetal anomalies are major and minor. Minor anomalies about 14% which won’t seriously interfere with viability or physical well being which can or cannot be detected during Prenatal sonography. In this study pattern of different embryological anomalies and sex ratios of foetuses were conducted. Materials and methods SOURCE                       Fifty Antenatal Ultrasound scan reports of defective embryological anomalies and their foetal specimens obtained after medical termination of pregnancy or delivery. Study Design                       Descriptive Study Case series. Data Analysis                        Student t-test using SPSS Software version 17 and Microsoft Excel. Materials           This study ( SGMC : IEC No.10/95/01/2014/)  was conducted during the period of 2014 to July 2016. Ultrasound scanning reports obtained from Ittyavirah Scan Centre, Thiruvananthapuram. Specimens of those foetuses were obtained from various hospitals were delivery or medical termination was conducted including Placenta. Autopsy was  conducted  at  Sree  Gokulam Medical College & Research Foundation, Thiruvananthapuram. Inclusion criteria          Embryologically defective foetuses detected by Autopsy, agreeing with their Ultrasound Scan reports. Exclusion criteria          Embryologically defective foetuses whose Ultrasound Scan reports are not available. Detailed recording of the history of the patients were obtained from parents in the form of a Proforma including 1. Maternal age 2. Duration of Gestation 3. History of Consanguineous marriage 4. Socio-economic status 5. History of the maternal consumption of medicine taken by the mother during pregnancy. 6. History of dietary habits 7. Exposure to radiation, chemicals. 8. History of abortions or still births. 9.  Previous history of defective embryological  anomalies. 10. Similar history in the family .            The cases were followed up till delivery or Medical termination of pregnancy at various hospitals in Thiruvananthapuram. The fetuses after expulsion / delivery were collected. The external appearances of the babies were examined & noted down and compared with the Ultrasound reports.        Collected foetuses and Placenta were obtained ranging from sixteen to twenty weeks of gestation were preserved in 10% formalin which is the fixative used.          Consent for Autopsy was obtained from parents after explaining the necessity. The Autopsies were conducted in the Department of Anatomy, Sree Gokulam Medical College after comparing with the Ultrasound report. Each foetuses were exploded using surgical knife, scissors and forceps. Internal findings correlated with the Ultrasound and other extra findings looked for. Updating of findings were done by Periodical  photography. Placenta also studied. OBSERVATION AND RESULTS                Correlating the findings of Prenatal, Ultrasound and Foetal Autopsy of the specimens of varied Congenital anomalies classification was done system wise under the following four categories.   Category A – Both findings (Ultrasound and Autopsy) were agreed. Category B – Additional data of other anomalies detected.                      Category C - Foetal autopsy revealed only certain Ultrasound findings. Category D - Ultrasound and Autopsy findings were totally mismatching. Limb Anomalies                      Sixteen foetuses showed Talipes Equino Varus. Out of that four specimens had shortening of Upper and Lower segments of both limbs due to Skeletal dysplasias as given in Graph 1: Limb Anomalies and Table 1: Limb Anomalies. Talipes Equino Varus                              “A combination of talus and pes together with an elevated heel resembling that of a horse (L.Equinus, horse); which is also turned inwards (Varus).Inverted foot, Plantarflexed ankle, Adducted forefoot as shown in Fig 01,Fig 02 and Fig 03(turned toward the midline in an abnormal manner)”. Incidence is approximately one per thousand live births with males affected twice than females.1,2         Three fetuses were there with Omphalocele as shown in Fig 04, Fig 05, Table 02 and Graph 02.    Other findings in one foetus   i.    Short neck with oedema around   ii.   Head twisted towards right  iii.   Left lower limb absent  iv.   Spine with Scoliosis   v.   Right foot with 1,2 and 3 toes fused  vi.   Ambiguous genitalia vii.   Omphalocele contain Intestine and Liver viii.  Umbilical cord contain one Umbilical artery.   ix.  Kidney was Horse shoe shaped shown in Fig 06 Second specimen  i.  Short neck ii.  Dysmorphic facies iii. Fusion of digits of Hand and Feet. iv. Left Foot Talipes Equino Varus. v.  Single Palmar Crease. vi. Lungs were two lobbed. Third Specimen                 Presented only with Omphalocele. Cleft Palate             Cleft Palate constitute 4% of the total anomalies as shown in Table 3, Graph 3 and Fig 07. One was a male baby with dysmorphic facies, low set ears with flattened ear lobes, upper lip bilateral cleft lip with cleft palate, nose poorly formed, polydactyly with six digits in left hand and right foot, phallus is short with  Hypospadiasis. Diaphragmatic Hernia                There were three cases of Diaphragmatic Hernia which shows the frequency is more on the left side as shown in Table 4, Fig 08. Imperforate Anus              Detected in three foetuses shown in Table 5, Graph 4. Two of them were with Mermaid syndrome . Single Palmar  crease          It was hydrops baby with multiple Congenital anomalies, dysmorphic facies, short neck, fusion of digits of hand and feet, left foot Talipes Equino Varus, Single Palmar crease, Omphalocele  and  both lungs were  two  lobbed shown in Fig 09,Table 6 and Graph 5.  DISCUSSION             In this study Ultrasound and  Foetal Autopsy findings of  Foetuses up to 20 weeks of gestation were compared and contrasted; obtained four category results in which                                                                                      Category A – Both findings (Ultrasound and Autopsy) were agreed. Category B -  Additional data of other systemic anomalies detected. Category C -  Foetal autopsy revealed only certain Ultrasound findings. Category D – Ultrasound and Autopsy findings were totally mismatching.               Antonsson et al(3) examined Ultrasound and Autopsy on an equivalent methodological basis and came to a conclusion that autopsy could have significant limitation in CNS malformations. During this study we could ready to notice a high degree of correlation between Ultrasound and Autopsy in twenty two cases. 44% of Foetal anomalies revealed in Ultrasound were demonstrated in Autopsy also. These anomalies are grouped under Category A which incorporates neural tube defects, Cystic hygroma, Hydrops foetalis and Omphalocele.      Akgun et al(4) in 2007 concluded that analysis of Foetal autopsy following termination of pregnancy enables the diagnosis of anomalies which isn&#39;t detected by Ultrasound. In Category B, limb anomalies, Skeletal defects and Genitourinary anomalies are included mostly. Skeletal dysplasia are often revealed through Ultrasound, but confirmation is required from autopsy. Renal Cystic diseases could even be difficult to define on an Ultrasound scan as Oligohydramnios is usually associated. Other anomalies like Cardiovascular, Cleft lip / Cleft palate and Urinary tract defects are detected in autopsy (Category B) 38% .       Category C included mainly complex, CNS because it gets macerated due to improper preservation of the foetus after death and also due to the delay in autopsy. Moreover it should be borne in mind that certain conditions of expulsion hinder examination as they involve an excessively long period of foetal retention resulting in maceration in Utero and tissue lysis, of brain tissue especially and Cardiovascular anomalies like Valve insufficiencies due to the small size of the heart, Pericardial and Pleural effusions. Seven cases were included in Category C which constitute 14% of the entire anomalies.       In Category D there was total disagreement between Ultrasound and Autopsy. Two cases comes under Category D which constitute 4% of the entire anomalies.       Finally this categorization evidently shows that both Ultrasound and Autopsy may have some important limitations in diagnosing Foetal abnormalities and both are complementary.      The mothers who had undergone Ultrasound scanning and were found to be having Congenitally abnormal foetuses were grouped consistent with the Socio-economic status into High, Middle and Low income groups.  CONCLUSION                  Reasons for Common defective embryological anomalies are  i.   Genetic factors (Chromosome and Single gene mutation) ii.   Environmental factors (Infectious agents, Chemical compounds, Radiations) iii.  Use of medication by mother iv.  Maternal metabolic diseases v.   Multiple pregnancies vi.  Maternal stress vii. Prematurity of the Infant.                By this study the potential and limitations of Ultrasound and Autopsy and categorization into four categories was possible. Even though Ultrasound fairly detects the malformations, Foetal autopsy is vital for obtaining extra information.Ultrasound findings rely upon the accuracy of the machine and the experience of the person. The Autopsy also depends on the ability and experience of a Specialist Paediatric Pathologist. Placental examination is also can give supportive findings like Macroscopic study of the Placenta, Position of Umbilical cord, Foetal and Maternal surfaces of the Placenta and Evidence of Placental infections. Earlier detection of Foetal anomalies by Ultrasound leads to early termination of  Pregnancy without Autopsy. This results in missing important informations from Paediatric Pathologist which can cause risk of repetition in the subsequent pregnancies.       Defective embryologically malformed infants is prone for morbidity and mortality. Treatment and Rehabilitation of these infants is tough. Recovery is usually not possible. So early diagnosis, interpretation and awareness to parents is very crucial. Conflicts of  interest                                  All authors have none to declare. Financial support and sponsorship                                  No funding to declare.                                 Acknowledgements                                  We acknowledge the contribution of Dr.Alex.K.Ittyavirah, Radiologist and Ultrasonologist, Ittyavirah Scan and Research Centre, Thiruvananthapuram and therefore the faculties of the department of Anatomy.  Englishhttp://ijcrr.com/abstract.php?article_id=3327http://ijcrr.com/article_html.php?did=33271.Standring S.Development of Pelvic Girdle and Lowerlimb, R Shane Tubbs, Cheryll Tickle. Gray’s Anatomy: The Anatomical Basis of Clinical Practice, Forty-first Edition, Elsevier.2016.9:1336. https://www.worldcat.org/title/grays-anatomy-the-anatomical-basis-of-clinical-practice/oclc/213447727 [last accessed on 2020, Oct 02] 2.Moore KL, Dalley FA, Agur MR Anne. Lower Limb. Clinically Oriented Anatomy, Sixth Edition, Wolters Kluwer (India). 2010.5:668.  ISBN-13:978-81-8473-183-5. 3.AntonssonP,SundbergA,KublickasM.CorrelaionbetweenUltrasound&Autopsyfindingsafter2ndTrimesterterminationsofPregnancy.JPerinatMed.2008;36(1):59-69.doi:10.1515/JPM.2008.005. 4.Hulya Akgun, Mustafa Basbug,Mahmut TuncayOzgun.Correlation between Prenatal Ultrasound & Foetal Autopsyfindingsin Foetalano maliesterminatedinthesecondtrimester.Prenat. Diagn.2007;27:45762.doi:10.1002/pd.1710. 5.A.Kaasen, J.Tuveng, A.Heiberg et al. Correlation between Prenatal Ultrasound & autopsy findings: a study of secondtrimesterabortions. Ultrasound Obstet Gynecol.2006,28:925-933.doi:10.1002/uog.3871. https://obgyn.onlinelibrary.wiley.com/doi/10.1002/uog.3871 [last accessed on 2020,Oct 02] 6.Zhraa Abd-Alkader Taboo. Prevalence and Risk Factors for Congenital Anomalies in Mosul City.The Iraqi Postgraduate Medical Journal.2012, Volume11, Issue4, Pages458-470. https://www.iasj.net/iasj?func=article&aId=62828 [last accessed on 2020, Oct 02] 7.Reeka Pradhan, Sajeeb Mondal, Shouvanik Adhya, Gargi Ray Chaudhuri. Perinatal Autopsy: A study from India; JIndianAcadForensicMed.2013Jan-March, Vol. 35, No.1.ISSN0971-0973. https://www.researchgate.net/publication/286858542_Perinatal_autopsy_A_study_from_India [last accessed on 2020, Oct 02] 8.Hashan Amini, Per Antonsson, Nikos Papadogiannikis.Comparison of Ultrasound and autopsy findings in Pregnancies terminated due to foetal anomalies. Acta Obstetricia et Gynecologica Scandinavica. 2006;85:1208-1216.https://obgyn.onlinelibrary.wiley.com/doi/full/10.1080/00016340600880886 [last accessed on 2020,Oct 02] 9.Globus M S, Hall B D, Filly RA, PoskanzerLB.Prenatal diagnosis of achondrogenesis. J Paediatrics. 1977,91;464. 10.Santosand & Duenheolter.1975. 11.Carr D H.Heredity & the Embryo.Science J.1970,6:75. 12.Persaud T V N.Problems of Birth Defects.From Hippocrates to Thalidomide & after.Baltimore, University Park Press.1979 13.Chen-Chith J Sun, Kathy n Grumbach, Donna T. DeCosta.Correlation of Prenatal Ultrasound Diagnosis and Pathologic Findings in Foetal Anomalies, Paediatric & Developmental Pathology.1999, Vol, Issue 2:pp 131-142. 14.Zsanett Szigeti M D, Akos Csaba M D, Barbara Pete M D.Correlation of Prenatal Sonographic Diagnosis and Morphologic Findings of Foetal Autopsy in Foetuses with Trisomy 21.2002  15.Mandeep Singh Bindra.Congenital Malformation in Perinatal Autopsy.A Prospective Study.2010 16.Nayab Alia, Irshad Ahmed, Amir Hayat Maha is. Congenital Anomalies: Prevalence of Congenital anomalies in 2nd Trimester of Pregnancy in MadinaTeaching Hospital, Faisalabad on grayscale ultrasound. JUMDC,2010 Vol.1,Issue 1,Jan-Jun. 17.Rema Devi, Preetha Tilak, Sayee Rajangam.MultipleCongenitalanomalies-an aetiological Evaluation. Bombay Hospital Journal.2007 18.Kulkarni M L.Congenital malformation.Indian Paediatr 1989;26:5-9.  19.Bai N S, Mathew E, Nair PM, Sabrinathan K.Perinatal mortality during a South Indian Population. J Indian Med Assoc.1991;89:97-98. 20.Sharma A K.The Clinical Value of Perinatal Autopsy. Indian Paediatr.1994;31:5-7. 21.Valerie Desilets, Luc Laurier. Fetal and Perinatal Autopsy in Prenatally Diagnosed Foetal Abnormalities with Normal Karyotype. SOGC Technical Update. 2011;No-267:1047-1057. 22.Kobayashi,Fleisher,Sample,Brown,Leopold,Filly,Sanders and Winsberg.1960. 23.Arthur C, Fleischer M D, Sandra G, Krihner M D, and Grey A, Thoma MD. Prenatal detection of foetal anomalies with Ultrasonography. Pediatric Clinics of North America,1985, Vol.32, No.6. 24.TanakaK, MiyajimaG, WagaiT, YasuuraM. Detection of  Intracranialanatomicalabnormalities by ultrasound.TokyoMed.J.1950,69:52. 25.Mishra P C, Baveja R.Congenital anomalies in Newborns A Prospective study.Indian Paediatrics. 1989Jan., Vol. 26. 26.GhoshS, BhargavaSK, BhtaniR; Congenitalanomaliesinlongitudinally studied birth cohortinaurban community. Indian J.Med. Res.Nov.1985,82:427. 27.MohanH, Bhardwaj, Bala. Congenital Visceral Malformations Role of Perinatal Autopsyindiagnosis. Foetaldiagnosisand Therapy.2004;19:131-133. 28.AiyarRR, AgarwalJR. Observationon Newborn: A Study of 10,000 consecutive live births. IndianPaediatr 1969;6:729-742. 29.Antonella Vimercati,Silvana Grasso,Marinella Abruzzese.Correlation between Ultrasound diagnosis and autopsy findings of foetal malformations.2010.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareAutomated Brain Tumour Detection using Deep Learning via Convolution Neural Networks (CNN) English148153Sanjay KumarEnglish Naresh KumarEnglish RishabhEnglish Inderpreet KaurEnglish Vivek KeshariEnglishIntroduction: Brain tumours are the most known and aggressive disorder, leading to a poor lifetime at the highest level. Treatment is one of the main benefits of development that saves a life. Imagery is used to analyse the tumour in brain, lung, liver, bosom, neck, etc, through tomography, appealing reverb imagery (MRI) and ultrasound imaging. And that&#39;s it. Objective: In this study, in particular, the tumour of the mind is examined through enticing reverse imagery. The enormous amount of knowledge produced by the MRI scanner, however, at any one time obstructs the manual tumour against non-tumour order. Result: The process has had several challenges, as computations for several images are reliable. An unambiguous necessity is to increase the survival rate of the programmed order. The scheduling of the mind tumour is an incredibly problematic task in the exceptional spatial and basic fluctuation that accompanies the local brain tumour. Conclusion: In this research, a programmed exploration of mind tumours is proposed using the characterization of convolution neural networks (CNNs). The most important type of composition is the completion of the use of small pits. CNN&#39;s paper has less predictability and 97.5 accuracies. EnglishMagnetic Resonance Imaging, Convolution Neural networks, Deep learning, Brain Tumour, Tomography, Brain cancerINTRODUCTION The Brain tumour in the human body is one of the essential organs; the irregular collection of cells consists of uncontrolled cell division, which is also called a tumour. Tumours of the cerebrum fall in two. Such second rate types (rating 1 with rating 2) as well as elevated evaluation tumours (rating 3 and grade 4). Bad quality mind Favorable is said to be the tumour. Besides, the high calibre. The Malian tumour involves cells of malignancy and affects the tissues involved. The benign tumour is non-malignant, and those parts of the mind do not spread to others. Otherwise, a malignant tumour is called a lymph tumour. It brings swift passage. 12 For the most part, brain-attractive reverberation imaging is worn to identify. The tumour plus the tumour progression model procedure. Attractive reverberation imaging offers increasingly clinical image data since the CT or ultrasound image. Attractive reverberation imaging gives in mind .1-3 Tissue subtlety data on the structure and deviation from the norm of the position of the cerebrum. Scholastics have proposed different strategies for discovering mind tumours, compiling inventories with MRI images when digitizing and shipping is conceivable Clinical photos of a PC. Neural networks (CNN) and bolster vector machines (SVM) are the strategies regularly used for your grand proclamation in the late years.4 However, as of late, profound learning models (DL) rectification of a moving trend in machine learning underground architecture can effectively stand for complex relations with no the need for a great number of nodes as in surface architectures. Ex: adjacent Vector machine K-Nearest (KNN) and bolster (SVM). They grew up fast along these lines to become the best in class, not at all like that. Informatics well-being areas, such as clinical imaging, clinical computing and bioinformatics.5 Brain cancer has arisen when the cell is in-between and growing unusually. This tends to be a rough accumulation when diagnosing an observational imaging technique. Two types of brain cancer are the primary brain tumour and metastatic brain cancer. Main brain cancer is the condition while the tumour is formed in the brain and tends to remain present while the brain is metastatic. The reason for select CT images upon MRI images be as follows: 1. CT is much easier than MRI, providing an opportunity to learn in shock luggage and other acute neurological emergencies. CT can be made available at a significantly lower price than MRI. 2. The CT container shall be obtained at a significantly lower price than the MRI. 3. CT is less responsive to continuous movement throughout the test. 4. Imaging can be performed much more easily, and CT can be safer to do in claustrophobic or extremely serious cases. 5. CT can be done at no risk to the stamina with implantable control plans, such as a cardiac pacemaker, ferromagnetic vascular clips and intestinal stimulators.  Past research Work The FCM segmentation of tumours and non-tumour districts shall be used. Besides, wavelets are isolated using a variety of discrete Wavelet Shift (DWT) phases. In the long run, deep neural red (DNN) is incorporated into the tumour order with incredible precision. This approach is in contrast to KNN, simple discriminate (LDA) and marginal successive streamlining (SMO) ordering techniques. Precision levels of 94.96 per cent in the DNN cerebral cancer base classification, however, the unpredictability is extremely high and the sensitivity is exceedingly poor.3 Biophysiomechanical tumour the development model is used to break down the growth of patients&#39; tumour bit by bit. Will be used for gliomas and large tumours with incentives to achieve enormous tumour mass tests. Discreet and persistent techniques are combined for the creation of a tumour model. The proposed conspiracies offer the possibility of potentially imaging a tumour-dependent portion of the tumour in the vault-based map book. In any case, the calculation hastens. The new multi-fractal (MultiFD) involves the extraction and identification of the Gadabouts spontaneity act and the cerebral tumour fragment.6 Mind surface tumour hankie is evacuated using a MultiFD function extraction map. Improved Gadabouts characterization strategies are used to discover that the brain tissue given is a tumour or non-tumour tissue. The unpredictability of this is high. En4, for vowel image brain projection put together structure, works concerning. The work of the course is also extricated in this technique. And there is no real need for any improvement in LIPC accurate.5 A seeded tumour division strategy with new cell automation (CA) is introduced, which is contrasted and realistic cutting depending on the division technique. Seed determination and amount of suspense (VOI) shall be calculated for the successful division of the cerebral tumour. The division of the tumour region is also organized in this research. Unpredictability is very weak.7 The accuracy, however, is low. En6, the division of the mind tumour conspires. Alternate division calculation to perform High execution than the current strategy. In any case, there is a high multifaceted nature. Analysis of the division of cerebral tumours is added. Talk about different division techniques, for example, division areas, edge-based division, fluffy C represents division, Atlas-dependent division, Margo Random Field Segmentation (MRF), deformable model, deformable geometric model, precision, power, validity. En8, the determination of half-and-a-half capacity with fixed characterization applies to the mental tumour demonstrative procedure GANNIGMAC, choice.8,9 An all-encompassing tree-based methodology is used, packing C to meet the choice standards. It also deviates from the preference criteria using the determination of half and half of the functions comprising the blend (GANNIGMAC+ MRMR C + Bagging C + Decision Tree). In 9, the diffuse regulation theory is extended to order and division. The Diffuse Interference Method (DIS) is an unusual technique for mind division the controlled classification is favoured for fluffy enrollment. The execution is high and the accuracy is poor. In 10, the histogram balance is used to differentiate optimization. So fluffy Means-based division (FCM) is used to separate the tumour from the working mind image. From that point on, the Gabor utility is withdrawn from the anomaly synapses of the channel. In the long run, the haze with K is used by the closest neighbor grouping (KNN) to discover the irregularity of the desirable reverberation picture of the mind.8 The multifaceted nature is small, streaming with poor precision. Another programmed characterization of mind tumours in this work. This is achieved by the convolution of the neural network. Literature Survey Convolve the creation of addition to its limited neighbours near the seed of any component of the picture. This is the same as mathematical convergence. It must exist known for the sense of the medium procedure life form perform convolution, despite being similarly indicated with the example, that we keep two-three with matrix, the main one being instantly the process of flipping the sequence along with the pillar of the kernel, added to increase the shutter. The coordinate component9 in the resulting picture will be a partial grouping in which all participants join the medium panel into a discretionary appetizer base. The objective is to test downhill an illustration of the input (image-secret deposit-quantity produced medium) that falls to its dimensionality so that total rests of the type in a district scrap can be survived on the way.10 This is the implementation in the portion to help in a daydreaming form of the character more than suitable. Since the computational prices are good, by dipping the number of the study parameter plus it provides a fundamental invariance of conversion towards the interior symbol. FCN includes filled relative within a completely connected layer in the previous deposit for each activation while seeing during standard Neural Networks. Their container activations are therefore determined by a modest increase and overcome partiality. Collective weights are mainly used in two layers in the copy to use weights. This money is used to fund two separate modes with the incentive of the corresponding parameter.11 This is mainly the income that could exist in similar medium rudiments during or after different rear radiation. The specific rudiments make it simple to convert as an alternative of people on or after a solitary layer next to a single layer since they are predictable. MATERIALS AND METHODS The human mind is placed in recognition of the structure and use of the counterfeit neural system. The neural system is mainly used for vectors, evaluation, estimation, a gathering of information, shape coordination, improvement of capacity and clustering procedures.12 The neural system is divided into three types, as indicated by its interconnections. Three characterizations of neural systems are followed by input, criticism and repetition. The Feed-Forward neural system separates further Monolayer organizing and multilayer organizing. There is no hidden layer in the monolayer set. Yet, it only includes sources of knowledge and a layer of yields.13 However it may be, the multilayer consists of a layer of information, a layer of the enclosure and a layer of yield. The closed circled input is called the red repeater. CNN-based classification algorithm Apply the convolution channel to the primary layer. The channel affectability can be reduced by smoothing the Convolution channel subsampling. Moving the sign happens as of one coating to another, the layer is being monitored the initiation layer. Set the time frame of preparation using a direct crushing unit. The neuron in the process coating is associated with each neuron in the back layer. In the planning, the misfortune layer is included at the end, providing comment to the neural system (Figure 1). The dataset provided with brain tumour features is alienated keen on two courses, which are a preparation set and a testing set, making the system in two phases. First of all, the training phase, in this process, we fit the training set of data in CNN using a feature detection modelling the Brain Tumour Prediction System18. After finishing the model making, we fit the test dataset over the model to the test process and then measure the loss value. This is the procedure for the CNN network to predict brain tumours. System Architectural Design Convolution Neural Network is a nourishing onward neural system to be usually worn to analyse visual imagery by dispensation data with lattice-like topology. A CNN is also recognized as a “ConvNet” In CNN each picture is represented in the shape of an array of pixel principles (Figure 2). ResultS AND DISCUSSION In the Brain Tumour using the CNN technique and test the result of a Brain tumour or Non-Brain Tumour Images are: Below are some images showing the dissimilarity amid automatic segmentation plus the real earth truth values. From the images shown below, we can see that the future model for LGG patients might notice the size, shape, size and the intra tumoural arrangement fairly exactly. Though the segmentation of tumour in LGG patients is considered as a very hard job owing to the not have of statistics, our replica for LGG patients based on move knowledge is drama quite well as tin can be seen as of the imagery underneath. Figure 3 showed two classes that are having brain tumour images and not having brain tumour images.   Finally, the lossless and segmented image and the data are available in Table 1 showing the result losses and accuracy and find the resultant data. When the neural convolution network is implemented, the accuracy of the system is 0.8111 in the first epoch and the system loss is 0.4299. Throughout more times, the system increases its accuracy and reduces its losses by back-spreading and forward-spreading.15 In the last epoch, i.e. the 25th epoch, the accuracy of the system is as high as 1.0000 and the system losses are reduced to 3.3743e (Figure 4). The image above shows the output of the brain tumour and shows the output of the brain tumour after the compilation process. In this picture, there is not showing any defects according to the result ( Figure 5 and 6).                      Conclusion The fundamental goal of this thesis is to structure a highly precise, functional and ineffective programmed order of cerebral tumours. In the normal cerebrum, the tumour is grouped using the Fuzzy C Segmentation (FCM), the surface and structure, and the SVM and DNN-dependent extraction highlight the orders are made. The multifaceted complexity is very weak. In any case, the processing time is long and Accuracy is poor. Similarly, toward getting better correctness and decrease the time of measurement, a convolutions Implementation of a neural dependent grouping in the proposed plot. Besides, order the tests as predicted by the tumour or the mind.CNN is one of the deep learning strategies containing a grouping of layers for direct feed. So much Python is used for use. So many. The image is used for grouping in the net database. It&#39;s one of the models that were prepared. The preparation is finished for the last coat at this point. The rough pixel estimate with depth, width and stature values is also distinguished from CNN. Finally, the optimal angle is the average. The work of misfortune is used to achieve high accuracy. Accuracy of planning, the accuracy of approval and disasters of approval are determined. Preparation for accuracy is 97.5%. The approval quality is therefore high and the approval loss is extremely high. Acknowledgement: Researchers examine the Automated Brain Tumour Detection using Deep Learning via Convolution Neural networks (CNN). In the CNN, convolution layer squeeze the picture as elevated skin tone, then the volitional layer reconstructs the segmented picture on or after this covering tone [12]. In this research PGI Chandigarh, Neurology Department helps in this in research provide data for experimental purpose. Conflict of interest:  There Is No Conflict Interest. Englishhttp://ijcrr.com/abstract.php?article_id=3328http://ijcrr.com/article_html.php?did=3328 Kumar S, Singh JN, Kumar N. An Amalgam Method efficient for Finding of Cancer Gene using CSC from MicroArray Data. Int J Emerg Technol 2020;11(3):207–211. Kumar S, Negi A, Singh JN, Verma H. Deep learning for brain tumour MRI images semantic segmentation using FCN. 4th International Conference on Computing Communication and Automation (ICCCA) 2018; 14:1-4. IEEE. Kumar S, Negi A, Singh JN. Semantic segmentation using deep learning for brain tumour MRI via fully convolution neural networks. information and Communication Technology for Intelligent Systems 2019;11-19. Springer, Singapore. Kumar S, Negi A, Singh JN, Gaurav A. Brain Tumour Segmentation and Classification Using MRI Images via Fully Convolution Neural Networks. International Conference on Advances in Computing, Communication Control and Networking (ICACCCN) 2018; 12:178-1181). Altman NS. An introduction to kernel and nearest-neighbour nonparametric regression. The Am Stat 1992;46(3):175-185. Zhang J, Shen X, Zhuo T, Zhou H. Brain tumour segmentation based on refined fully convolutional neural networks with a hierarchical dice loss. arXiv preprint arXiv. 2017;1712.09093. Bidros DS, Liu JK, Vogelbaum MA. Future of convection-enhanced delivery in the treatment of brain tumours. Future Oncol 2010; 6(1):117-125. Sanai N. Emerging operative strategies in neurosurgical oncology. Curr Opin Neurol 2012;25(6):756-766. Carlson SM, Gozani O. Emerging technologies to map the protein methylome. J Mol Biol 2014;426(20):3350-3362. Eberlin LS, Norton I, Dill AL, Golby AJ, Ligon KL, Santagata S, Cooks RG, Agar NY. Classifying human brain tumours by lipid imaging with mass spectrometry. Cancer Res 2012;72(3):645-654. Dahlquist KD, Salomonis N, Vranizan K, Lawlor SC, Conklin BR. GenMAPP, a new tool for viewing and analyzing microarray data on biological pathways. Nat Genet 2002;31(1):19-20. Simek K, Fujarewicz K, ?wierniak A, Kimmel M, Jarz?b B, Wiench M, Rzeszowska J. Using SVD and SVM methods for selection, classification, clustering and modelling of DNA microarray data. Engi Applic Artif Intellig 2004;17(4):417-427. Bilban M, Buehler LK, Head S, Desoye G, Quaranta V. Normalizing DNA microarray data. Curr Issues Mol Biol 2002;4:57-64. Cho SB, Won HH. Machine learning in DNA microarray analysis for cancer classification. In Proceedings of the First Asia-Pacific bioinformatics conference on Bioinformatics 2003;19:189-198. Maulik U, Chakraborty D. Fuzzy preference based feature selection and semisupervised SVM for cancer classification. IEEE Transactions on Nano Bioscience 2014 Mar 18;13(2):152-160. Maji P. Mutual information-based supervised attribute clustering for microarray sample classification. Transac Knowl Data Engi 2010;24(1):127-140. Duan KB, Rajapakse JC, Wang H, Azuaje F. Multiple SVM-RFE for gene selection in cancer classification with expression data. IEEE Transactions on Nano Bioscience 2005;4(3):228-234. Wang X, Gotoh O. Accurate molecular classification of cancer using simple rules. BMC Med Genom 2009;2(1):64. Liu H, Liu L, Zhang H. Ensemble gene selection for cancer classification. Patt Recog 2010;43(8):2763-2772. Tsai YS, Aguan K, Pal NR, Chung IF. Identification of single-and multiple-class specific signature genes from gene expression profiles by group marker index. PloS One 2011;6(9):e24259. Tabakhi S, Najafi A, Ranjbar R, Moradi P. Gene selection for microarray data classification using a novel ant colony optimization. Neurocomputing 2015;168:1024-1036. Ren Z, Wang W, Li J. Identifying molecular subtypes in human colon cancer using gene expression and DNA methylation microarray data. Int J Oncol 2016;48(2):690-702. Motieghader H, Najafi A, Sadeghi B, Masoudi-Nejad A. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareEfficacy and Safety of Various Oral Isotretinoin Treatment Regimens in Moderate to Severe Acne Vulgaris: A Prospective, Randomised Controlled, Single-Blinded, Parallel-Group Comparative Study English154158Anuj KothariEnglish Deval VoraEnglish Mohit SaxenaEnglish Simran Singh AujlaEnglishBackground: Isotretinoin is the most potent anti-acne agent available today and only one that addresses all pathogenic mechanism; However, it is associated with multiple dose-dependent side effects. Objective: To evaluate the efficacy and tolerability of various therapeutic regimens (daily; alternate and low dose) of oral isotretinoin in moderate to severe acne vulgaris. Methods: This randomised, prospective, single-blind, parallel-group study was carried out in 90 randomised with a group of 30 patients each categorized as Group A receiving a conventional daily dose of oral isotretinoin 0.5mg/kg/day for 24 weeks, Group B receiving alternate day dose of oral isotretinoin 0.5mg/kg for 24 weeks and Group C receiving low dose 20 mg daily regimen of oral isotretinoin for 24 weeks for the total duration of 24 weeks with every 2 weeks follow up visits for their efficacy and safety. Results: Out of total 90, only 6 patients lost to follow up during study period, so remaining 84 patients included in the final analysis as 27 patients in Group A, 28 patients in Group B and 29 patients in Group C. The comparison of mean initial acne load at each visit in all three groups suggested no significant difference at initial acne scores in various treatment groups, which was found to be significantly decreased at each follow-up and the end of therapy and no significant difference at the end of the therapy. Frequency of all the side effects was higher in treatment group A. Severity of the all the side effects including mucocutaneous and systemic were maximum in group A and minimum in group C. Conclusion: Looking at the efficacy and safety profile of various oral isotretinoin regimens, one can plan for reducing dose regimen of oral isotretinoin for severe acne and low dose isotretinoin for mild to moderate acne. English Acne Vulgaris, Isotretinoin, Low Dose Treatment RegimensIntroduction Acne vulgaris is a chronic inflammatory disease of the pilosebaceous unit, characterized by comedones, papules, pustules, nodules, cysts, abscesses, later on sometimes as widespread scarring.1 Acne is a multifactorial disease, although the basic cause is unknown. According to the severity of acne, there are various treatment modalities. It includes both topical and systemic therapy. In topical therapy, commonly used drugs are benzoyl peroxide, erythromycin, clarithromycin, clindamycin, tretinoin (0.025-0.05%), adapalene, azelaic acid. In systemic therapy commonly used drugs are oral antibiotics; tetracycline, minocycline, doxycycline, azithromycin and oral isotretinoin. Isotretinoin is a 13-cis retinoic acid which is a derivative of retinol (Vitamin A). It represents the single most important advance in acne therapeutics. It is the most potent anti-acne agent available today and only one that addresses all pathogenic mechanism.2 Isotretinoin should only be given to healthy individuals. It is contraindicated in females of childbearing potential unless stringent contraception is secured as it is a known teratogen. Common adverse side effects are mucocutaneous and they are dose-dependent e.g. cheilitis (occurs in almost 100% of cases), dry skin, dry nose with epistaxis sometimes, ocular and vaginal dryness, increased susceptibility to impetigo and furunculosis. Other side effects are skin fragility, bone and joint pain, osteoporosis, visual disturbances, depression and rarely pseudotumor cerebri. Occasionally, patients may have mild to moderate hypertriglyceridemia and raised transaminases, anaemia, thrombocytopenia, all these are reversible. Thus, baseline blood counts, liver function tests and fasting lipid profile are suggested, with recommendations for follow-up monitoring ranging from every 4 to 8 weeks to less frequently if baseline values are normal.3 As proved by various studies, lower doses of isotretinoin are also effective in terms of side effects and cost, therefore other regimens should be used instead of a daily conventional dose of 0.5-1.0mg/kg/day. Thus, the present study was undertaken to compare the efficacy and tolerability of various therapeutic regimens (daily; alternate and low dose) of oral isotretinoin in moderate to severe acne vulgaris.4,5 Materials and Methods This randomised, prospective, single-blind, parallel-group study was carried out with the primary objective to compare the efficacy of various oral isotretinoin treatment regimens (daily; alternate; and low dose) in moderate to severe acne vulgaris and to compare their side effects in Skin and Venereal Disease department of Guru Gobind Sing Hospital, Jamnagar, Gujarat for the total duration of 24 weeks. After obtaining the approval from the Institutional Ethics Committee, the patient of age more than 12 years with moderate to severe acne vulgaris and willingness to participate in the study and taking oral isotretinoin were included in the study. Patient with mild acne vulgaris, married female planning to conceive, already pregnant or lactating females, history of hypersensitivity to isotretinoin therapy as well as drug-induced acne and unwilling to give consent for participation were excluded for the study. The calculated sample size with 80% power and 95% confidence interval with a 10% drop out rate for this study found to be 90 were randomized in subgroups by simple random sampling method. Each group of 30 patients categorized as Group A receiving a conventional daily dose of oral isotretinoin 0.5mg/kg/day for 24 weeks, Group B receiving alternate day dose of oral isotretinoin 0.5mg/kg for 24 weeks and Group C receiving low dose 20 mg daily regimen of oral isotretinoin for 24 weeks.Along with oral isotretinoin all patients were also advised to apply topical 1% clindamycin gel twice daily. Each participant was given pre-designed Case Record Form (CRF) to obtain a detailed history of age, sex, age of onset of disease, duration of disease, type of skin and relation of disease with diet, premenstrual flare, pregnancy, seasonal variation, sweating, stress and seborrhea. Psychosocial effects (shame, embarrassment, anxiety, anger, lack of confidence and impaired social contact) observed by the patients were also taken. The assessment of the acne was done according to the Pillsbury’s classification: Grade I: comedones, occasional papules(mild), Grade II: papules, comedones, few pustules (moderate), Grade III: predominant pustules, nodules, abscess (severe) and Grade IV: mainly cysts, abscesses, widespread scarring (cystic). Total lesion count was calculated at the 1st visit as the baseline total acne load in each patient and after that on each subsequent visit. The response and adverse effects were recorded according to number and type of lesions on follow up at 2 weekly intervals for 6 months. Complete blood cell counts, liver function tests and serum lipid profile (cholesterol and triglycerides) were done initially and repeated every 4 weeks. The criterion for discontinuation of therapy was a blood test rising above the following values in the first 2 months: triglycerides > 400 mg/dL (4.52 mmol/L), alkaline phosphatase > 264/UL (female), > 500/UL (male), ALT > 62/UL, AST > 80/UL, cholesterol > 300 mg/dL (> 7.7 mmol/L). Improvement in lesions was recorded by measuring total acne load at each visit. A failure was defined as no improvement, requiring a subsequent increase in isotretinoin dosage or even additional treatment at the end of 24 weeks of treatment. Results A total of 90 patients with a mean age of 18.74 years were included in the present study.  Out of these 90 patients, 6 patients lost to follow up during the study period. For the final result analysis, there were 84 patients. Of these 84 patients, 27 patients in Group A, 28 patients in Group B and 29 patients in Group C completed the study (Table 1). Out of 84 patients, 6 (7.14%) patients were of 10 - 15 years, 46 (54.76%) were of 15-20 years and remaining 32 (38.10%) patients were of age more than 20 years. A total number of 40 (47.62%) patients had a family history of acne and 44 (52.38%) had no family history of acne. A total number of 29 (34.52%) patients were from a rural background and 55 (65.48%) patients were from the urban area. Out of 84 patients, 21 (25.00%) patients had 2-year duration.The face is the most common site involved in all patients (100%). Out of 84 patients, 31 (36.90%) patients had a lesion on the trunk along with face and 53 (63.10%) patients had no involvement of trunk. Normal skin type was present in 20 (23.81%) patients; oily skin was present in 55 (65.48%) patients and dry skin was present in 9 (10.71%) patients (Figure 1). Out of 84 patients, 80 (95.24%) patients had one or more exacerbating factors (stress, seborrhea, sweating, diet, seasonal change and premenstrual flare). No exacerbating factors were present in 4 (4.76%) patients (Figure 2). Psychological factors were present in 69 (82.14%) patients. A total number of 48 (57.14%) patients had complained of shame, 33 (39.29%) patients had embarrassment, 34 (40.48%) patients had anxiety, 26 (30.95%) patients had lack of confidence and 17 (20.92%) impaired social contact (Figure 3).             The comparison of mean initial Acne load at each visit in all three groups suggested no significant difference at initial acne scores in various treatment groups (Table 2). Scores in each group were found to be significantly decreased at each follow-up and the end of therapy. At the end of the therapy in all the three groups, there was no significant difference between different treatment groups. Mean percentage change in score was comparable in all the three groups (Table 3). Treatment group A performed best in term of response till the end of treatment as compared to the rest of the treatment groups. The earliest response was noted in treatment group A (Table 4).             Most common side effects were cheilitis and dry skin. Dry mouth was more common in treatment group Aand least common in treatment group C. Dry eyes, dry nose and facial redness/rashes were noted mostly in Group A. Lipids were raised in treatment group A and B only while Liver function tests were deranged in only treatment group A. In group B and C this side effect was almost equal. Frequency of all the side effects was higher in treatment group A. Severity of the all the side effects including mucocutaneous and systemic were maximum in group A and minimum in group C. All the side effects were successfully managed and no patient required discontinuation of therapy (Table 5). Discussion             Age of maximum involvement of acne in girls was seventeen and amongst boys was eighteen years.4 Epstein also reported that the greatest incidence of acne to be in the sixteen to twenty years of age group5, which is comparable to the present study. Bloch and Hamilton in 1964 reported that males had a more common and more severe form of acne as compared to the females due to more androgens secretion by males which is comparable to our study. Oily skin in acne patients may be correlated with the excess sebum production which was also observed by Pochi and Strauss6 which very much correlates with our study findings of having most people with oily skin type. Pochi & Strauss also noted that the output of sebum on the forehead was quantitatively more than the other body area. As the face is the presenting body part. People are more conscious; therefore, such cases make a major bulk amongst acne group. This is well depicted in our study by 100% involvement of the face.6             Pandey et al., 1980 also conducted that acne was found more common in urban boys than in their rural counterparts as seen in our study. It may be because urban patients are more conscious of themselves.7 A survey in Germany showed that acne has been present in one or both parents of 45% of schoolboys with acne, in only 8 % of parents without acne, which is more or less similar to our study findings.             In the present study majority of the patients gave a history of shame, embarrassment, anxiety, anger, lack of confidence and impaired social contact due to acne. Jowest et. al. (1988)also reported that acne is associated with stress, shame, lack of confidence and lack of employment. In our study majority of patients had one or more exacerbating factors (stress, seborrhea, sweating, solar radiation, diet, seasonal change and premenstrual flare). Likewise, stress is responsible for exacerbating the disease and sweating to exacerbate the acne due to hydration of the pilosebaceous follicle.8,9 Premenstrual flare-up was observed in around 60-70% of females due to hydration of the pilosebaceous follicle10 which is comparable with our study. The role of diet in the etiopathogenesis of acne vulgaris has remained controversial. Rasmussen and Smith10,11 in 1983 reported that there was a relationship between acne and diet. Our finding is comparable with Rasmussen and Smith et al. and diet as an exacerbating factor were present in 24 (28.57%) patients which mainly included oily food, milk, spicy food and chocolates. Comparing the effects and side effects of various regimens we found that the low-dose isotretinoin is almost equal in efficacy to high dose but with the advantage of lesser side-effects and more cost-effective than the full-dose protocol. All our results were comparable to the previous studies of conventional and low doses of oral isotretinoin. Conclusion             Looking at the efficacy and safety profile of various oral isotretinoin regimens one can plan for reducing dose regimen of oral isotretinoin i.e. initially give higher doses for early remission followed by low dose maintenance therapy for a prolonged period with lesser side effects especially in cases of severe acne. For mild to moderate acne, we can directly use low dose isotretinoin which is an effective and safe treatment option. Acknowledgements: Our humble thanks and gratitude towards all the patients who gave consent to participate in the study as well as the administration and staff of GGG hospital Jamnagar. A special mention to Dr Atul Rajpara, for guidance related to the publication of the manuscript. Source of Funding: None Conflict of Interest: Nil Englishhttp://ijcrr.com/abstract.php?article_id=3329http://ijcrr.com/article_html.php?did=3329 Dreno B, Poli F. Epidemiology of acne. Dermatology 2003;43:1042–1048. Harper JC, Thiboutot DM. Pathogenesis of acne: Recent research advances. Adv Dermatol 2003;19:1-10. Cunliffe W, Gollnick H. Acne. In: Arndt KA, LeBoit PE, Robinson JK, Wintroub BU, eds. Cutaneous Medicine and Surgery. Philadelphia, Pa: WB Saunders Co; 1996:461-480. Ghodsi SZ, Orawa H, Zouboulis CC. Prevalence, severity, and severity risk factors of acne in high school pupils: a community-based study. J Invest Dermatol 2009; 129(9):2136-2141. Epstein E. Incidence of facial acne in adults. Derm Digest 1968;7:49-58. Pochi PE, Strauss JS. Sebum Production causal sebum level. J Invest Dermatol 1964; 43:383-88. SS Pandey, P Kaur, G Singh. Has Acne Urban Bias? Indian J Dermatol Venerol Lep 1980;46:80-82. Kenyon FE. The psychosomatic aspect of acne. Br J Dermatol 1966;76:344-351. Williams M, Cunliffe WJ. The explanation for premenstrual acne. Lancet 1973;11:1055-1057. Cunhiffe WJ, Cotterill JA. The Acnes. London WB Saunders, 1975. James E, Rasmussen MD, Smith SB. Patient Concepts and Misconceptions About Acne. Arch Dermatol 1983;119(7):570-572.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareFactors associated with Sleep Quality in Undergraduate Physiotherapy Students: A Cross Sectional Study English159163Darshana NariyaEnglish Subhash KhatriEnglish Krinal MangukiyaEnglish Mansi ShahEnglish Khyati DiyoraEnglishIntroduction: Sleep also is considered a time when other body system restores their energy and repairs their tissues and is important to wellbeing and optimal health. Lack of sleep is reason for many mental conditions in all stages of human lives specially during studentship. Objective: To evaluate the factors associated with quality of sleep among undergraduate physiotherapy students. Methods: Undergraduate physiotherapy students aged 18-25 years and studying in Nootan College of Physiotherapy, Visnagar and SPB Physiotherapy College, Surat were explained about the procedure and informed consent was obtained. Participants were asked to fill the hard copy of Pittsburgh Sleep Quality Index (PSQI) for assessment of the sleep quality, Depression Anxiety Stress Scale (DASS) for assessment of the depression, stress and anxiety. Participants were asked to fill the questionnaire. Body Mass Index (BMI), total minutes of physical activity done by participant per week and the total duration of use of electronic devices during bedtime of each participant were recorded. Results: Regression analysis shows that obesity contributes to 0%, depression contributes to 9%, stress contributes to 13.7%, anxiety contributes to 10.6%, physical activity contributes to 2.4% and use of the electronic device during bedtime contributes to about 2.2% in affecting sleep quality. Conclusion: Our results support the idea that sleep quality in physiotherapy students is notably associated with several psychological factors like Stress and Anxiety. Hence, Psychological Stress and Anxiety should be evaluated and treated for good quality of sleep in undergraduate physiotherapy students. There is a need to do further study with a large sample size to check various factors associated with poor sleep quality. English Sleep quality, Factors affecting sleep quality, PSQI, DASS, Physical activity, Electronic device useIntroduction Sleep is a part of what is called the sleep-wake cycle. This sleep-wake cycle, which consists of roughly 8 hours of nocturnal (night) sleep and 16 hours of daytime wakefulness in humans. It is controlled by a combination of two internal influences: sleep homeostasis and circadian rhythms.1 Sleep also is considered a time when other body system restores their energy and repairs their tissues2 and is important to wellbeing and optimal health.3,4 People who get adequate quality sleep are more energetic. They have a better cognitive function; likewise improved memory and better immune system. Alongside their alertness, attentiveness and performance throughout the day are considerably enhanced.5 Although sleep is amongst others one basic need of human beings and is important to their health6 its problems have a plethora of causes including medical and psychological conditions.7 Many factors were reported to affect sleep. Major ones include emotional well-being, physical activity, and social factors. Sleep problems cover a vast range of symptoms and are mostly characterized by one or more of the symptoms like restlessness, fatigue, insomnia, daytime sleepiness, loud snoring, gasping sounds during sleep, inability to fall asleep at night or appropriate sleeping hours, unable to move, and abnormal behaviours like sleepwalking and others like excessive sleepiness during day time.8-10 Poor sleep has been closely related to mood disturbance and other health issues,11 which include increased Body Mass Index (BMI), high blood pressure and Depression.12 The recent trend of using electronic gadgets like mobile phone, laptops or others for gaming, social networking or other uses also contribute to the quality of sleep.13 The reason for using such devices varies though it does have a relation with stress and sleep quality directly and indirectly on obesity.14 Less number of studies is prevailing to explore the sleep quality and factors affecting it, for Indian undergraduate students. This research measures the quality of sleep in undergraduate physiotherapy students and the effect of depression, stress, anxiety, obesity, physical activity and the duration of use of electronic gadgets during bedtime on the quality of sleep. Materials and Methods This is a cross-sectional study approved by the Institutional Ethical Committee of SPB Physiotherapy College, Gujarat, India. Convenient sampling was performed to select undergraduate physiotherapy students as study population. This study was conducted at Nootan College of Physiotherapy, Visnagar and SPB Physiotherapy College, Surat in 257 students. Inclusion and Exclusion Criteria Undergraduate students of physiotherapy aged between 18-25 years of both gender were included in this study. The student with illness and were not present in class during ongoing studies were excluded. Procedure Prior information regarding the study and questionnaire to be filled were given to the students. After taking consent from each physiotherapy students of the first, second, third and final years, demographic data like age, gender, height, the weight of each student were recorded. BMI was calculated by dividing the weight (kg) by square of height (m)15. The total duration of exercise per week in a minute and the total duration of use of electronic devices like mobile phone, TV, laptop during bedtime in a minute of each student were recorded. The hard copy of Pittsburgh Sleep Quality Index (PSQI), Depression Anxiety Stress Scale (DASS) was given to the student and asked to fill. After the data collection, all the data were analysed. Outcome measures Body Mass Index (BMI): It was calculated by dividing the weight (kg) by square of height (m).15 Pittsburg Sleep Quality Index (PSQI) It is used for the subjective assessment of sleep quality.16 There is "Global Sleep Quality" (GSQ) which is a computed score of the total of all the response values for seven components included in the PSQI scale. PSQI has seven components with score 0 (no difficulty) to 3 (severe difficulty). Summation of all the component scores is known as the global score with a range of 0 to 21. A score of more than 4 indicates poor sleep quality and score less than 4 indicate good sleep quality. Higher the score poorer is sleep quality.17 Depression Anxiety Stress Scale (DASS) The DASS is a 42 item scale design to measure the three related negative emotional states of depression, anxiety, and stress. The 42 questions are related to depression, anxiety and stress are summed up respectively. The score interpretation is based on normal, mild, moderate, severe, and extremely severe.18 Physical activity According to world health organization (WHO) adults of age 18-64, Should do at least 150 minutes of moderate-intensity physical activity throughout the week, or do at least 75 minutes of vigorous-intensity physical activity throughout the week, or an equivalent combination of moderate- and vigorous-intensity activity to be called as a physically active.19 We have recorded the total duration of physical activity in a minute per week of each participant. Use of electronic devices during bedtime We have recorded a total duration of use of electronic devices like mobile phone, TV, laptop in a minute during bedtime. Statistical Analysis SPSS 24.0 was used for data analysis. Demographic data were presented as mean and standard deviation.  Frequencies and percentages were calculated for the categories of Body Mass Index (BMI), Pittsburgh Sleep Quality Index (PSQI), Depression Anxiety Stress Scale (DASS), physical activity and use of the electronic device during bedtime. Regression analysis was done to find out the association between BMI, depression, anxiety, stress, physical activity, duration of electronic device use during bedtime and sleep quality. A level of significance was considered at P Englishhttp://ijcrr.com/abstract.php?article_id=3330http://ijcrr.com/article_html.php?did=3330 Phillips B, Gelula R. Sleep-wake cycle: Its physiology and impact on health. National Sleep Foundation 2006:1-9. Pooler C. Porth pathophysiology: concepts of altered health states. Lippincott Williams & Wilkins; 2009. Frist ever great British bedtime report launch, 2013. [Cited 2020 February 3]. https://sleepcouncil.org.uk/latest-news/first-ever-great-british-bedtime-report-launched/ Holfeld B, Ruthig JC. A longitudinal examination of sleep quality and physical activity in older adults. J Appl Gerontol 2014; 33(7):791-807. Berhanu H, Mossie A, Tadesse S, Geleta D. Prevalence and associated factors of sleep quality among adults in Jimma Town, Southwest Ethiopia: a community-based cross-sectional study. Sleep Disord 2018;8342328. Abdulghani HM, Alrowais NA, Bin-Saad NS, Al-Subaie NM, Haji AM, Alhaqwi AI. Sleep disorder among medical students: relationship to their academic performance. Med Teac 2012;34(1):37-41. World Health Organization Regional Office for Europe and the European Centre for Environment and Health Bonn Office. Report of the WHO technical meeting on sleep and health. Bonn, Germany 2004. Report of the WHO technical meeting on sleep and health (ilo.org) Manmee C, Janpol K, Arsayot K, Ainwan P. Sleep Quality among Residents and Fellows in Rajavithi Hospital. J Med Assoc Thail 2017;100:205-211. Committee on Improving the Health, Safety, and Well-Being of Young Adults; Board on Children, Youth, and Families; Institute of Medicine; National Research Council. Public health. In Richard J. Bonnie, Clare Stroud and HeatherBreiner. Investing in the health and well-being of young adults. Washington (DC): National Academies Press (US); 2015. Landry GJ, Best JR, Liu-Ambrose T. Measuring sleep quality in older adults:  a comparison using subjective and objective methods. Front Ageing Neurosci 2015;7:1-10. Shittu RO, Issa BA, Olanrewaju GT, Odeigah LO, Sule AG, Sanni MA et al. Association between subjective sleep quality, hypertension, depression and body mass index in a Nigerian family practice setting. J Sleep Disord Ther 2014;3(157):1-5. Fortunato VJ, Harsh J. Stress and sleep quality: The moderating role of negative affectivity. Pers Ind Diff 2006;41(5):825-836. Saji J, Muraleedharan K, Clement N. Impact of Electronic Gadgets on Quality of Sleep among Adolescents. Int J Res Rev 2019;6(8):431-435. Hasler G, Buysse DJ, Klaghofer R, Gamma A, Ajdacic V, Eich D et al. The association between short sleep duration and obesity in young adults: a 13-year prospective study. Sleep 2004;27(4):661-666. World Health Organization. Body Mass Index. [Cited 2020 Feb 3]. Available from:http://www.euro.who.int/en/health-topics/diseaseprevention/nutrition/a-healthy-lifestyle/body-mass-index-bmi Riedel BW, Lichstein KL. Insomnia and daytime functioning. Sleep Med Rev 2000;4(3):277-298. Buysse DJ, Reynolds CF, Monk TH, Berman SR, Kupfer DJ. The Pittsburgh Sleep Quality Index: a new instrument for psychiatric practice and research. Psych Res 1989;28(2):193-213. Brown TA, Chorpita BF, Korotitsch W, Barlow DH. Psychometric properties of the Depression Anxiety Stress Scales (DASS) in clinical samples. Behav Res Ther 1997; 35(1):79-89. World Health Organization. Physical Activity. [Cited 2020 Feb 3]. Available from: https://www.who.int/news-room/fact-sheets/detail/physical-activity. Alfarhan FA, Al MM, Gaowba H, Hamely R, Tork HM. Association between sleep pattern and body mass index among undergraduate health colleges’ students at Qassim University, Saudi Arabia. J Nurs Educ Pract 2018;8:86-95. Jniene A, Errguig L, Hangouche AJ, Rkain H, Aboudrar S, Ftouh M, et al. Perception of Sleep Disturbances due to Bedtime Use of Blue Light- Emitting Devices and Its Impact on Habits and Sleep Quality among Young Medical Students. BioMed Res Int 2019; 7012350. Zawadzki MJ, Graham JE, Gerin W. Rumination and anxiety mediate the effect of loneliness on depressed mood and sleep quality in college students. Health Psych 2013; 32(2):212-222. Ghrouz AK, Noohu MM, Manzar MD, Spence DW, BaHammam AS, Pandi- Perumal SR. Physical activity and sleep quality in relation to mental health among college students. Sleep Breath. 2019;23(2):627-634. Wu X, Tao S, Zhang Y, Zhang S, Tao F. Low physical activity and high screen time can increase the risks of mental health problems and poor sleep quality among Chinese college students. PloS one. 2015;10(3): 1-10.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareSocio-demographic Profile of Snakebite Fatalities: An Autopsy based Study from Eastern India English164168Deepsekhar DalalEnglish Tanmay SardarEnglish Saswata BiswasEnglish Arijit DeyEnglishIntroduction: World Health Organization considers snakebite envenoming as priority neglected tropical diseases. India contributes to 50 per cent of the estimated deaths due to venomous snakebites globally. People from rural areas still believe on traditional healers instead of hospitalisation. Objectives: To depict the socio-demographic analysis of fatal snakebite envenomation by examining medicolegal autopsy in a government medical college in Kolkata, West Bengal. Methods: Total 125 hospitalised snake bite cases with fatal outcome, undergoing autopsy were examined. Sex, age, occupation, socio-economic status of the victims, seasonal variation, time and site of the bite was noted in proforma and analysed. Results: Males, engaged in agricultural activities were mostly the victims who suffered snake bites on their lower limbs in most of the cases. Cases increase in monsoon season. Snake bites occur in highest numbers during the daytime between 6 AM12Noon. Amongst the identifiable species, Krait was responsible for most of the fatalities.37.6% of victims died within the first day, while another 50% died within two weeks after the snakebite. More than 80% of victims were taken to a local therapist/ quack before they were hospitalized. Only 10 patients (8%) were brought within 3 hours after snakebite, while 48% (60) patients were hospitalized within 3-6 hours after the bite and in 15 cases (12%), more than 12 hours elapsed between snakebite and hospitalization. Conclusion: Fatality due to snake bite is preventable. Use of protective gears while working in the field, quick hospitalisation after a snake bite and timely administration of Anti Snake Venom can prevent or reduce its morbidity or mortality. English Anti Snake Venom, Farmers, Krait, Lower limb, SnakebiteIntroduction Snakebite envenoming was added to World Health Organization (WHO) priority list of neglected tropical diseases (NTDs) in June 2017.1 Although there are currently more than 3000 species of snakes in the world, approximately 250 of these are listed by WHO as being of medical importance because of the harm their venoms can do.1 In tropical and subtropical countries, snake bite is a major health problem. There is evidence that globally 4.5-5.4 million people are bitten by snakes annually, 1.8-2.7million of them develop clinical illness (envenoming) after snakebite, and the death toll could range from 81,000 to 138,000. Amidst the variable distribution of envenoming and mortality worldwide, it is highest in Sub-Saharan Africa, South Asia and South-East Asia.2 India contributes to 50 per cent of the estimated deaths due to venomous snakebites globally.3 Snake bite cases, although a common medical emergency, mainly affects the rural population, who rather than going to the nearest hospital, often depend on local traditional healers for initial treatment and thus increasing the mortality. The present socio-demographic study was conducted on fatal cases of snakebite envenomation undergoing medicolegal autopsy in a government medical college in Kolkata, West Bengal to depict the current scenario prevailing in this state. Material AND Methods This study was conducted on fatal snakebite victims, subjected to medico-legal autopsy at the Department of Forensic Medicine& Toxicology, Nil RatanSircar Medical College and hospital, Kolkatabetween July 2014 to June 2016 (two years). Proper approval was obtained from the Institutional Ethics Committee before the commencement of study. Only hospitalized cases with a prior confirmed history of snakebite or local findings corresponding to snakebite were included in this study while brought dead cases were excluded. The details regarding age, sex, the month of occurrence, residence, were obtained from the inquest papers and Bed Head Tickets. In each case the accompanying relatives were questioned about the circumstances of the bite, time is taken to reach the hospital, reasons for delay if any and socio-economic status (based on Modified Kuppuswamy scale). Information about the snakebite, such as identification of snake, time of snakebite, pre-hospital care, latency between bites and admission were gathered from hospital treatment records. During an autopsy, sites of bites on the body were noted. All these data were entered in a standard proforma and analysed using standard statistical tools and represented in the form of graphs and charts. Results Out of a total 5589 autopsies conducted between July 2014 to June 2016, 125 (2.2%)cases were hospitalised snakebite cases which proved fatal and sent for autopsy. Majority of the victims were male (61.6%, 77) and male to female ratio was 1.6:1. As shown in Figure 1, the most commonly affected age group was 21-30years (28%, 35), followed by 11-20 years (24.8%, 31). The snakebite victims mostly belonged to the lower socio-economic class (60%, 75) [Table 1] and rural population was more affected(76.8%, 96) than its urban counterpart, as seen in Figure 2. The most common occupation involved was that of farmers (52%, 65) and labourers (22.4%, 28), as shown in Figure 3. July (20.8%, 26), September (16%, 20) and June (14.4%, 18) recorded the highest number of cases in decreasing order of frequency while there was no fatality in December, as shown in Figure 4. The majority of snakebites (46.4%, 58) occurred in the early hours of the day (between 6 am to 12 noon), while the least cases were during 12 noon to 6 pm (8.8%, 11) [Table 2]. As seen in Table 3, the involved snake was identified in 50 instances (40%), the most common being Krait (23.2%, 29) followed by Cobra (9.6%, 12). The lower limb was the most preferred site of snakebite (54.4%, 68), followed by upper limb (25.6%, 32) and the least common site was facing/scalp (6.4%, 8) [Figure 5]. 37.6% (47) victims died within the first day, while another 50% (63) died within two weeks and 12% (15) patients survived more than a fortnight following the snakebite [Table 4]. 101 patients (80.8%) were taken to a local therapist/quack before they were hospitalized, while the other 24 (19.2%) were directly brought to hospital [Table 5]. As far as the interval between snakebite and admission to hospital is concerned, only 10 patients (8%) were brought within 3 hours after snakebite, while 48% (60) patients were hospitalized within 3-6 hours after the bite and in 15 cases (12%), more than 12 hours elapsed between snakebite and hospitalization [Table 6]. Discussion As per WHO, snakebite is one of the most neglected diseases that affect mainly the rural poor population.4In the present study, male to female ratio is 1.6:1; males were more affected owing to their outdoor activities than their female counterpart which is similar to previous studies from Madhya Pradesh 5 Maharashtra6and Karnataka.7 Studies from other countries also indicate male victim preponderance; male: female ratio was reported as 1.9:1 in a study from Thailand8 and 1.3:1 in another study from Pakistan.9 Although in the current study, all the age groups faced fatal outcomes, 21-30 years carried the most brunt like some other previous studies where 21-50 years ago group were mostly at danger.10 Sharp decline of fatalities after the 60 years of age is most probably due to less agricultural works by older people. Another cause may be less outdoor movement by the older persons after the evening.11 Globally, snakebites affect people in rural areas disproportionately.12-14 In this study snakebite mortality was around 3.3 times higher in the rural than an urban setting. Several reasons for higher rural mortality have been reported by previous studies, such as poorly constructed housing, increased agricultural work, treatment-seeking from traditional healers, and limited access to anti-venom therapy.15 Availability and accessibility of anti-venom is known to be limited in sub-Saharan Africa and Asia,16-18 resulting in a supply-price mismatch affecting medical treatment for the rural population and lower confidence in the public health sector&#39;s ability to provide effective and safe anti-venom.19,20 Several other kinds of literature also found higher incidences of snakebite cases in rural population. Farmers (52%) were the highest amongst the victims which are at par with other literatures.21,22 This may be attributed to working barefoot in the fields, not using protective gears like footwear etc. Snake bites are common during daytime23 and so was the finding in this study. Most of the bites occurred between 6 am to 12 noon. Studies conducted in Davangere21 and Maharashtra24 also reported high incidence during day time. This higher proportion in the earlier hours of the day corresponds to the increased outdoor activity time. Although, similar studies conducted in other parts of the country showed a relatively higher incidence of snakebite cases between 6:00 PM and midnight25-27 unlike the findings in our study.Seasonal peaks of snakebite incidences are usually associated with rainy seasons, associated agricultural activity and the profusion of prey organisms like frogs.28 Most human snakebites occur during the monsoon season because of flooding of the habitat of snakes and their prey. The breeding habits of frogs closely follow the monsoons and rats and mice are always close to human dwellings. 21 July, September, June and August hold the highest position in terms of the number of victims in decreasing order of frequency which corresponds with the monsoon season in West Bengal. November, December, January and February had very few cases due to hibernation of the reptile in the winter season. Lower limbs (54.4%) were the most preferable site for a bite which is in concurrence with other previous studies.10,21,25,29 Barefoot farmers working in poor visibility during the monsoon seasons in day time along with chances of accidental stomping on the snakes when the fields are full of their prey, can be attributed for this. Harrison RA30,31 found a positive correlation between snake envenomation and poverty. In the current study, we found the lower socio-economic class to fall victims in most of the cases (56%). Modified Kuppuswamy Scale33 was used to derive the socio-economic status of the victims after interviewing the accompanying relatives, in all the cases. The involved snake was identified in 50 instances (40%), the most common being Krait (23.2%, 29) followed by Cobra (9.6%, 12).Out of the total of 125 victims, only 47 (37.6%) patients succumbed to the snakebite within the first day itself, while the 62.4% survived for a variable period after hospitalization. Only 12% of the victims survived for more than two weeks and they received haemodialysis and mechanical ventilation before they died. All patients that suffer venomous snake bite should be resuscitated as per Advanced Trauma Life®Support (ATLS®) guidelines.32 All the hospitalised cases received Anti Venom sera in this study population.The most rapid threat to life is with neurotoxic bites in which respiratory depression secondary to muscle paralysis is a frequent cause of mortality.33 Dialysis and a supportive treatment appear to be the mainstay of the therapy in the cases which are complicated by renal failure.35 More than 80% of the victims were initially taken to local faith healers and quacks, which is a common finding in Indian scenario, as similarly observed in other studies.7,10,11 In the present study, only 10 (8%) victims were brought to the tertiary hospital within the first 6 hours, while 88% (110) patients were hospitalized within 12 hours after suffering from the alleged snakebite, who were referred to the tertiary hospital after receiving initial treatment in primary and secondary level healthcare facilities. This time latency between bite and hospitalization depends on several factors like the time of day when the alleged bite occurred, the distance of victim from a tertiary hospital, awareness about the treatment of snakebite, etc. and it eventually plays a very important role in survivability of the patient after hospitalization. Conclusion Snakebite affects mainly the poor people residing in rural areas doing agricultural activities mostly. 21-30 years age group is most vulnerable whereas people more than 61years are less affected. Snakebite cases wax and wanes around the year, with most cases occurring during monsoon season. Victims are mostly bitten by snakes in early daytime. Public awareness programmes are necessary to prevent the victims from being taken initially to local traditional healers and so that the crucial first few hours can be utilized by giving appropriate care at tertiary healthcare facilities. Farmers should be encouraged to use protective gears while farming and Government should ensure proper safety of our feeders. Ethical Clearance: Ethical Committee approval No. NMC/354, Dated 15/01/2014 of Nil Ratan Sircar Medical College, Kolkata, West Bengal. Funding: None 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: None declared Englishhttp://ijcrr.com/abstract.php?article_id=3331http://ijcrr.com/article_html.php?did=3331 What is snakebite envenoming? Available at https://www.who.int/snakebites/disease/en/ (Accessed on 2nd June 2020) Prevalence of snakebite envenoming-WHO. Available at https://www.who.int/snakebites/epidemiology/en (Accessed on 2nd June 2020) Gutiérrez JM, Calvete JJ, Habib AG, Harrison RA, Williams DJ, Warrell DA. Snakebite envenoming. Nat Rev Dis Primers 2017;3:17063. Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, et al. Snakebite mortality in India: A nationally representative mortality survey. PLoS Negl Trop Dis 2011;5:e1018. Kalantri S, Singh A, Joshi R, Malamba S, Ho C. Clinical predictors of in-hospital mortality in patients with snakebite: a retrospective study from a rural hospital in central India. Trop Med Int Health.2006;11:22–30. Mulay DV, Kulkarni VA, Kulkarni SG, Kulkarni ND, Jaju RB. Clinical profile of snake bites at SRTR Medical College Hospital, Ambajogai (Maharashtra). Indian Med Gazette 1986;131:363-366. Kulkarni ML, Anees S. Snake venom poisoning: experience with 633 cases. Indian Pediatr 1994;31:1239-1243. Buranasin P. Snake bites at MaharatNakhonRatchasima Regional Hospital. Southeast Asian J Trop Med Public Health 1993;24:186-192. Rano M. A study of snakebite cases. J Pak Med Assoc 1994;44:289. Shetty AK, Jiri PS. Incidence of Snakebites in Belgaum. J Ind Acad Forensic Med 2010;32(2):139–141. Majumder D, Sinha A, Bhattacharya SK, Ram R, Dasgupta U, Ram A. Epidemiological profile of snakebite in South 24 Parganas district of West Bengal with focus on underreporting of snakebite deaths. Ind J Public Health 2014;58:17-21. World Health Organization. Prevalence of snakebite envenoming.: WHO; (Accessed on 02nd June 2020). Available from: http://www.who.int/snakebites/epidemiology/en/ Gutierrez JM, Warrell DA, Williams DJ, Jensen S, Brown N, Calvete JJ, et al. The need for full integration of snakebite envenoming within a global strategy to combat the neglected tropical diseases: the way forward. PLoS Negl Trop Dis 2013;7(6):e2162. Chippaux JP. Snake-bites: an appraisal of the global situation. Bull WHO 1998;76(5):51-24. Chippaux JP. Snakebite envenomation turns again into a neglected tropical disease! J Venom Anim Toxins Incl Trop Dis 2017;23:38. Gutierrez JM, Burnouf T, Harrison RA, Calvete JJ, Brown N, Jensen SD, et al. A Call for Incorporating Social Research in the Global Struggle against Snakebite. PLoS Negl Trop Dis 2015;9(9):e0003960. Williams D, Gutierrez JM, Harrison R, Warrell DA, White J, Winkel KD, et al. The Global Snake Bite Initiative: an antidote for snake bite. Lancet 2010;375(9708):89-91. Chippaux JP, Massougbodji A, Diouf A, Balde CM, Boyer LV. Snake bites and antivenom shortage in Africa. Lancet 2015; 386(10010):2252-2253. Brown NI. Consequences of neglect: analysis of the sub-Saharan African snake antivenom market and the global context. PLoS Negl Trop Dis 2012;6(6):e1670. Dandona R, Kumar GA, Kharyal A, George S, Akbar M, Dandona L. Mortality due to snakebite and other venomous animals in the Indian state of Bihar: Findings from a representative mortality study. PLoS One 2018;13(6):e0198900. Sharma N, Chauhan S, Faruqi S, Bhat P, Varma S. Snake envenomation in a north Indian hospital. Emerg Med J 2005;22:118-120. Panna L, Srihari D, Rotti SB, Danabalan M, Kumar A. Epidemiological profile of snakebite cases admitted in Jipmer Hospital. Indian J Com Med 2005;26: 36-38. Vishwanath B, Ganesh P. Demography, clinical profile, morbidity and mortality pattern of snakebite cases in children: a study at the tertiary teaching hospital, India. Int J Contemp Pediatr 2019;6:1472-1475. Kulkarni RS, Sharma BD. Study of 1140 Cases of Poisonous Snakebite Envenomation In a Rural Hospital of South Konkan Coast of Maharashtra over a period of eight years (1986-1993). Indian Poisonous Snakes. 1stEdition. New Delhi: Anmol Publications Pvt. Ltd.; 2002:279-301. Anjum A, Husain M, HanifSA, Ali SM, Beg M, et al. Epidemiological Profile of Snake Bite at Tertiary Care Hospital, North India. J Forensic Res 2012;3:146. Suchithra N, Pappachan JM, Sujathan P. Snakebite envenoming in Kerala, south India: clinical profile and factors involved in adverse outcomes. Emerg Med J 2008; 25: 200-204. Yoshi S, Honma M. Snakebites in India. Snake 1975;7(1):1-16. Chandrakumar A, Suriyaprakash T.N.K, Linu Mohan P, Thomas L, Vikas PV. Evaluation of demographic and clinical profile of snakebite casualties presented at a tertiary care hospital in Kerala. Clin Epid Global Health 2016;4:140-145. Hati AK, Mandal M, De MK, Mukherjee H, Hati RN: Epidemiology of snake bite in the district of Burdwan, West Bengal. J Indian Med Assoc 1992;90(6):145-147. Harrison RA, Hargreaves A, Wagstaff SC, Faragher B, Lalloo DG. Snake Envenoming: A Disease of Poverty. PLoS Negl Trop Dis 2009;3(12):e569.  Kasturiratne A, Wickremasinghe AR, de Silva N, Gunawardena NK, Pathmeswaran A, et al. The Global Burden of Snakebite: A Literature Analysis and Modelling Based on Regional Estimates of Envenoming and Deaths. PLoS Med 2008;5:1591-1604. American College of Surgeons Committee on Trauma. Advanced trauma life support for doctors [8th Edition], American College of Surgeons, Chicago, 2008. Warrell DA. Snake Bite. Lancet 2008;375:77-88. Harshavardhan L, Lokesh AJ, Tejeshwari HL, Halesha BR, Siddharama SM. A Study on The Acute Kidney Injury in Snake Bite Victims in A Tertiary Care Centre. J Clin Diagn Res 2013;7(5):853-856.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareMental Health in Digital India- EHR Perspective English169171Suresh Kumar SharmaEnglish Manisha Dinesh MantriEnglish Gaur SunderEnglishNoble mental health improves self-assurance and self-confidence and enables a person to love and motivate other people, daily life and surroundings. In this era of globalization, to maintain the mental health of society, it is necessary to adopt technological advancement and grow various mental health faculties. Digital India initiative of Government of India (GoI) for healthcare is taking a momentum through the new guidelines, policies and regulations. Use of EHR and EMR has been an important aspect to manage patient health information. NMHS discovered that approximately 80% of individuals affected had not received any type of care after the start of their disorder. The ill-health associated with these illnesses were severe in nearly 0.7% to 28.2% of individuals along with the significant socioeconomic effect on individuals who are affected. As its well-known psychiatric treatment is last longer as per the patient’s prognosis and maintaining psychiatric patients record for long years is a crucial task by the patient’s self and his caregivers. EHR serves as a well-documented record for patient’s official treatment records & can be used for shielding malpractice, regulatory action or ethics complaint. MoHFW, GoI took national membership of SNOMED International and made SNOMED CT clinical terminology offered free-for-use in India. National Release Centre (NRC) for SNOMED CT was set up for pervasive acceptance and support of SNOMED CT in the nation. We may suggest that eHealth and EHR standard enabled clinical applications can improve rendering mental health services to patients and society. English Mental Health, Digital India, Mental health EHR Perspective. EHR standard for India, EHR in Mental HealthIntroduction Noble mental health is essential for wealth and normal health. It improves self-assurance and self-confidence and enables a person to love and motivate other people, daily life and surroundings. When the individual is psychologically healthy, he/she can form positive relations, practice the abilities to reach their optimal level and deal with life’s problems. In this era of globalization, to maintain the mental health of society, it is necessary to adopt technological advancement and grow various mental health faculties. Such practices help to develop the domain and allow it to persist in a state of brilliance. Be it fire or be it technologically, no great discovery or innovation has come without overcoming problems and more so not without the rationality of a stable mind.1 Person health record to be clinically significant it needs to be accessible and documented from beginning or birth. Each of these records may be irrelevant or relevant depending on the present difficulties that the individual is suffering from. Thus, it becomes essential that these records be accessible, longitudinally organized as a time series, and be clinically significant to provide an outline of the many healthcare events in the life of an individual.2 The usage of Information and Communication Technology for healthcare services delivery, management and planning is known as Health Informatics (HI). It is applicable for four major multidisciplinary constituents; evolving ICT technologies, epidemiology and health management, health systems, and advanced statistics.3 Digital India initiative of Government of India (GoI)for healthcare is taking a momentum through the new guidelines, policies and regulations. Use of EHR and EMR has been an important aspect to manage patient health information. There is a clear vision to enable interconnected healthcare systems across the country. Many initiatives have been taken such as standardization of capture, storage, and exchange of health information, addressing confidentiality and safety concerns in the digital health world, building health data exchanges infrastructure.4-6 Mental Health Perspective of India As per NMHS of India, 2015-16, it is estimated that psychological illnesses contribute to a major load of morbidity and ill health, even some increasing mortality. Mental, neurological and substance use disorders (MNSuDs) well-known to be on the rise in current years, consist of a wide diversity of minor anxiety, severe disorders like Schizophrenia and Bipolar disorders. Further, voluminous MNSUDs are both an origin and concern of Non-Communicable Diseases (NCDs). Most suggestively, NMHS discovered that approximately 80% of individuals affected had not received any type of care after the start of their disorder. The ill-health associated with these illnesses were severe in nearly 0.7% to 28.2% of individuals along with the significant socioeconomic effect on individuals who are affected.7 A frightening fact which has been recognized for several years, is the vast gap, repeatedly mentioned as the treatment gap, in the care of the psychologically ill in India. This is because of poor awareness among societies and the unavailability of resources. To accomplish the aim of high standards in the quality of care and enhanced results based on the principles of universal care and equity, health systems must be reinforced and made responsive to changing health urgencies and alarms.8 Mental Health and EHR Standards To propose, develop, tool, monitor, evaluate, and reinforce psychological health facilities in India, there is a need to recognize the clear problem of mental illnesses as well as the previous resources and services across the country. As the documents from existing studies had its limitations which often excluded its use for planning mental health services in India, the necessity for good quality data has been reiterated.8 Patient information is made available and accessible can simplify continuity of care, improved health result and improved decision support. One of the key requirements to enable data exchange and availability is having standardized HCIT applications/systems across the country. With this vision to establish a system for interoperable Electronic Health Records (EHRs) of citizens, MoHFW notified the Electronic Health Record (EHR) Standards for India in September 2013. The informed standards were not only supported by professional bodies, regulatory bodies, stakeholders, but various technical and social commentators also. Reviewed EHR Standards for India were notified by MoHFW in December 2016.2 Significance of EHR Standards in Mental health There are numerous benefits of collecting medical records such as enabling enhanced and evidence-based care, gradually more accurate and more rapid diagnosis leading to superior cure at lower costs of care, unnecessary investigations should be avoided, advanced analytics such as prognostic analytics for preventive clinical care, health policy decisions can be made on highlighted issues etc. This all ultimately can help in civilizing individual and public health. Sharing of medical records can only be possible through a set of pre-defined standards for information capture, storage, retrieval, exchange, and analytics that includes images, clinical codes and data is imperative.2 In the world Mental illnesses escalating a major cause of concern. Increased psychiatric illness in all age groups & economic background shocked the psychiatrists all over the world as per WHO statistics. Current gaps in treatment for typical psychiatric conditions in several states are pierced by NMHS 2016. It is concluded that for typical psychiatric conditions, there was an 85% treatment gap across the various states.8 A study conducted by Chaudhury PK et all to evaluate psychiatric morbidity in the community through the application of schedule for clinical assessment.9 As its well-known psychiatric treatment is last longer as per the patient’s prognosis and maintaining psychiatric patients record for long years is the crucial task by the patient’s self and his caregivers. EHR serves as a well-documented record for patient’s official treatment records & can be used for shielding malpractice, regulatory action or ethics complaint. Electronic Health Record Standard at a Glance The notified EHR Standards for India (2016) were chosen from based on their international acceptance, availability, implement ability, suitability and applicability in India. The notification aims at standardization of identification, data capture, storage and transmission, etc. ensuring security and privacy (Figure 1). Few key EHR standards specified in the notification for implementation in Healthcare application to achieve interoperability are listed below ( Table 1): Note: For a complete list and details refer EHR standard for India Notification: 2016 EHR Standard Implementation Initiatives MoHFW, GoI took national membership of SNOMED International and made SNOMED CT clinical terminology offered free-for-use in India. National Release Centre (NRC) for SNOMED CT was set up for pervasive acceptance and support of SNOMED CT in the nation.  Further to support adoption and implementation of all the EHR Standard, NRCeS is setup at C-DAC, Pune. Conclusion             This article concludes that mental health professional should, directly and indirectly, involve themselves in designing, developing and using standard incorporated healthcare application in the facility. Health and EHR standard enabled clinical applications can improve rendering mental health services to patients and society. There is a great need to sensitize the community about eHealth (especially telemedicine), and Health IT standards which can open many future research areas in mental health research and healthcare advancement.  This review paper is anticipated to be a guide in the field of health IT in mental health and inspire the future generation for a more comprehensive study in the field of health IT advancement in mental health. Acknowledgement This work is carried out under the National Resource Centre for EHR Standards (NRCeS) project set-up at C-DAC, Pune, and funded by the Ministry of Health and Family Welfare (MoHFW), India. Englishhttp://ijcrr.com/abstract.php?article_id=3332http://ijcrr.com/article_html.php?did=33321.        Mental Health. National Health Portal Of India. https://www.nhp.gov.in/healthlyliving/mental-health. Accessed September 30, 2020. 2.        EHR Standards for India. Ministry of Health & Family Welfare. India, MHFWG eHealth Sect (2016) Electron Heal Rec Stand India. 2016:1-48. http://www.mohfw.nic.in/showfile.php?Lid=4138. 3.        Plague. National Health Portal of India. Government of India. https://www.nhp.gov.in/health-informatics_pg#Introduction. Accessed September 30, 2020. 4.        Sinha P, Sunder G, Bendale P, Mantri M, Dande A. Electronic Health Record: Standards, Coding Systems, Frameworks, and Infrastructures. Wiley-IEEE Press 2012. 5.        Shri B, Panda M. The data (privacy and protection) bill: Methods and principles of data collection and protection. Bill No.100 of 2017. 6.        NITI Aayog. National Health Stack Strategy and Approach. July 2018. NHS-Strategy-and-Approach-Document-for-consultation.pdf (niti.gov.in) Accessed on September 3o, 2020. 7.        National Institute of Mental Health and Neuro Sciences, Bengaluru. National Mental Health Survey of India, 2015-16 National Mental Health Survey of India. 2015-16. 8.        Prasad S. NIMHANS launches digital academy to help tackle India’s mental health  crisis. Citizen Matters, Bengaluru. Citizen matters. Https://bengaluru.citizenmatters.in/nimhans-digital-academy-virtual-learning-mental-health-care-25940. Published July 13, 2018. Accessed September 30, 2020. 9.        Chaudhury PK, Bhuyan D. Evaluation of psychiatric morbidity in the community through application of schedule for clinical assessment in neuropsychiatry (scan). Int J Cur Res Rev 2015;7(13):29-34.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareEffect of Pranayama on Cardiovascular Parameters among Indian Population- A Narrative Review English172175Sarika MLEnglish Ajaya GhoshEnglishPranayama is one among the breathing exercise practised in Yoga, which can control breathing voluntarily. This narrative review based on the scientific research findings used as the methodology in this study. The online data sources including Pubmed, Pubmed Central, Cochrane, Medline, Google Scholar were searched for the related studies. After applying the inclusion and exclusion criteria we got 30 related studies on the topic. The studies showed that there is an effect of pranayama on the cardiovascular parameters among the healthy as well as the hypertensive patients. Some types of pranayama affect the parasympathetic system and some types stimulate the sympathetic system. The Surya Anuloma Viloma or Surya Bhedana, Chandra Anuloma Viloma or Chandra Bhedana, Surya Nadi effect to increase the heart rate and Blood pressure. The alternative nostril breathing, Chandra Nadi pranayama, nadishuddhi, slow and fast pranayama effect to reduce the heart rate and blood pressure. Most of the studies show that pranayama affect blood pressure and a trained nurse can utilize the techniques in lowering the blood pressure level both in the clinical setting and in community English Pranayama, Systolic blood pressure, Diastolic blood pressure, Heart rate, Oxygen consumption, HypertensionIntroduction Globally cardiovascular diseases are the major cause of death among the world population. In 2016 around 17.9 million people died due to the same problem. It is around 31% of all death globally. For reducing the Non -communicable disease burden, all the WHO member countries (194) in 2013 agreed that a global action plan for the prevention and control of Non-communicable Disease by 2020. The main focus of this plan is to reduce premature death due to Non-communicable Disease by 25% by 2025. Also, another focus is to reduce 25%of the world prevalence rate of high Blood pressure. In 1975 the number of adults with raised Blood pressure was 594 million that increased to 1.13 billion in 2015.1 In India, around 52% of death occurs before the age of 70 years due to cardiovascular diseases. But in the Western population, the percentage was only 23%. The severity of cardiovascular diseases is more in low-income countries like India when compared to the high and middle income countries.2Cardiovascular diseases related conditions make the two-third burden of Non-communicable Disease in India. The cardiovascular diseases death rate in India is around 272 per 100000 populations which is higher than the world’s average death rate due to cardiovascular diseases of 235 per 100000 populations. Among the cardiovascular diseases death rate 255-525 per 100000 populations in men and 225-299 per 100000 populations in women.3 India has contributed more variety to the world especially Zero in mathematics, Ayurveda, Yoga in health etc. Among this golden contribution, Yoga is playing a pivotal role in the prevention of cardiovascular diseases. Breathing exercises are an important part of Yoga. Pranayama and related physiological effects Pranayama is one among the breathing exercise practised in Yoga, which can control breathing voluntarily. The word Pranayama formed from Parana means source in the body and Ayama means breath control.4 The respiratory cycle is an ultradian rhythm in which the cycle is repeating 24 hours in a day. In this cycle, the air entry through the patent right and left nostril are called the nasal cycle. The forced breathing via the right nostril block the left one was found to raise the blood sugar level and the heart rate of the individual. The left nostril has the reverse effect.5             The pranayama technique in the yoga is about to inhale and exhale through the alternative nostrils exclusively. Right nostril breathing pranayama practising for 40 minutes per day for months affect that different from the left nostril breathing pranayama/ Chandra Anuloma Viloma, and these two techniques are again different from the alternative nostril breathing pranayama or Nadishuddhi. These all three pranayama technique can practice at the same duration and frequency. When considering the oxygen consumption, the Surya Anuloma Viloma is causing more (37%) than the other two types that are 24% and 19% respectively. Also when considering the Surya Anuloma Viloma, Chandra Anuloma Viloma and Nadishuddhi, the Surya Anuloma Viloma and Chandra Anuloma Viloma have more effect on weight reduction (2.3 Kg) than the Nadishuddhi (1.5 Kg). This is suggesting that we can recommend these practice to reduce body weight.6 Methodology A narrative review based on the scientific research findings used as the methodology in this study. Mainly the online data sources including Pubmed, Pubmed Central, Cochrane, Medline, Google Scholar were searched for the related studies. We searched for the keywords pranayama, cardiovascular parameters, and healthy people and hypertensive patients for the study review. We searched the article until October 2019. Studies related to any type of pranayama, experimental studies, studies available in Pubmed, Pubmed Central, Cochrane, Medline, Google Scholar database,  studies finding the effect of pranayama on cardiovascular parameters like heart rate systolic and diastolic blood pressure and oxygen consumption were included in this review and the studies, not an experimental study, other yoga effects on cardiovascular parameters, full text not available studies, other databases not in the inclusion criteria, repeated studies were excluded from the review. After applying the inclusion and exclusion criteria we got 30 related studies on the topic. Effect of Pranayama on cardiovascular parameters Pranayama and sympathetic stimulation             Surya anuloma pranayama or right nostril pranayama effect on cardiac parameters was assessed among the group with no comorbidities. In which the first group practised Surya Anuloma Viloma for 45 minutes on the first day and normal breathing on the second day for same 45 minutes. In the second group, the first day went for normal breathing followed by next day Surya Anuloma Viloma. They showed that the systolic blood pressure and the oxygen consumption is increased after Surya Anuloma Viloma but not after the normal breathing session.6 In another group of men in the age group between 25-48 years. They randomly divided into 3groups, in which the first group practised the right nostril breathing left nostril breathing and alternative nostril breathing for 27 cycles, 4 times per day for one month. They had a significant increase in baseline oxygen consumption of 37% in the right nostril breathing group, 24% in the left nostril breathing group and around 18% in the alternative nostril breathing group. When comparing the heart rate among these groups showed that there is an increase in HR after one month of the breathing exercise.7 Pranayama and parasympathetic stimulation             The different types of pranayama are having a variety of cardiovascular changes in the human body. A study conducted by Madanmohan et al and Pal et al showed that the slow and deep breathing exercise can produce a significant reduction in Blood Pressure and Heart Rate after a continuous practice for 3 weeks and 3 months respectively. It also showed that the Chandra Nadi Pranayama effect reducing the heart rate and Blood Pressure among patients with hypertension.8,9A study was conducted among the 15 volunteers showed that the alternative nostril breathing can reduce the Systolic Blood Pressure.10 The Chandra Nadi Pranayama is the method in which the air is breathing through the left nostril alone. The cooling breath practices of the Chandra Nadi Pranayama are Sheetali and sheetkari effect reducing the BP without causing any adverse effect.11 The major difference between the Sheetali and Sheetkari are inhaling the cool air through the folded tongue and inhaling through the side of the mouth with a closed tooth respectively.12Among  hypertensive patients in the age group between 25 to 65 years practised two types of pranayama, Sheetali and Sheetkari pranayama each around 10 minutes per day. They showed that there is a decrease in the Heart Rate and Systolic Blood Pressure after the intervention.13 Bhramri pranayama is a type of pranayama in which the person inhaling through both nostrils and exhaling produce the sound of a humming bee. A group of volunteers with a mean age of 23.50 and the age 18 years and above with no comorbidities practised the bhramri pranayama and their Heart Rate, Systolic Blood Pressure and Diastolic Blood pressure were decreased after their pranayama.14The immediate effect of bhramari pranayama on resting cardiovascular parameters in healthy adolescents was conducted by Kuppusamy et al. In the experimental group they done the bhramari pranayama for 45 minutes that is 5 cycles and in the control group done the normal breathing, it was about 12-16 breaths per minutes. After 5 minutes of rest in the supine position, the Heart Rate and Blood Pressure checked. The adolescents had a significant reduction in the Blood Pressure and Heart Rate in the experimental group.15 School children were randomly selected to evaluate the effect of pranayama training. The students were divided into pranayama group and a control group. In the pranayama group, the students were underwent training on Nadishuddhi, Mukh- Bhastrika, Pranav and Savitri pranayamas, practised 20 minutes daily for 3 months. The results showed that the pranayama training modulates ventricular activity by increasing the parasympathetic activity.16 Bhavanani et al conducted a study among yoga trained subjects on effects of uninostril and alternative nostril pranayama on cardiac parameters. The study participants came to the lab on 6 days and checked their heart rate and blood pressure after the pranayama. The different pranayama includes Right Unilateral Breathing, (Surya Nadi), left Unilateral Breathing, (Chandra Nadi), Right initiated Alternative Nostril Breathing (Surya Bhedana) and left initiated Alternative Nostril Breathing (Chandra Bhedana), Nadi Shuddhi, and Normal Breathing. They showed that there is the reduction in Heart Rate and Blood Pressure following Chandra Bhedana, Chandra Nadi and Nadi Shuddhi with concurrent increase following Surya Bhedana and Surya Nadi.17 Medical students in (age 18-20 years) practised the nadishodhana pranayama for 10 weeks. They showed that there is a significant decrease in the Heart Rate, Systolic Blood Pressure and Diastolic Blood pressure after the pranayama training.4 A similar study among healthy young adults showed that after the 12 weeks training of alternative nostril breathing there is a significant decrease in the Heart Rate, Systolic Blood Pressure and Diastolic Blood pressure.18 Effect of alternative nostril breathing for 15 minutes for 8 weeks along young adults showed that there is a significant decrease in the Heart Rate and Systolic Blood Pressure among both male and female groups and a non-significant decrease in the Diastolic Blood pressure in both groups.19 Right, and left nostril breathing pranayama effect on the cardiac, respiratory and autonomic values among the healthy young adults in the age group 17-22 years also had a similar effect. In which one group practising right nostril breathing and the other group practising left nostril breathing, they practised 15 minutes daily for 8 weeks and after the training programme, they showed that there is a decrease in the Heart Rate, Systolic Blood Pressure and Diastolic Blood pressure in both group.20 Conclusion There is an effect of pranayama on the cardiovascular parameters among the healthy as well as the hypertensive patients. Some types of pranayama affect the parasympathetic system and some types stimulate the sympathetic system. Most of the studies are in a short duration effect only checked. Considering the benefits of the pranayama on the cardiovascular parameters a large scale sample with a long period studies are warranted with strong study design to control the extraneous variables. Nurse practitioners may be trained on pranayama and can utilize the techniques in reducing the blood pressure. Conflict of interest: No conflict of interest. Acknowledgements: The authors are thankful to Dr Vishnu Renjith. MSN, PhD, FRSPH, Lecturer, School of Nursing and Midwifery, Royal College of Surgeons of Ireland – Bahrain for his advice and guidance. Authors also 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. Source of Funding: The authors declare that there is no financial support received for this article at any stages. Englishhttp://ijcrr.com/abstract.php?article_id=3333http://ijcrr.com/article_html.php?did=3333 World Health Organization. Cardiovascular diseases. 2017. Prabhakaran D, Roy A. Cardiovascular diseases in India; current epidemiology and future direction. Circulation 2016;133:1605-1620. Dey S. Heart disease deaths rise in India by 34% in 26 years. Times of India 2018. Aravindkumar R, Ramaprabha P, Bhuvaneswari T. Effect of Nadishodhana Pranayama on cardiovascular parameters among first-year MBBS students. Int Res J Pharm App Sci 2013;3(4): 103-106. Saoji AA, Raghavendra BR, Manjunath NK. Effects of yogic breath regulation: a narrative review of scientific evidence. J Ayur Integr Med 2019;10:50-58. Telles S, Nagarathna R, Nagendra HR. Physiological measures of right nostril breathing. J Altern Complement Med 1996;2(4):479-484. Telles S, Nagarathna R, Nagendra HR. Breathing through a particular nostril can alter metabolism and autonomic activities. Indian J Physiol Pharmacol 1994;38(2):133-137. Madanmohan Udupa K, Bhavanani AB, Vijayalakshmi P, Surendiran A. Effect of slow and fast pranayamas on reaction time and cardiorespiratory variables. Indian J Physiol Pharmacol. 2005; 49(3):313-318. Pal GK, Velkumari S. Madanmohan.Effect of short term practice of breathing exercises on autonomic functions in normal human volunteers. Indian J Med Res 2004;120(2): 115-121. Telles S, Verma S, Sharma SK, Gupta RK, Balakrishna A. Alternate-Nostril Yoga Breathing Reduced Blood Pressure While Increasing Performance in a Vigilance Test. Med Sci Moni Basic Res. 2017; 23: 392-398. Swami M. Hata Yoga Pradipika.Yoga Publications Trust. 2013. Julius S, Majahalme S. The changing face of sympathetic overactivity in hypertension. Ann Med. 2000;32:365-370. Prashanth S, kirankumar RB, Lakshmeesha DR, Shivprasad S, Selvakumar G, Ryan B. effect of Sheetali and Sheetkari pranayama on blood pressure and autonomic function in hypertensive patients. Integr Med (Encinitas) 2017;16(5):32-37. Nivethitha L, Manjunath NK, Mooventhan A. Heart rate variability changes during and after the practice of Bhramri Pranayama. Int J Yoga 2017;10(2):99-102. Kuppusamy M, Kamaldeen D, Pitani R, Amaldas J. Immediate effect of bhramari pranayama on resting cardiovascular parameters in healthy adolescents. J Clin Diag Res 2016;10(5):17-19. Bhavanani AB, Madanmohan, Sanjay Z. Immediate effect of Chandra Nadi Pranayama(CNP) on cardiovascular parameters in hypertensive patients. Int J Yoga 2012;5(2):108-111. Udupa K, Madanmohan, Bhavanani AB, Vijayalakshmi P, Krishnamurhty N. Pranayama training on cardiac function in normal young volunteers. Indian J Physiol Pharmacol 2003;47(1):27-33. Bhavanani AB, Ramanathan M, Balaji R, Pushpa D. Differential effects of uninostril and alternative nostril pranayama on cardiovascular parameters and reaction time. Int J Yoga 2014; 7(1):60-65. Anupkumar DD, Nitin D, Arbind KC, Sadawarte SK, Lalita C. Effects of alternative nostril breathing on the cardiorespiratory variable in healthy young adults. Int J Pharm Bio Sci 2015; 6(2):1352-1360. Srivastava RD, Nidhi J, Anil S. influence of alternative nostril breathing on cardiorespiratory and autonomic functions in healthy young adults. Indian J Physiol Pharmacol 2005;49(4):475-483.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareSurgical Management of Distal Femur Fracture Using Anatomical Locking Compression Plate English176181Aditya K. AgrawalEnglish Anirudh BansalEnglish Sudheer RawatEnglish Shubham KapadiyaEnglish Sarvang DesaiEnglish Paresh GolwalaEnglishIntroduction: Distal femur fractures are common injuries and are mostly caused due to vehicular injuries in the middle-aged population. Operative treatment has been preferred in the current scenario with open reduction and internal fixation in these fractures. Objective: To observe the surgical outcome of distal femur fractures operated with anatomical locking compression plate. Methods: This is a prospective observational study in 24 patients (20 male and 4 female). We classified the fractures according to AO/OTA classification and the patients were treated accordingly with anatomical locking compression plating. Functional outcomes were assessed according to “Schatzker and Lambert Score” at final follow up. Results: The mean age of presentation at the time of injury in the present study was 40.6 years. Open fractures were seen in11 patients and associated ipsilateral limb injuries were seen in 8 and contralateral limb injuries were seen in 4 patients. The mean follows up in the present study was 9 months. There were 8 cases of infection with seven being superficial infection treated conservatively and one case hada deep infection which was treated with debridement and antibiotics.In our study, there were 79.2 % (n=19) excellent to good results and 20.8 % (n=5) fair outcome according to Schatzker and Lambert criteria). Conclusion: Distal femur fracture treated with anatomical locking compression plate needs careful anatomical reduction, rigid fixation, early knee mobilization and weight-bearing onsigns of healing with the early presentation to the hospital from the time of injury were the essential factors in achieving a better outcome for the patient. English Distal femur fracture, Anatomical locking plate, Schatzker and Lambert scoring system, Soft tissue contractures, Rehabilitation, Vehicular accidents INTRODUCTION Fractures in the distal femur have posed considerable therapeutic challenges throughout the history of fracture treatment.  These fractures are usually comminuted and readily deformed because of muscle forces acting on the distal fragment. This results in functional impairment of the knee joint and ankle because of injury to the quadriceps system. The distal femur fractures also often occur in elderly patients withosteoporosis.1 Distal femur fractures occur at approximately one-tenth the rate of proximal femur fractures and makeup 6-7% of all femur fractures.2,3 The most common high energy me chanism of injury is road traffic accident (53%) and the most common low energy mechanism is a simple fall (33%).4,5 These potentially serious injuries resulting in various degrees of permanent disability and continue to pose a therapeutic challenge to the orthopaedic surgeons, eventoday in achieving successful outcome. Various modes of treatment have been advocated by several authors. They vary from closed treatment with traction, application of cast brace following preliminary traction, open reduction and internal fixation with a variety of implants. Elderly patients and osteoporosis add to the difficulty in intra-articular fractures. Loss of stable fixation is of great concern. The Locking compression plate has added advantages in these patients.6  Despite the advance in techniques and the improvement in surgical implants, treatment of distal femoral fractures remains a challenge in many situations.1 Anatomic reduction of the articular surface, restoration of limb alignment, and early mobilization are effective ways of managing most distal femoral fractures.7 The locking compression plate has the advantage of the combination of compression plating, locked plating and bridge plating.8-10 This reduces soft tissue damage and periosteal vessels are preserved. Therefore, it acts as a closed external fixator.11 In this study, we evaluated the results of distal femur fractures treated with distal femur anatomical locking compression plate, their clinical, radiological outcomes & complications. MATERIALS AND METHODS The prospective study was carried out in the selected group of patients treated in the Department of Orthopedics at the tertiary care district hospital.Study was conducted on consecutive 24 patients diagnosed with distal femur fractures presented to the casualty and orthopaedic department from November 2016 to October 2018, after taking written and informed consent. The study was approved by the Ethics Committee of the university (SVIEC/ Medi/BNPG15/D16208). Patients were selected according to the inclusion criteria of the study and were briefed about the nature of the study, intervention to be done and post-operative rehabilitation. Inclusion Criteria included patient aged 18 years and above, the fractures of the distal femoral metaphyseal, metaphyseal-diaphyseal with or without intra-articular extension and distal third fractures of the femur, comminuted distal femur fracture, close fractures, fractures with Gustilo Anderson open grade I and II wounds were also included. The exclusion criteria included patients who didn’t want to participate in this programme, patients under 18 years of age, patients medically unfit for surgery and patients who did not have minimum six months followup. All the patients were treated according to a protocol which consisted of standard antero-posterior and lateral digital X-ray and pre-operative CT scan. Open wounds were taken to the operation theatre for wound debridement within 5 hours ofadmission. Polytrauma patients were fixed as soon as their general condition allowed for surgery. Passive quadriceps exercises were started after 3-5 days post-operative.The patient was discharged with non-weight bearing walking for 12-16 weeks depending on the fracture pattern. Partial weight-bearing was started after early signs of the clinical and radiological union. Patients were followed up depending on the clinical examination as well as the radiological findings ofthe union. The statistical analysis was done using SPSS software (Illinois, Chicago) with a p-value less than 0.05 considered as statistically significant. RESULTS The prospective study was carried out in the selected group of patients treated in the Dept Orthopedics of a tertiary care district hospital from November 2016 to October 2018 on 24 consecutive patients. These included closed as well as open injuries and polytrauma patients. The average age of our present study was 40.6 years. The youngest patient in ourstudy was 21 years and the oldest patient in our study was 68 years. There were 17 patients below 50 years of age and only 1 patient above the age of 61 years. We observed more of the young active population in our study. In our study, there was a male preponderance (n=20, 83.33%). It is generally observed that the number of males out ranks females in a trauma series in ourcountry. Manual labourer and farmer sustained a maximum injury to the distal end of the femur. Vehicular accident and fall from height were the main  modes of injuries in our study fordistal end of femur fractures. In our study, there were 13 cases of closed injuries (54.2%) and 11 cases of open injuries (45.8%) in which Gustilo Anderson Grade-I and Grade-II were (25%) & (20.8%) respectively. According to AO/OTA classification, Type–A accounted for 37.5%, Type B accounted for 0% and Type C accounted for 62.5% fracture in our study. Half of the patients (n=12, 50%) were operated within 2 days of admission. In our study 19 patients (79.2%) were fixed with distal femur lock compression plate (DFLCP) as definitive treatment primarily and 5 patients (20.8%) were fixed with DFLCP in second procedure due to the presence of open grade II fractures fixed with external fixator primarily. In our study, 62.5% (15 patients) required only one surgical procedure followed by five patients who required two surgeries due to open injuries and three patients who required more than two surgical procedures due to post-operative complications (infection and non-union). The average time of hospitalization in our studywas 18.8 days. In our study, the most common complication was an infection which occurred in eightpatients (33.3%). Seven patients had developed a superficial infection and one patient had developed a deepinfection. All patients except one resolved with intravenous antibiotics for two weeks and regular dressing. One patient had to get operated for debridement. The second most common complication was fatembolism which occurred in 2 patients (8.3%) developed on second and third days after the operation and had recovered with treatment (oxygenation & heparinisation). Seven (29.2%) patients had knee joint stiffness at long term follow up. The rate ofmal-union was 8.3% (n=2 patients) due to comminuted fracture type, delayed union was 8.3% (n=2 patients) and non-union was 4.2% (n=1 patient where additional bone grafting was done). The average time of union in our studywas18.2 wks. Majority of fractures (75%) united in between (15-20)  weeks. The rate of fracture union in our study with anatomical locking compression plate was 95.8%. Out of 24 patients, only one patient had non-union and three patients developed union at >20 weeks follow up. In our study, 66.7% of patients (n=16) returned to their previous occupation while 12.5% of patients (n=3) had to change their occupation (clerical from manual).7,8,9 In the present study 16 (66.7%) patients had no shortening, 5 (20.8%) had to shorten less than 1.5 cm, 2 (8.3%) had shortening in between 1.5-2.5cm. All seven patients were given shoe compensation as they denied further surgical intervention. In our study total, 5 (21%) patients developed fixed flexion deformity (10±2°, range 5-23°). All five patients had open fracture grade II. All patients opted for aggressive physiotherapy and continuous passive motion devices. In our study, there were 79.2% (n=19)  excellent to good results and20.8% (n=5) fair outcome according to SCHATZKER AND LAMBERT’criteria. The fair results were due to open type of injury, more than two surgical procedures, presence of deep infection, shortening and fixed flexion deformity of the knee due to soft tissue contractures. DISCUSSION An impacted linear or slightly displaced fracture results from a trivialtrauma to the flexed knee from the anterior and slightly medial aspect ofthe knee. Usually, this kind of fracture pattern is seen in an osteoporoticbone. A violent force applied on the anterolateral side of the flexed kneeproduces an oblique fracture extending just proximal to the lateral epicondyle to well above the medial epicondyle. A transverse fracture is produced by severe force applied to the lateral side of the extended limb. This usually produces a condylar segment which islonger on the lateral side classically seen when a limb is struck by a motor vehicle at the knee.10,11 The extensive force applied to the anterior aspect of the flexed knee, as in afall from a height or a ‘DASHBOARD’ injury, produces conjoined fracture of the distal femur extending on the shaft of the femur with communication. Compression adduction forces on knee joint produce condylar fractures. Shearing force when applied right angle to the articular surface of the distal end of femur produces a fracture line parallel to the direction of the force. This is the mechanism of injury in most cases of distal femur fracturewith an inter-condylar extension. The quadriceps and the hamstrings produce longitudinal tension, which tends to produce overriding and angulation of the fragments, driving the proximal fragment into the supra-patellarpouch, and hence causing further displacement and haemorrhage. The posterior angulation and displacement of the distal fragment are caused by the strong pull of gastrocnemius. There is much controversy regarding the best method of treatment for the distal femur fractures, as most of the time-poor results are obtained. In the past, closed treatment with traction, application of cast following preliminary traction was used forthe treatment of open and close distal femur fractures. Outcomes after non-operative treatment were generally unsatisfactory, with a high incidence of fixed flexion deformity, varus mal-alignment, valgus mal-alignment, shortening and mal-rotation. As a result, since the late 1970s, opens reduction and internal fixation through plateosteo synthesis has emerged as the gold standard of operative therapy. In our study, most of the patients belong to the 4th decade (31-40 years) which included 7 (29.2%) patients. The mean age was 40.6 yrs which was almost equivalent to the study of Vishwanath C et al.,12 of 44.0 yrs (range 22-74yrs). All trauma series have high male preponderance. Similarly, we also had a  maximum male preponderance with a ratio of male to female of 5:1. In Vishwanath C et al. study, out of 50 patients, there were 32 male &  18  females. Hence, the male to female ratio was 1.7:1 and in Sabarisree M et al.,13 male to female ratio was 2:1. Males are inmajority as they comprise the majority of the earning population who drive for long distance daily. In our study, the most common mode of trauma was motorcycle accidents in 62.5% (15 patients), which is comparable to the study conducted by Vishwanath et al., (66%). In our country, motorcycles are the most common mode of transport in youngmales who are the bread earners of the family. With the rapid increase in populationand number of vehicles plying on the roads in a developing country like ours, the relative expansion and maintenance of roads are not adequate and so the number of road traffic accidents are increasing along with the pattern of injuries. In our study, the right side was most commonly injured in 66.6% (16 patients) who were comparable to the study done by Vishwanath et al., (66%). Most of the patients had right side involvement and it’s due to left lane driving pattern in our country making right lower limb more vulnerable in the head-on collisions. 33.4% (8 patients) had a left-sided injury in our study. In our study, out of 24 patients, 13  (54.2%)  patients had closed fractures and 11(45.8%) patients had open fractures. This shows the gravity of injury and damage to the soft tissue envelope which is vital for healing. Open fractures are one of the most challenging injuries to a trauma surgeon. Compared to closed fractures, they have a significantly higher risk of infection, delay in wound healing, high rate of non-union and often require multiple surgeries for definitive care. This in turn poses a mental trauma to the patient. In our study, the average hospital stay was 18.8 days which was comparable to 17.2 days in the study done by Yeap et al.14   The shortest stay was 5 days. The longest stay was 61 days in a patient who had open grade 2 distal femur fracture along withboth bone forearm fracture, proximal tibia fracture and 2,3,4 metatarsal fracture on the same side. External fixator for the femur and proximal tibia, rush pin and K- the wire was done as additional procedures for associated fractures.  In our study, the average union time was 18.2 weeks who had a union at final follow up.This is comparable to study done by Vishwanath et al., which states average union as 13 weeks and Satish et al which states average union as 19.3 weeks. Rate of the union inour study was 95% which was similar to the studies of Vishwanath et al., (95%) Full knee range of motion (flexion & extension) was attained in 5 of our patients. Because of restricted knee movements, 58.3% of ourpatients had either difficulty or inability to squat.  54.2% of patients had either difficulty or inability to sit cross-legged. The possible causes for restriction of knee movement in our study were associated quadriceps injury, intra-articular comminution, open injuries leading to development of intra-articular adhesions  andextra-articular  adhesion of quadriceps. CONCLUSION The present study on surgical outcome of distal femur fracture treated with anatomical locking compression plate was done at our institute from November 2016 to October 2018. In our study there were 79.2% ( n=19) excellent to good results and 20.8 % (n=5) fair outcome according to SCHATZKER AND LAMBERT’ criteria). The fair results were due to open type of injury, more than two surgical procedures, presence of deep infection, shortening and fixed flexion deformity of the knee due to soft tissue contractures. Open, comminuted and fractures with intra-articular extension had more number of unsatisfactory results. Incidence of infection was comparatively more in open cases due to late presentation as discussed earlier. Proper and adequate debridement is mandatory to minimize the incidence of infection in open cases. In accordance with knee range of motion, 5 (20.8%) patients had less than 90 degrees of range of motion. So we conclude that rigid fixation after anatomical reduction followed by early mobilization of the knee should be implemented in allcases. Injury to quadriceps mechanism or impingement to quadriceps mechanism should be recognized early and should be taken care of, to prevent extensor lag and fixed flexion deformity of the knee. ACKNOWLEDGEMENT: Authors would like to express their gratitude towards the Department of Orthopedics, Smt. B. K. Shah Medical College and Research Centre, Piparia, Vadodara and Hospital management for their constant support encouragement for the successful completion of the study and utilizing the facilities. 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. They are also thankful to the subjects of this study for their valuable participation. Authors also grateful to IJCRR editorial team and reviewers to bring quality of this manuscript. CONFLICT OF INTEREST: NONE SOURCE OF FUNDING: NONE Figure 1: A. 68 years old female with Type- A extra-  articular distal femur fracture B. operated with distal femur anatomical plating C. Patient shows good results of knee extension at 12 weeks followup. D. Patient shows good results of knee extension at 12 weeks followup. Figure 2: A. 42 years old male with Open Type-C distal femur fracture B. Patient was operated primarily with external fixator. C & D. This was followed by distal femur anatomical plating E. Patient with knee extension showing fair result at 12 weeks follow up. F. Patient with knee extension showing fair result at 12 weeks follow up. Englishhttp://ijcrr.com/abstract.php?article_id=3334http://ijcrr.com/article_html.php?did=33341. Brown A, D&#39;Arcy J. Internal fixation for supracondylar fractures of the femur in the elderly patient. J Bone Joint Surg1971;53-B(3):420-424. 2. EnnekingW, Horowitz M. The Intra-Articular Effects of Immobilization on the Human Knee. J Bone Joint Surg 1972;54(5):973-985. 3. Connolly J, King P. Closed Reduction and Early Cast-Brace Ambulation in the Treatment of Femoral Fractures.  J Bone Joint Surg 1973;55(8):1559-1580. 4. Pavel A, Smith R, Ballard A, Larsen A. Prophylactic Antibiotics in Clean Orthopaedic Surgery. J Bone Joint Surg 1974;56(4):777-782. 5. Schatzker J, Horne G, Waddell J. The Toronto experience with the supracondylar fracture of the femur, 1966–1972. Injury 1974;6(2):113-128. 6. Gustilo R, Anderson J. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. J Bone Joint Surg 1976;58(4):453-458. 7. Zickel R, Fietti V, Lawsing J, Van B. Cochran G. A New Intramedullary Fixation Device for the Distal Third of the Femur. Clin Orthop Relat Res 1977;12:185-191. 8. Patterson B, Benirshcke S, Mayo K, Henley M. Comminuted, Intraarticular Fractures of the Distal Femur. J Orthop Trauma 1993;7(2):170. 9. Kolmert L, Wulff K. Epidemiology and Treatment of Distal Femoral Fractures in Adults. Acta Orthop Scandinavica 1982;53(6):957-962. 10. Mize R, Bucholz R, Grogan D. Surgical treatment of displaced, comminuted fractures of the distal end of the femur. J Bone Joint Surg 1982;64(6):871-879. 11. Papagiannopoulos G, Clement D. Treatment of fractures of the distal third of the femur. A prospective trial of the Derby intramedullary nail. J Bone Joint Surg 1987;69-B(1):67-70. 12. Machhi R, Namsha B, Namsha V. Surgical outcome of distal femur fracture by locking compression plate. Int J Orthop Sci 2016;2(4d):233-239. 13. Babu S, Sunku N. A Study on Functional Outcome of Comminuted Supracondylar Fracture Femur Treated by Plating with Fibular Bone Grafting. J Bone Rep Recom 2017;03(01). 14. Yeap E, Deepak A. Distal Femoral Locking Compression Plate Fixation in Distal Femoral Fractures: Early Results. Malaysian Orth J 2007;1(1):12-17. 15. Rajaiah D, Ramana Y, Srinivas K. A study of surgical management of distal femoral fractures by distal femoral locking compression plate osteosynthesis. J Evid Based Med Healthcare 2016;3(66):3584-3587.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241132EnglishN2021January16HealthcareRATIONALE OF BONE GRAFTS FOLLOWING PERIAPICAL SURGERY: A REVIEW English0912HARKANWAL PREET SINGHEnglishFollowing periapical surgery, restoration of the destroyed bony architecture is a pre-requisite. Previous studies had shown that supplementing with artificial bone substitutes, growth factors or barrier membranes in the osseous defects is essential in influencing the healing following surgical intervention. This review is intended to focus on whether tissue regeneration with the aid of bone grafts coupled with a membrane barrier will suffice or is there a need for recruiting progenitor/stem cells. A literature search was conducted on several medical databases. All studies that used bone graft following periapical surgery were included Around 38 relevant articles were selected for this review. Literature shows that the mere use of a membrane barrier and/or bone graft following surgery would not yield the desired outcome. Previous studies show that some substitutes are capable of generating progenitor/stem cells and induce the undifferentiated mesenchymal cells to differentiate. Bone augmentation with the aid of bone graft materials along with biologically active molecules in addition to a mechanical barrier in the form of a membrane would enhance the healing of periapical tissues following periapical surgery. Better bone fill, gain in clinical attachment level is achieved with the use of various grafts as compared to non grafted sites. Englishperiapical surgery, allogenous bone grafts, PRF, Guided tissue regenerationIntroduction A periapical pathology inevitably results in the presence of a nonvital tooth which is left unattended. This ultimately will result in osseous destruction in the periapical area. It is also a familiar observation that despite an accurately accomplished endodontic treatment failure can be encountered due to microbial infection. This can lead to the formation of a periapical lesion as a result of an inflammatory response to bacterial infection within the root canal.1 An important goal in periapical surgery is to enrich healing along with removing the unhealthy tissues.2 Periapical surgery not only eliminates the unhealthy tissues in the periapical region but also cleanses the root surface along with contouring the surrounding bone. However, few studies have suggested that the healing of the tissues by the newly formed tissue generally fails to fully restore the architecture of the pre-existent bone.3,4 The concept of tissue regeneration has been introduced to improve the quality of healing. The kind of cells that repopulates the wound initially determines the quality of healing.5 Literature shows that the use of either bone graft materials or incorporation of biologically active molecules in addition to the placement of a mechanical barrier following periapical surgery enhances tissue regeneration in the periapical tissues. Bone grafts It is a well-known fact that periapical lesions that are relatively small in size would heal satisfactorily with the aid wound healing but larger lesions would require recruitment of stem cells and their differentiation. In huge osseous defects, insufficient osseous regeneration occurs.6 Numerous studies in the past have demonstrated a better outcome with regards to tissue healing following periapical surgery with the aid of regenerative technique using bone graft compared to the same lesions without regenerative techniques.7,8 It is believed that a simple enucleation of the periapical cyst usually leaves a bony defect. Because the maxilla demonstrates a relatively high regenerative capacity, optimal obliteration of this osseous defect in presence of a background of an inflammatory reaction may be hindered.9 Inadequate or less optimal bone healing results when the regenerative technique is not employed due to the invagination of overlying tissue into the osseous defect, preventing osteogenesis.10 According to Jansson et al., the survival rates of periapical surgery was found to be 68% in molars and 77% in single-rooted teeth over 10 years.11 This highlights the fact that augmentation with the aid of bone grafts is essential to facilitate optimal tissue healing in the periapical region following periapical surgery. Augmented bone graft plays a key role by acting as a template for osteogenesis and slowly resorb to permit replacement by new bone.10Bone grafts have either osteogenic, osteoinductive or osteoconductive properties. 12 Hydroxyapatite can be considered to be a very effective alloplastic material particularly in large bone destruction caused by periradicular lesion where it can facilitate effective bone replacement in the later stages as well as provide functional support to the tooth in the initial stages.10 A recent study evaluated bone regeneration in the periapical region using Platelet-rich fibrin(PRF) and nanocrystalline hydroxyapatite with collagen in combination with PRF and their effects on healing and concluded that the combination of PRF and nanocrystalline hydroxyapatite with collagen produced a significantly faster bone regeneration and that conventional technique and PRF were less predictable with its healing response.13,14 Biologically active molecules             PRP play a critical role in enhancing wound healing due to the discharge of some growth factors via α granules.12,14 These growth factors generally act both locally and systemically.15 It increases early wound strength by enhancing collagen synthesis and angiogenesis. Few studies suggested that the use of a triple antibiotic paste for canal disinfection along with PRF strengthens the effectiveness of sterilization in carious teeth, infected dentin, periapical lesions and necrotic pulp.16 Huang et al. in his study concluded that PRF can multiply pulp cells in addition to enhancing the expression of osteoprotegerin and Alkaline phosphatase activity.17 In vitro studies have demonstrated that PRF has shown no cytotoxicity toward many normal cells present in the periapical region.18 A recent study showed that the PRF membrane has a slow sustained release of growth factors for 7-28 days.19 A recent study used PRF with tricalcium phosphate (TCP) bone graft for treating a periapical cyst and advocated that usage of PRF and TCP together would yield enhanced results than the usage of biomaterials alone.20 Study done by Keswani et al on the revascularization of immature pulp apices concluded that PRF acts as a biological connector for neoangiogenesis and vascularization.21 This highlights the fact that augmentation with the aid of bone grafts coupled with biologically active molecules is essential to facilitate optimal tissue healing in the periapical region following periapical surgery. Barrier membranes To prevent invading of the overlying soft tissue into the osseous defect, it is advisable to use a mechanical barrier on top of the defect. This would create an environment for the cells to repopulate into the defect.22 Resorbable membranes are available alternatives to non-resorbable membranes.23 They are resorbed by proteolytic enzymes and excreted via kidney.24 An in vitro study advocated that resorbable membranes stimulate cellular proliferation more than non-resorbable membranes.25 Literature shows that collagen membrane coupled with a bone graft significantly enhances the preservation of alveolar bone.26 Membranes containing greater than 5% metronidazole show antibacterial activity deprived of any cytotoxic effects.27 Amnion membrane is derived from the human placenta. It incorporates growth factors presenting anti-inflammatory and antimicrobial properties.28 The thickness of the amnion membrane is lesser than collagen membranes which assist a proper adaption over the osseous defect.29,30 Amnion membrane facilitate the proliferation of endothelial cells and angiogenesis in addition to recruitment of mesenchymal progenitor cells assisting accelerated wound healing.31,32 Inference The application of graft materials in the form of hydroxyapatite, tricalcium phosphate or xenograft alone would lead to the formation of fibrous encapsulation of the graft material and thereby interfere with the ideal healing in the periapical tissues following surgical intervention.32 It is believed that a blood clot plays a key role in stabilizes the wound matrix in the event of wound healing. Platelet alpha granules of PRP act as a source of growth factors that facilitate cellular proliferation and bone formation.33 PRF facilitates the preservation of the integrity of the bone graft material by revascularizing the bone graft particles through neo-angiogenesis.2,34 Once PRF starts resorbing slowly it releases growth factors that maintain a viable field to enhance healing.35,36 In addition to this placement of a barrier membrane would avoid the invagination of soft tissue into the osseous defect thereby enhancing the wound healing. Recent advances Conventional periapical surgical generally results in a big osseous defect. With the aid of the 3D printed template, the osseous defect resulted in surgical intervention is limited to 3–4 mm. This confines injury to osseous tissues resulting in less bleeding, less postoperative complications, shorter healing time and better prognosis.37 A recent study employed Cone Beam Computed Tomography(CBCT) imaging, 3D printing technology and a 3D surgical guide designed with computer-aided software. A hollow trephine bur was used to perform the osteotomy, resection of the root, and enucleation of the lesion. The intact cortical plate was salvaged and used as a graft along with plasma-rich fibrin acquired preoperatively from the patient&#39;s blood. The positioning guide allowed the clinicians to precisely achieve targeted tissues and shorten the procedure time. Modified soft tissue management helped achieve a small surgical wound for uneventful healing.38 Conclusion Guided tissue regeneration acts as an adjunct to surgical intervention that can employ an extensive range of biomaterials. Augmentation with the aid of bone graft materials along with biologically active molecules in addition to a mechanical barrier in the form of a membrane would enhance the healing of peripheral tissues following periapical surgery. We conclude that that better bone fill, gain in clinical attachment level are achieved with the use of various grafts as compared to non grafted sites. Acknowledgment: Authors acknowledge the enormous help received from the authors 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=3338http://ijcrr.com/article_html.php?did=3338 Alnemer NA, Alquthami H, Alotaibi L. The use of bone graft in the treatment of the periapical lesion. Saudi Endod J 2017;7:115-118. 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