Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareThird Wave of COVID-19 in Thailand
English0102Pongsak RattanachaikunsoponEnglish Parichat PhumkhachornEnglishEnglishCOVID-19, SARS-CoV-2 variant B.1.1.7, Thailand, Vaccinehttp://ijcrr.com/abstract.php?article_id=3680http://ijcrr.com/article_html.php?did=3680Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareThe Desideratum of Nanomaterials for DNA Sensing
English0303Anurag RoyEnglishEnglishhttp://ijcrr.com/abstract.php?article_id=3681http://ijcrr.com/article_html.php?did=3681Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareOccupational Hypertension among Professionals of Bijapur City: A Letter to the Editor
English0404Debasish Kar MahapatraEnglishEnglishhttp://ijcrr.com/abstract.php?article_id=3682http://ijcrr.com/article_html.php?did=3682Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareFood Hygiene and Nutrition Management of Nursing Homes in Korea
English0512Joo-Eun LeeEnglishIntroduction: The elderly population is on the rise all over the world, and the importance of quality meals that affect the life of the elderly is increasing. In particular, elderly people who have been admitted to facilities such as nursing homes have a high possibility of malnutrition due to their poor appetite, and hygienic meal management is very important due to their low immunity.
Objective: To recognize the performance of meal service management in nursing homes in Korea and to provide appropriate management of meals for the elderly and the need for hygiene and nutrition education.
Methods: This study surveyed the foodservice management performance targeting a total of 300 nursing homes with no duty to hire dietitians as the number of foodservice recipients was less than 50. It calculated the mean and standard deviation of the performance score. To understand differences in mean foodservice performance following the matter of hygiene education and nutrition education, the t-test was carried out for each item and category.
Results: The questionnaires were mostly filled in by directors of facilities (n=70, 80.5%) or office managers (n=12, 13.8%). Total 57 respondents (65.5%) had experiences in hygiene education, and a total of 22 respondents(25.3%) received nutrition education. When the total of 33 items was divided into six categories and then questioned, the category showing the highest mean performance score of the six categories was foodservice facilities & environment’ (4.33/5.0) while the lowest category was ‘cooking process management’ (3.70/5.0).The mean foodservice management performance score of the whole 33 items was3.96. In five categories and 22 items of foodservice management, the case of receiving hygiene education showed a significantly higher mean performance score than the case without it (pEnglishFood, Hygiene, Nutrition, Education, Nursing home, the ElderlyINTRODUCTION
The WHO predicted that the aged population would be continuously increasing in the whole world, and the percentage of the elderly in 60 or up would be almost doubled from 12 % in 2015 to 22% in 2050.1 Even in Korea, the aged population is continuously increasing. The percentage of the elderly in 65 or up was 7.2% in 2000 as an ageing society and 14.3% in 2018 as an ageing society. It is predicted that Korea would become a super-aged society (20.3%) in 2025.2 The national problems caused by the increase of the aged population are not only a burden on healthcare costs, but also led to problems of the whole society that has to treat and support them.1,3 Thus, Korea is establishing the national system for supporting the elderly by implementing the Long-Term Care Insurance from July 2008, and the percentage of the elderly using it is gradually increasing from 5.89% in 2010 and 7.80% in 2017 to 10.02 % in 2019.4
In the aspect of pursuing the quality of life of the elderly, such a nutritionally balanced and pleasant dietary life is regarded as important because the hygiene and nutrition management of overall meals are the fundamental conditions for preventing diseases.5,6 Actually, the elderly with weak immune systems are at greater risk to be exposed to food poisoning, and some cases of food poisoning at nursing homes have been reported in reality7,8. From 1975 to 1987, a total of 115 cases of food poisoning occurred at nursing homes in 26 states of the United States, which was led to 51 deaths. The most causative organism of this food poisoning was known as Salmonella.7 Also, in 1993, a total of 119 old people were infected with food poisoning at a nursing home with 580 sickbeds in Brooklyn, New York of the United States, and the cause was revealed as cross-contamination happened in the process of grinding meat and poultry by a culinary employee infected with the disease.8 Even though the average calorie of food provided for five days to 74 old people in a nursing home of Belgium was 1,783.3 kcal per day, the actual ingested calorie was significantly low as 1,552.4 kcal, so that the risk of malnutrition was very high.9 As the malnutrition of the elderly in nursing homes could increase the outbreak of diseases and mortality risks, the actual intake which was less than half of distributed food or the cycle of checking their weight was closely related to malnutrition.10 There were significant correlations between malnutrition and specific contents of meal service such as the possibility of handling plates or lids in each meal, mass-delivery system, overall satisfaction, length of menu cycle, and the use of chinaware.11 Thus, this research was purposed to recognize the foodservice management performance of nursing homes in Korea and also the necessities of proper meal management for the elderly and hygiene/nutrition education.
MATERIALS AND METHODS
Research subject and methods
From July to August 2019, this study sent the questionnaires for understanding the foodservice management performance through mail and post to the total of 300 nursing homes registered in the Ministry of Health and Welfare, with no duty to hire dietitians as the number of foodservice recipients was less than 50. And after explaining the purpose of this study by telephone, the questionnaires were collected through mail or post. As a total of 87 questionnaires of 300 were collected, the return rate was 29%. Before the survey, the respondents were explained that their replies would be confidential and anonymous, and the results not be used for purposes other than this research. And they were asked to write a consent form.
Survey contents and composition
The questionnaire used for this study was written by referring to the research tool used for research targeting the welfare facilities for the elderly by Seo et al.12 ‘2019 Guidelines for the Centers for Children’s Foodservice Management by the Ministry of Food and Drug Safety,13 and the hygiene & nutrition management checklist for foodservice facilities shown in ‘2019 Guidelines for Foodservice Management Support Trial Operation of Social Welfare Facilities’.14 The questionnaire was largely composed of general aspects of nursing homes, general aspects of respondents, and foodservice management performance of nursing homes. The general aspects of nursing homes and respondents suggested region, number of residents, operation period, operation type, menu writer, the place for meals, and sex, age, position, academic background, work experience, hygiene education experience, and nutrition education experience of recipients as nominal scale. Regarding the foodservice management performance, a total of 33 items were divided into six categories and then questioned like six items of ‘foodservice facilities & environment’, six items of ‘personal hygiene’, seven items of ‘cooking process management’, three items of ‘food ingredients management’, two items of ‘washing & disinfection management’, and nine items of ‘nutrition management’. The Likert 5-Point Scale(1: very bad∼ 5: very good) was used for food service management performance.
Data analysis
The SPSS ver. 20.0 for Windows(Statistical Package for Social Science, SPSS Inc, Chicago, IL, USA)was used for statistical analysis. On top of calculating the frequency and percentage of general aspects of nursing homes and respondents, this study also calculated the standard deviation and the mean of each item of foodservice management performance. Also, to understand differences of mean foodservice performance following the matter of hygiene education and nutrition education, the t-test was conducted for each item and category.
results
General aspects of nursing homes and respondents.
The general aspects of nursing homes as the research subjects are shown inTable 1. In the number of residents in nursing homes, there were 21 nursing homeswith less than ten residents (24.1%), and 66 nursing homes with10-49 residents (75.9%). In the operation period of facilities, the nursing homes for 5-10 years were the most (32 places, 36.8%). In the operation type, the direct management (77 places, 88.5%)was more than consignment(10 places, 11.5%). Regarding the menus in use, most cases received them from the association of long-term care centres (31 places, 35.6%). There were 30 places (34.5%) using the menus written by dietitians in their own or other institutions, and also 24 places (27.6%) using the menus of local health centres. Regarding the place for meals, most cases (43 places, 49.4%) used a cafeteria mixed with the bed. In the case of drinking water, most nursing homes (67 places, 77.0%) used water purifiers.
The general aspects of respondents to the questionnaires sent to nursing homes are shown in Table 2. The questionnaires were mostly filled in by directors of facilities(n=70, 80.5%) or office managers (n=12, 13.8%). In the sex ratio of respondents, there were a bit more women (n=46, 52.9%) than men (n=41, 47.1%). In their age, the respondents in their 50s (n=31, 35.6%) were the most, which was followed by the 60s and 40s (n=20, 23.0%). In the academic background, the college graduates (n=39,44.8%)were the most. Regarding the work experience, the respondents with experiences for 5-10 years (n=27,31.0%)were the most. There were 57 respondents (65.5%) with hygiene education experience and 22 respondents (25.3%) with nutrition education experience.
Mean score of food management performance of nursing homes
Understanding the foodservice management performance of nursing homes in each category, the mean and standard deviation were shown inTable 3. The category showing the highest mean performance score of the total six categories was ‘foodservice facilities & environment’(4.33/5.0) while the category showing the lowest score was ‘cooking process management’(3.70/5.0). The mean foodservice management performance of the whole 33 items was 3.96.
Comparison of food management performance following the matter of hygiene education
The results of comparing the food management performance of nursing homes through t-test to see if there would be differences in mean score following the matter of hygiene education are shown in Table 4. In total five categories and 22 items of foodservice management, the case of receiving hygiene education showed a significantly higher mean performance score than the case without it (pEnglishhttp://ijcrr.com/abstract.php?article_id=3683http://ijcrr.com/article_html.php?did=3683
World Health Organization. Ageing and health. 2018 [cited 2021 Jan 12]. Available from: https://www.who.int/news-room/fact-sheets/detail/ageing-and-health.
Statistics Korea. Major population index. [updated 2019 Mar 28; cited 2021 Jan 12]. http://kosis.kr/statHtml/statHtml.do?orgId=101&tblId=DT_1BPA002&checkFlag=N. Korean.
Koohsari MJ, Nakaya T, Oka K. Activity-friendly built environments in a super-aged society, Japan: current challenges and toward a research agenda. Int J Environ Res Public Health 2018 Sep;15(9):1-9.
National Health Insurance Service. Homepage of Long-term Care Insurance for the Elderly. 2020. http://www.longtermcare.or.kr/npbs/index.jsp. Korean.
Hoffmann AT. Quality of life, food choice and meal patterns - field report of a practitioner. Ann Nutr Metab 2008;52:20–24.
Buccheri C, Mammina C, Giammanco S, Giammanco M, La Guardia M, Casuccio A, et al. Knowledge, attitudes and self-reported practices of food service staff in nursing homes and long-term care facilities. Food Control 2010 Oct;21(10):1367-73.
Levine WC, Smart JF, Archer DL, Bean NH, Tauxe RV. Foodborne disease outbreaks in nursing homes, 1975 through 1987. JAMA. 1991 Oct;266(15):2105–9.
Layton MC, Calliste SG, Gomez TM, Patton C, Brooks S. A mixed foodborne outbreak with Salmonella heidelberg and Campylobacter jejuni in a nursing home. Infect Control Hosp Epidemiol 1997 Feb;8(2):115–21.
Buckinx F, Allepaerts S, Paquot N, Reginster JY, de Cock C, Petermans J, et al. Energy and nutrient content of food served and consumed by nursing home residents. J Nutr Health Aging 2017;21(6):727-32.
Papparotto C, Bidoli E, Palese A. Risk factors associated with malnutrition in older adults living in Italian nursing homes: a cross-sectional study. Res Gerontol Nurs 2013;6(3):187-97.
Carrier N, Ouellet D, West GE. Nursing home food services linked with risk of malnutrition. Can J Diet Pract Res. 2007;68(1):14-20.
Seo JE, Kwon KI, Kim GH. Study on the actual conditions of institution foodservice management in the elderly welfare facilities by the employment of dietitians. Korean J Food Cook Sci 2019;35(2):216~25.
Korean Ministry of Food and Drug Safety. Guideline of Center For Children’s Foodservice Management. Cheongju: Korean Ministry of Food and Drug Safety Press; 2019. p.123-30. Korean.
Korean Ministry of Food and Drug Safety. Guidelines for trial operation of food management support for social welfare facilities. Cheongju: Korean Ministry of Food and Drug Safety Press; 2019. p.77-86. Korean.
Choi JH, Kim DH, Choi EH, Chung MJ, Lee HS, Lee MJ, et al. Assessment of foodservice management practices according to types of elderly foodservice facilities. J Korean Soc Food Sci Nutr 2019;48(4): 469-81.
Lee JE. Dietitians’ perception of importance about standards of foodservice management associated with long-term care hospital accreditation. J Korean Soc Food Sci Nutr 2015; 44(10):1558-66.
McCabe-Sellers BJ, Beattie SE. Food safety: emerging trends in foodborne illness surveillance and prevention. J Am Diet Assoc 2004;104(11):1708-17.
Rodríguez M, Valero A, Posada-Izquierdo GD, Carrasco E, Zurera G. Evaluation of food handler practices and microbiological status of ready-to-eat foods in long-term care facilities in the Andalusia region of Spain. J Food Prot 2011;74(9);1504-1512.
Church SM. The importance of food composition data in recipe analysis. Nutr Bull 2015;40(1):40–4.
Crogan N, Dupler AE, Short R, Heaton G. Food choice can improve nursing home resident meal service satisfaction and nutritional status. J Gerontol Nurs 2013;39(5):38-45.
Grieger JA, Nowson CA. Nutrient intake and plate waste from an Australian residential care facility. Eur J Clin Nutr 2007;61(5):655-63.
Schoner W. Salt abuse: the path to hypertension. Nat Med 2008;14(1):16-7.
Cummins RO. Recent changes in salt use and stroke mortality in England and Wales. Any help for the salt-hypertension debate? J Epidemiol Community Health 1983;37(1):25-8.
Kim JN, Park SY, Ahn SH, Kim HK. A Survey on the salt content of kindergarten lunch meals and meal providers` dietary attitude to sodium intake in Gyeonggi-do area. Korean J Community Nutr 2013;18(5):478-90.
Jung EJ, Kwon JS, Ahn SH, Son SM. Blood pressure, sodium intake and dietary behavior changes by session attendance on salt reduction education program for pre-hypertensive adults in a public health center. Korean J Community Nutr 2013;18(6):626-43.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareManagement of Multiple Gingival Recessions by Coronally Advanced Flap with and without Connective Tissue Graft: A Case Report
English1315Mohammad AlmagbolEnglishBackground: Gingival recession is the most common and undesirable condition of the gingiva and usually caused by improper tooth brushing technique. The techniques used for the root coverage are based on tissue displacement either by displacement flap or by subepithelial connective tissue grafting (SCTG).
Case Presentation: In the present case report, a 38 years old, healthy male patient reported to the clinic with bilateral class I gingival recession on the buccal aspect of maxillary canines and premolars. The patient used a medium bristle toothbrush with horizontal strokes for oral hygiene maintenance. The depth of gingival recession was measured 2-3 mm from the cementoenamel junction (CEJ). After scaling and root planning correct brushing technique was advised to the patient. The main objective of the treatment was to cover the exposed root surfaces to improve esthetics and reduce dentinal hypersensitivity. According to the treatment plan, the 1stquadrant was treated by a coronally advanced flap (CAF) and the 2nd quadrant by CAF+SCTG.
Results and Conclusion: One-year post-operative evaluation revealed uneventful healing at both surgical sites. Almost 80 % and 100% root coverage was reported at the 1st and 2nd quadrant respectively. In the present case, CAF+SCTG showed a favourable outcome for root coverage and hypersensitivity compared to CAF alone.
EnglishGingival recession, Coronally advanced flap, Connective tissue graft, Root coverage procedure, Dentinal hypersensitivityINTRODUCTION
Gingival recession is the most common and undesirable condition of the gingiva with a high prevalence rate in the adult population. More than 50 % of the population has one or more sites with a gingival recession of 1 mm or more.1 Furthermore, improper tooth brushing is one of the important etiological factors for gingival recession.2 Patient education and sustained motivation about brushing technique is the key to the long-term success of the management for traumatic gingival recession.3 Even though the gingival recession may occur without any symptoms it can give rise to pain from exposed dentin, patient concern about tooth loss, poor esthetics and inability to perform proper oral hygiene procedures or development of root caries.4 The recessions can act as a local contributing factor for the initiation and progression of periodontal inflammation because the alteration in gingival morphology leads to greater plaque accumulation.
The widely used clinical classification for the gingival recession was proposed by Miller in 1985.5 The classification is based on the amount of periodontal tissue loss and prognosis of the case. The greater the amount of periodontal tissue loss, the worst will be the prognosis related to the root overage procedure. The techniques used for root coverage are based on tissue displacement whether by displacement flap or by free soft tissue grafting. Several modifications to the conventional techniques have been developed in an attempt to obtain optimal root coverage and better esthetic integration. The present case report aimed to describe the management of multiple gingival recessions by coronally advanced flap with and without connective tissue graft, as well as to compare the success predictability of both techniques.
CASE REPORT
Thirty-eight years old, male patient was referred to the Department of Periodontology, College of Dentistry at King Khalid University with a complaint of the sensitive tooth to cold and long tooth display while smiling. Complete clinical examination revealed bilateral class I gingival recession, 2-3 mm in depth from CEJ, on the buccal aspect of maxillary canines and premolars (Figure 1a). Moreover, no significant findings were recorded on radiographic examination. The patient was using a medium bristle toothbrush with horizontal strokes for oral hygiene maintenance. The patient was instructed to use Modified Stillman’s technique to prevent a progressive recession. Scaling and root planing was done to eliminate the local etiological factors. After re-evaluation, it was decided to treat the quadrants by Coronally Advanced Flap (CAF) with and without Connective tissue graft depending on the availability of keratinized tissue in each quadrant.
It was decided to treat the 1st quadrant by CAF alone, because of the presence of an adequate zone of keratinized tissue and attached gingiva. Following administering infiltration local anaesthesia, the surgical site was prepared according to the technique described by Allen & Miller (figure 1b).6 Initial incisions comprised of two oblique divergent bevelled incisions directed apically in the alveolar mucosa, by using no.15 blade at the mesial and distal line angles of the teeth with gingival recession (Figure 1b). After intrasulcular incisions, cross sub-marginal and interproximal incisions preserved the interdental surgical papillae which were de-epithelized. A split-full-split approach was used to elevate the flap. A passive coronal mobilization of flap was achieved at the level of the cemento-enamel junction by sharp apical dissection. The flap was secured in coronal position by using a sling and simple interrupted 4-0 Vicryl suture material (Figure 1c).
For the 2nd quadrant, it was decided to use CTG along with CAF for the management of recession. This technique was selected due to the availability of inadequate width of attached gingiva with the area of interest (figure 1a). Following the administration of local anaesthesia (infiltration), the recipient site was prepared according to the technique described by Allen & Miller.6 Recipient site was prepared similarly as described in the 1st quadrant operation. The recipient site was covered with a moist gauze piece to avoid dehydration. A tinfoil template was used to transfer measurements on the palate for the donor tissue. A similar size of subepithelial connective tissue graft was harvested by the trap door approach from the right palatal vault, 10 mm away from the gingival margin and mesial to the first maxillary molar. The harvested graft was kept in a moist gauge piece and inspected for size and thickness. Excess connective tissue and fat were carefully removed with the help of Castroviejo scissor. The graft was placed on the recipient site, stretched and stabilized with the help of a 4-0 Vicryl suture (Figure 2b). The flap was secured in coronal position by sling and simple interrupted suture using 4-0 Vicryl suture (Figure 2c).
Post-operative medications and instructions were prescribed to the patient and directed to avoid brushing at the surgical site for at least two weeks. Follow up on the tenth day revealed signs of graft acceptance in the 2nd quadrant and uneventful healing of the flap in the 1st quadrant. At the same time, sutures were removed from the donor as well as recipient site in quadrant 1 and 2 respectively. Oral hygiene instructions were reinforced and the patient was kept under regular follow-up. One year follow-up showed that the entire graft was accepted with complete root coverage (100%) in the 2nd quadrant compared to partial (80%) in the 1st quadrant (Figure 1d and 2d). Besides, the patient reported a marked reduction in dentinal hypersensitivity as compared to baseline in both quadrants.
DISCUSSION
The present case report evaluated and compared the clinical efficacy of CAF alone and in combination with SCTG to cover the exposed root surfaces of Miller Class I. The success of surgical procedures for root coverage depends on several factors, such as elimination and/or control of the aetiology of gingival recession, evaluations of the interproximal bone level and choice for the most appropriate surgical technique.5 In 1985, Langer and Langer described a technique of subepithelial connective tissue graft for root coverage in the treatment of recessions at single or multiple areas.7 Although all periodontal plastic surgical procedures are e?ective in reducing the extent of the exposed root surface, with a concomitant gain in clinical attachment level (CAL) and width of keratinized tissue but from an aesthetic and subjective point of view, complete root coverage represents the desired treatment goal.
Several techniques have been introduced in the literature such as coronally positioned flap, laterally displaced flap, and the combination of coronally positioned flap with free gingival graft. The use of subepithelial Connective tissue graft was disseminated; assuring the obtainment of excellent results in areas with localized root exposure.8 The objective of mucogingival plastic surgeries was the successful coverage of exposed root surfaces, assuming patient’s esthetic and function. Many surgical techniques have been evaluated in an attempt to achieve a more effective and predictable root recession coverage while minimizing surgical complications.9 The only limiting criterion in utilizing a coronally advanced flap is the need for a band of at least 1mm of keratinized tissue.10 This rate of long-term successful outcomes of the treatment was similar to that previously reported in the literature for other root coverage procedures.10,11 Some clinical and biological advantages of the technique adopted in the present study might be related to the split–full–split-flap elevation as already suggested by Zucchelli & de Sanctis.12 the split-thickness elevation at the level of the surgical papilla guarantees anchorage and blood supply in the inter-proximal areas mesial and distal to the root exposure; the full-thickness portion, by including the periosteum, confers more thickness, and thus better opportunity to achieve root coverage.
The predictability of the SCTG procedure was excellent. The main advantage of this procedure is that it provides a good blood supply to the graft and, therefore, has very good predictability of success, and provides gingival colour match and esthetics. However, the disadvantages of this technique include technically sensitivity and increase morbidity compared to CAF because of the second surgical site.
CONCLUSION
In the present case report, CAF along with SCTG showed the best outcome for root coverage and a significant increase in the width of the attached gingiva. In addition to root coverage with CAF alone, CAF+SCTG showed good results in terms of colour matching and root coverage. Both surgical procedures resulted in significant relief in dentinal hypersensitivity. A good clinical diagnosis, the width of keratinized gingiva and cooperation of the patient plays a vital role in decision making and expected outcomes.
Acknowledgement: The author has nothing to acknowledge
Conflict of interest: Nothing to declare
Financial support: No financial funding
Englishhttp://ijcrr.com/abstract.php?article_id=3684http://ijcrr.com/article_html.php?did=36841. Kassab M, Cohen R. The aetiology and prevalence of gingival recession. J Am Dent Assoc 2003;134:220-225.
2. Khocht A, Simon G, Person P, Denepitiya JL. Gingival recession concerning the history of hard toothbrush use. J Periodontol 1993;64:900-905.
3. Baelum V, Fejerskov O, Karring T. Oral hygiene, gingivitis and periodontal breakdown in adult Tanzanians. J Periodontal Res 1986;21:221-232.
4. Zucchelli G, Cesari C, Amore C, Montebugnoli L, De Sanctis M. Laterally moved coronally advanced flap: a modified surgical approach for isolated recession-type defects. J Periodontol 2004;75:1734-1741.
5. Miller Jr. PD. A classification of marginal tissue recession. Int J Periodon Restor Dent 1985;5:8-13.
6. Allen EP, Miller PD Jr. Coronal positioning of existing gingiva: Short term results in the treatment of shallow marginal tissue recession. J Periodontol 1989;60:316-319.
7. Bouchard P, Malet J, Borghetti A. Decision-making in aesthetics: root coverage revisited. Periodontol 2000;2001:97-120.
8. Langer B, Langer L. Subepithelial Connective Tissue Graft Technique for Root Coverage. J Periodontol. 1985;56:715-20.
9. Alghamdi H, Babay N, Sukumaran A.Surgical management of gingival recession: A clinical update. Saudi Dental J. 2009;21:83-94.
10. Wennstrom JL, Zucchelli G. Increased gingival dimensions. A significant factor for the successful outcome of root coverage procedures? A 2-year prospective clinical study. J Clin Period 1996;23:770-7.
11. Zucchelli G, Cesari C, Amore C, Monte-Bagnoli L, de Sanctis M. Laterally moved coronally advanced flap: a modified surgical approach for isolated recession-type defects. J Periodon 2004;75:1734-1741.
12. Zucchelli G, de Sanctis M. Treatment of multiple recession-type defects in patients with esthetic demands. J Periodontol 2000;71:1506-1514.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareSpecific Speed and Agility Drills to Improve the Performance of Field Hockey Players: An Experimental Study
English1621Neha Ingale ChaudharyEnglish Muzahid SheikhEnglish Milind KahileEnglish Sachin ChaudharyEnglish Vasant GawandeEnglishIntroduction: Field hockey is a popular sport across the world and is a national sport of India. The world of field hockey is constantly mounting, and thus a thorough analysis of skilled performance to evaluate its functionality is necessary. Many studies have stated the continuous wear and tear phenomena in structure and functions of the musculoskeletal systems and posture due to overload in the players.
Objective: This study focuses on improving the speed and agility of the players which eventually reduces the risk of injuries and thereby enhancing a better performance.
Methods: 20 professional male field hockey players aged 18-25 yrs. were purposively selected as potential participants for this study. All the subjects were evaluated using Illinois Agility Run Test, Hexagonal Obstacle Agility Test and Shuttle Run Test pre and 6 weeks post speed and agility training programme.
Results: The paired t-test was used to analyze the pre-post results which found to be significantly different, denoting that the time consumed for completion of the parametric tests was significantly improved (less time consuming) than that of before speed and agility training.
Conclusion: So, this study concludes that speed and agility training along with an effective exercise programme, improves the quality of the game in field hockey players.
EnglishSpeed agility training, Illinois Agility Run Test, Hexagonal Obstacle Agility Test, Shuttle Run Test, field hockey, Weave In – Weave Out, Box drill, Mini shuttle, Super shuttle, SlalomINTRODUCTION
Field hockey is a popular sport across the world and is a national sport of India. The world of field hockey is constantly mounting, and thus a thorough analysis of skilled performance to evaluate its functionality is necessary. Many studies have stated the continuous wear and tear phenomena in structure and functions of the musculoskeletal systems and posture due to overload in the players. On grass, watered turf, artificial turf or synthetic ground, as well as indoors, the game can be played. Every team plays with ten players on the field and a goalkeeper. Sticks made of wood, carbon fibre, fibreglass, or a mixture is used by players. The hockey stick's length is dependent on the actual height of the player.1,2
Field hockey is a team sport to put the ball into the opponent’s goal using hockey sticks. A field hockey match consists of two halves during match and the team of 11 players who score more goals wins. Field hockey games are played outdoors, on a 91 × 55 m field covered with artificial grass. The goalkeeper and defenders protect their own goal; the forwards try to score goals and the midfielders create offensive actions and assist the defenders.3,4
A field player during a field hockey game runs an averagely of 10 km, maximum of which is by jogging or walking and only a shorter one is by sprints. The forwards are the fastest, and defenders are the slowest players. An average HR for a field hockey player is 135 bpm, and there are no significant differences in HR between the formations. The main technical elements of field hockey are dribbling, passing and shooting.1
Being able to run fast is not as effective as chasing faster the ball with a stick. Being able to turn and change direction is easier than doing it with a stick to chase the ball. Speed and agility training will provide improvement in the overall aspects of techniques of a field hockey player. Agility refers to the ability to quickly stop and re-start motion.
Agility is defined as an effective and quick coupling of braking, changing directions and accelerating again while maintaining motor control in either a vertical/horizontal direction.2 Speed is defined as the rate at which an object moves or how fast an object moves. Performance is defined as how you do something, how well you do it, and how much work you put into it.5
Agility is fundamentally important to sports performance for 3 reasons;
The agility skills build up a strong neuromuscular control and thus help ineffective performance in sports.
The injury risk decreases due to effective training of movement mechanics by agility and speed drills training.
The agility drills will enhance the proactive offensive and reactive defence mechanisms by swiftly altering the directions.
Speed training is a neuromuscular activity and thus requires athletes to perform these types of activities. Speed and Agility are two of the most important physical factors for a professional field hockey player to improve performance.6,7
NEED FOR THE STUDY
Due to repetitive use, the highly trained muscles become hyperactive and shortened.3 In the infield of hockey, the player needs to do adapt extensive postures such as bending sideways and forward, keeping one upper limb in external rotation and another in internal rotation. There are many ways to hit a ball in hockey such as scoop, drag-flick, drive, slap shot as well as push.1,3
International hockey is a highly competitive game. Winning and losing is a matter of the application of skills and hard work. It has been observed that the national team despite the great hard work has not been able to consistently maintain the top position in international hockey. There is a need to improve the basic and special skills. Many researchers have explained the role of repetitive strain and of overload-induced changes in field hockey players which caused various postural and structural as well as functional impairments in them.3-6 This study focuses on improving the speed and agility of the players which eventually reduces the risk of injuries and thereby enhancing a better performance.7
BIOMECHANICS
It focuses on 3 main areas:
Posture
Leg action
Arm action
Biological and biomechanical characteristics of field hockey
Due to alterations in the speed, the vital parameters do not significantly change in field hockey players.8
It requires a swift interchange of lumbar flexion, extension, side flexion, rotation, one arm in external and other in external rotation with consistent elbow flexion-extension interplay to pass shots in a variety of forms like flicks, drives, pushes, scoops, and slap shots.9
The characteristic and effective posturing is attained as of feet in stride standing and terminal flexion of the lumbar spine (Figure 1 and 2).10,11
These attainment pf postures on longer and repetitive period may cause high strain and overload on intervertebral discs, spine and pelvis structures. This results in micro-tears to annulus fibrosis with resultant changes in spine articulature.6,12,13
MATERIALS AND METHODS
The Experimental study aimed at examining the effect of Speed and Agility drills to improve the performance of field hockey players of the field hockey club Nagpur. with objective as to examine the effect of Speed and Agility drills to increase the speed and agility skills, to examine the effect of Speed and Agility drills to reduce the risk of injury and to examine the effect of Speed and Agility drills to improve the overall performance.
Information regarding the procedure was provided to each player. The due consent was taken. 20 professional male field hockey players (age 18-25 yrs.) without any history o injury or any systemic illness, were purposively selected as potential participants for this study. Each subject signed informed consent before taking part in the study.
All the subjects were evaluated using Illinois Agility Run Test, Hexagonal Obstacle Agility Test and Shuttle Run Test. The scores were documented as pre-test values. Materials used for the study were agility cones, a stopwatch and a hockey field. The study was conducted for 6 weeks (3 sessions/week).14
Procedure
All the players were asked to perform the Speed and Agility drills with clear explanations and brief instructions with initial 10 minutes of the warm up period. Post-test values of the Agility tests and Shuttle Run test are taken at the end of the 6th week and documented for statistical analysis. Initially, the players were introduced to a warm-up session of 15 minutes duration which involves;
2 laps of jogging and
self-stretching upper limb, back and lower limb muscles (Figure 3).15
This is followed by the Speed and Agility drills. The players end up the session with a cool-down period of 10 minutes.16
The drills are as follows:
Weave In – Weave Out
Box drill
Mini shuttle
Super shuttle
Slalom
Prescription:
Mode - Aerobic
Frequency - 3 sessions per week (with 1 set per day)
Repetitions - 3 times
Duration - 45 minutes (per day)
Intensity - Initially 25 seconds each drill on average (varies
according to individual’s ability).
Then gradually reduces.
Illinois Agility Run Test
Equipment Required ( Figure 4):
Flat nonslip surface
Marking cones
Stopwatch
Procedure for illinois agility run test
The total length of the course is 10 meters and the distance between the start and finish points is 5 meters.
Four cones are used to denote the start, finish and each of the turning points.
Another four cones are placed down the centre equidistant from each other.
The distance between every two cones is 3.3 meters. The subject should stand in bent stride standing.
On the 'Go' command, and the athlete gets up and runs as fast as he can in the direction indicated, without knocking the cones over, to the finish line. The time from start to finish is recorded by stopwatch in seconds ( Table 1).
Hexagonal Obstacle Agility Test
Equipment Required:
Flat nonslip surface
Marking cones
Stopwatch
Procedure for hexagonal obstacle agility test:
The Hexagonal Obstacle Test is conducted as follows:
The athlete stands in the middle of the hexagon, facing line A at all times throughout the test the athlete is to face line A
On the command GO, the athlete jumps with both feet over line B and back to the middle, then over line C and back to the middle, then line D and so on.
When the athlete jumps over line A and back to the middle this counts as one circuit.
Three circuits should be completed without interval in between and the time recorded between the start and finish of the task in seconds ( Table 2 and figure 5).
Equipment Required:
Two marked parallel lines 30 feet apart
Wooden blocks
Stopwatch
Procedure for shuttle run test:
The athlete is required to sprint from the starting line to pick up a block and then place it on the ground behind the starting line.
The athlete then sprints to pick up the second block and turns to sprint over the starting line ( Figure 5)
The stopwatch is started on the command "Go" and stopped when the athlete's chest crosses the line
An attempt is not counted if the block is dropped rather than placed on the floor. Also, the block must be placed behind and not on the line
Repeat the test 3 times Record the best time.
Speed and Agility Drills
Weave In – Weave Out 17
Place 4 markers/cones straight 3m apart.
Place another marker between each cone 3m to the left.
Sprint from one marker to the next and bend down to reach the cone with hands. Quick side steps should be taken (Figure 6).
Box Drill:17
Use 4 cones/markers to mark out a square approximately 5m by 5m.
Place a cone in the centre of the square to start.
Each corner should be numbered.
Sprint to the corner named and return to the middle (Figure 7).
Mini Shuttle:17
2 markers/cones are placed 20m apart. Place a mark in the middle 3m to the side.
Starting from the middle marker sprint to one end (10m), turn and immediately sprint to the other end (20m) and then back to the start (10m).
Turn on a different foot at each marker and try to touch the ground with the hand (Figure 8).
Super Shuttle:17
a series of cones are placed in a cross formation.
Run backwards to the centre cone, sidestep to the right cone, sidestep back to the centre cone still facing the same way.
At the centre, the cone turns and sprint forward to the end mark. Then run back to the centre cone, sidestep to the left, sidestep back to the centre, then turn and sprint back to the start ( Figure 9).
Slalom: 17
Place 10 shuttles in a line 5m apart.
Weave in and out as fast as possible and walk back to the start.
This drill is to improve speed ( Figure 10).
Paired t-test is used to compare the pre and post-test values of Agility tests and Speed tests.
RESULTS
In the Illinois agility run test, the comparison of the pre and post-training data was done. On application of paired t-test, with p Englishhttp://ijcrr.com/abstract.php?article_id=3685http://ijcrr.com/article_html.php?did=3685
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Kawa?ek K, Garsztka T. An analysis of muscle balance in professional field hockey players. Trends Sport Sci.2013;4(20):181-187.
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Konarski J. Characteristics of chosen parameters of external and internal loads in Eastern European high-level field hockey players. J Hum Sport Exerc 2010;5(1):43-58.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareInfertility, Assisted Reproductive Technology and Motherhood in the Context of Indian Society
English2225Gitika BorahEnglish Mouchumi KalitaEnglishIntroduction: In Indian societies, infertility has been considered a disease even after developing several alternative ways to have a child in the field of medical science. Despite knowing the fact that the inability to have a child may come from both husband’s side or wife’s side, most of the time it is the woman or wife who is considered responsible and blamed for infertility. Apart from a willingness to have a child, various other reasons like familial pressure, societal pressure, stigmatising a woman for not being able to conceive a baby, etc. compel a woman to take help of Assisted Reproductive Technologies (ARTs).
Objective: This paper is an endeavour to understand the issue of infertility in the context of Indian society along with the impact of ARTs on women.
Methods: The present study follows a descriptive analytical method and the data are collected from secondary sources like journal and newspaper articles and government reports etc.
Results: It was found that infertile women have to face a lot of discrimination and abuse. Infertility is a taboo in Indian society. Therefore, women are ready to go to any extent to deal with such taboo and stigmas. ARTs are very costly and it’s a very long process. It also has certain health-related side effects. The societal pressure is such that women go through all these difficulties to bear a child.
Conclusion: It is high time to destigmatise childlessness and be more aware of the rights of individual human beings. The women should be informed about the benefits and side effects of ARTs before undergoing such treatment.
EnglishAssisted Reproductive Technologies (ARTs), Infertility, Women, Societal pressure, MotherhoodIntroduction
Infertility is projected as the new/latest ‘disease’ and provides the reason for expensive treatment for an otherwise healthy body. It has been seen that even though both men and women are affected by infertility ‘it is often women, particularly in developing countries, that bear the sole blame for childless marriages.[i] The stigma that is connected with infertile women in Indian society force women to take help of Assisted Reproductive Technologies (ARTs) irrespective of the health risk and cost that comes from the use of such technology. Hence infertile couples found new rays of hope from the time when the world’s first test-tube baby came into this world. It has been seen that subsequently, ‘reproductive technology has become a lucrative industry. Women are viewed as producers of babies and treated as consumers in this market. Infertility is no more a ‘private matter’; it has become a ‘public matter’ and has largely been medicalised.[ii]
It has been found that available literature presents various consequences of infertility like ‘anxiety, depression, lowered life satisfaction, guilt, helplessness, reduced job performance, marital problems, dissolution of marriage and abandonment, economic hardship, loss of social status, social stigma, isolation and physical violence etc.[iii] This paper is an attempt to understand the infertility in the context of Indian society and the impact of assisted reproductive technologies on women.
Methodology and Data Sources
The data for this paper have been collected from various secondary sources like books, journals, articles published in various newspapers, government reports, unpublished research works and other internet sources. This paper mainly follows the descriptive-analytical method of study.
Understanding Infertility
Infertility can be analysed from a variety of perspectives. It can be seen as a disease from a medical science perspective that can be cured through treatment. In a society, it is stigmatised and women born the burden of the stigma, although man and woman both can be the reason behind infertility. Infertility deprives a couple not only of personal happiness for not being able to have a child, but it has also social consequences, particularly in developing countries, and it deprives couples of societal happiness too[iv] Indian peoples have been experiencing various kinds of social traditions and such traditions are linked with infertility too.[v]
“Having a child is the couple’s decision, without outside interference. However, in most developing countries, infertility is not a personal problem for the couple. The parents, relatives, neighbours and probably the entire community around the infertile couple are anxious and concerned.”[vi]
“Infertility is projected as the new/latest ‘disease’ and provides the reason for expensive treatment for an otherwise healthy body. Also, IVF is incorrectly publicized as an established and successful therapy rather than as an experimental and largely ‘research and development-oriented business’.”[vii]
Assisted reproductive technologies can be considered as attempts at a ‘quick technological fix’ which are often applied without ameliorating the underlying problem of infertility. Apart from that, the failure to address underlying macro-epidemiological causes of infertility like environmental pollution, workplace, toxicity, iatrogenic factors and untreated or undiagnosed pelvic inflammatory diseases indicates the politics behind scientific research.[viii]
Assisted Reproductive Technology
The term "Assisted Reproductive Technologies" (ARTs) encompasses various procedures, ranging from the relatively simple intrauterine insemination (IUI) to variants of in-vitro fertilisation and embryo transfer (IVF-ET), also referred to as IVF and more commonly known as "test-tube baby technology”.[ix] It has been seen that such technologies have been developing by leaps and bounds since the latter half of the 20th century. These technologies have also brought changes to how society views issues like pregnancy, reproduction and motherhood.[x] Infertile couples of both developed and developing countries have been benefited from such technologies. Moreover, the growing economic conditions also help such couples to use ARTs and afford such sophisticated treatments. Therefore, a rise in terms of clinics that provides such treatments can also be seen. India has probably recorded the biggest growth in ART centres and the number of ART cycles being performed in our country has steadily risen over the last decade.[xi]
In July 1987, the first documented IVF baby came to this world, named Louise Brown. In October 1987 itself, Subhas Mukherjee from Kolkata declared the birth of the first IVF baby of India and the second one in the world, named Durga, but his claim was rejected as the case was not scientifically documented. The first scientifically documented IVF baby of India, Harsha Chawla, was born in 1986 in a collaborative government research programme of the National Institute for Research in Reproduction (NIRR), the Indian Council of Medical Research's (ICMR) and the King Edward Memorial Hospital, a municipal hospital in Mumbai.[xii]
Motherhood and Societal Pressure
Motherhood is seen as an integral part of a woman’s life in Indian societies. Women are always seen as caregivers and the bearing and rearing of children are considered to be their responsibility. The societal norms are constructed in such a way that to be a perfect woman one needs to be fertile enough to give birth to a baby. In Indian society, a newlywed couple is put under tremendous pressure to welcome a baby to carry the family name forward. This practice is slowly fading in the present day. Infertility or inability to conceive a child is a stigma; women are ridiculed and put under a lot of pressure to adopt any means to have a biological child. Women who are unable to conceive a child are refrained from participating in any auspicious occasions. Motherhood is seen as an essence of a woman in our societies. It is internalised by women to such an extent that the women feel guilty for not being able to conceive.[xiii] Women and men both can be the reason behind infertility. But it is the woman who has to take the whole burden and guilt of being infertile. Several myths associated with infertility disturb and humiliates the life of the woman in Indian society. It is believed by many people that infertility is caused by past misdeeds; it is a curse or punishment given by God.[xiv]
In Indian societies, infertility is largely associated with women. The social pressure a woman faces for not being able to conceive is tremendous. The women are isolated, abused and humiliated. They are often not allowed to participate in auspicious ceremonies. The stigma associated with infertility is such that sometimes the women face physical violence and abused by their husbands and the in-law’s family. Even sometimes the husband disowns the wife for not being able to give birth and remarries. The social pressure not only impacts the mental and emotional health of the couple but also on their social life. This pressure makes them use every possible way to have a child. The poor and the less educated section of people initially seek help from ayurvedic or homoeopathic remedies as these are comparatively cheap. If these measures fail then they took help from the allopathic doctors. Assisted Reproductive Technologies are very costly and it takes a long period to show results.
Impact of Assisted Reproductive Technology on the lives of women
Talking about infertility is still a taboo in India; therefore, the medical measure to deal with this problem is also less talked about. But things are gradually changing with the advancement of science and technology and the spread of education among the people. The popularity of Assisted Reproductive Technology is increasing as people want to have a biological child rather than having an adopted child. The impact of these Assisted Reproductive Technologies on the lives of women is manifold. These kinds of treatments have some health-related side effects. The whole process of ART treatment is very long and therefore needs patience on the part of the patients. Most women find it “mentally exhausting”, “tiring” and “frustrating”. The work-life, as well as the social life of the couples, get disrupted because of the “frequent visits to the clinic”. The ART clinics are mostly situated in the big cities; therefore, the patients from other cities need to travel a long distance to get the treatment.[xv] Infertility treatment is very expensive, so a lot of families cannot even afford it. In India, women are mostly blamed for infertility and in many instances, the cost of the treatment is borne by the family of the girl.[xvi]
Conclusion
Motherhood is seen as a great responsibility on the part of women in Indian societies. The role of women has been largely confined to bearing and rearing children for very long. Although with the advancement of education women have become an active participant in all the fields be it economics, politics, business, health or sports; even today the significance of a woman’s life is associated with the ability to give birth. Women without children are looked down upon in our societies. It is mostly the women who bear the blame for infertility. They are excluded from auspicious ceremonies, abused, humiliated and often threatened that their husbands will remarry. The stigma associated with infertility is such that the women are ready to go to any extent to have a biological child. This is one of the reasons behind mushrooming growth of ART clinics in the country. The treatment for ARTs is very expensive and painful for some women. The medication and treatment sometimes lead to other health issues. But women should have the right to know about the repercussions of taking help from Assisted Reproductive Technology before going through such treatment. ART service providers should inform them about the pros and cons of taking the help of such technologies. Moreover, societies should be liberal enough to not stigmatise women who are incapable to conceive a baby. Apart from this adoption should be considered as a viable alternative to wiping out the soreness of childlessness.
Acknowledgement: The 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 which the literature for this article has been reviewed and discussed.
Source of Funding: We hereby declared that the work done in the Article was self-funded
Conflict of Interest: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=3686http://ijcrr.com/article_html.php?did=3686
Mukherjee M, Nadimipally SB. Assisted Reproductive Technologies in India. Development, Palgrave Macmillan;Society for International Development 2006; 49(4), pages 128-134.
Varada M. Infertility, Women and Assisted Reproductive Technologies: An Exploratory Study in Pune, India. Ind J Ged Stud 2011;18 (1):1-26.
Varada, M. Infertility, Women and Assisted Reproductive Technologies : An Exploratory Study in Pune, India. Ind J Ged Stud 2011; 18 (1) 1-26.
Forooshany S, Yazdkhasti F, Hajataghaie SS, Esfahani MH. Infertile Individuals’ Marital Relationship Status, Happiness, and Mental Health: A Causal Model. Int J Fertil Steril 2014; 8(3): 315–324.
Ranjan A., Kumar D. & Shinde P. Pre-Conception and Pre-Natal Diagnostic Techniques Act: Knowledge and Attitude of Students of Commerce College in Rajasthan. Int J Curr Res Rev. 2020;12 (20) 148-151.
[vi]Indian Council of Medical Research. ICMR bulletin, New Delhi 2000..
[vii]Mukherjee M., Nadimipally S. B., & Springer Link (Online service). Assisted Reproductive Technologies in India 2006.
[viii] Mukherjee M. & Nadimipally S. Assisted Reproductive Technologies in India, Society for International Development 2006; 49 (4)128–134.
[ix]Sama Team. Assisted Reproductive Technologies in India: Implications for Women. Eco Polit Week. 2007; 42 (23) 2184-2189.
[x]Sama T. Assisted Reproductive Technologies in India: Implications for Women. Eco Polit Week. 2007; 42 (23) 2184-2189.
[xi]Malhotra N, Pai R, Pai HD. Assisted reproductive technology in India: A 3 year retrospective data analysis. J Hum Reprod Sci. 2013; 6 (4) 235.
[xii]Sama T. Assisted Reproductive Technologies in India: Implications for Women. Eco Polit Week. 2007; 42 (23) 2184-2189.
[xiii]Sama T. Assisted Reproductive Technologies in India: Implications for Women. Eco Polit Week. 2007; 42 (23) 2184-2189.
[xiv]Malpani A. The Right and The Plight of the Infertile Couple in India. Available from https://www.contemporaryobgyn.net/view/right-and-plight-infertile-couple-india, 2011.
[xv]Sama T. Assisted Reproductive Technologies in India: Implications for Women. Eco Polit Week. 2007; 42 (23) 2184-2189.
[xvi]Sheoran P, Sarin J. Infertility in India: social, religion and cultural influence. Int J Reprod, Contrac, Obstet Gynec. 2015; 1783-1788.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareEffectiveness of Multidirectional Wobble Board Lateral Step Up Exercise and Unidirectional Wobble Board Lateral Step Up Exercise on Joint Position Sense in OA Knee
English2632K. KotteeswaranEnglish Sowmya M.V.English V. MeenaEnglishBackground: Osteoarthrosis (OA) is defined as a degenerative condition of the synovial joints. OA of the knee is ranked as one of the most significant causes of disability among the elders. It is a common disorder of cartilage degradation, synovial inflammation, osteophyte formation, thinning of joint space and subchondral sclerosis.
Methods: 219 participants were allocated into three groups multidirectional wobble board lateral step-up exercise group (MD), unidirectional wobble board lateral step-up exercise group (UD) and control group. All the participants’ basic subjective data, clinical measurements including the age, gender, body mass index (BMI) and joint position sense were measured. Data were analyzed with a paired t-test, unpaired t-test and ANOVA.
Results: This study shows both the unidirectional wobble board exercise group(UD) and multidirectional wobble board exercise group(MD) showed a better reduction in mean test angle of joint position sense in OA knee participants than the control group but multidirectional wobble board exercise group(MD) was better than unidirectional wobble board exercise group (UD). The longer 4 weeks duration was more beneficial than the shorter 2 weeks of weight-bearing wobble board protocol.
Conclusion: This study proved that the multidirectional wobble board lateral step-up exercise is more beneficial than unidirectional wobble board lateral step-up exercise in OA Knee.
EnglishOsteoarthrosis, BMI, Multidirectional wobble board, Unidirectional wobble board, Lateral step-up, ProprioceptionINTRODUCTION
Osteoarthrosis (OA) is defined as a degenerative condition of the synovial joints. OA of the knee is ranked as one of the most significant causes of disability among the elders.1,2 Osteoarthrosis is a heterogeneous condition that will cause symptoms in the joint and are involved in damaging the integrity of the articular cartilage and bone at the margins of the joint.3 OA in the knee and hip is now ranked as the 11th leading cause for disability as per the global burden of disease study.4 OA is diagnosed as per the clinical symptom which exhibits eburnation, more wear and tear due to repeated loading leading to restrict ROM and pain of knee joint 5. The second risk factor for OA knee is the BMI of the individual.6 This is because of the joint overloading and inflammation-induced due to adiposity.7 It is a common disorder of cartilage degradation, synovial inflammation, osteophyte formation, thinning of joint space and subchondral sclerosis.8,9
Worldwide estimation reported that more than 100 million people suffer from OA, and it was clinically one of the leading causes of disability.10 The prevalence rate for symptomatic OA worldwide is estimated to be 9.6% in male and double in the female which is around 18%.11 In India due to reduced physical activity majority of the population will increase the risk of early occurrence of OA knee. The prevalence of osteoarthrosis of the knee was 21.6% among women in the age group between 30-60 years. Prevalence was higher in menopausal women due to hormonal changes. So clinically men had a lower risk of OA knee than women. In India, the prevalence rate is estimated to be 17–60.6 %.12
The knee undergoes many alterations of force pattern in the muscle biomechanics during the daily event.13 Biomechanically increased obesity and inactive physical activity are the risk factors for the prevalence of OA knee.14 OA knee creates a burden on future health problems among the Indian population in modern health scenario. The female population other than their age and obesity are susceptible to high risk due to other factors like menopause, genetics, poor diet, joint overuse and muscle weakness.15
The management for OA includes Ultrasound therapy,16 interferential therapy, 17 Neuromuscular electrical stimulation (NMES),18 Laser and acupuncture19, Deep heat (microwave diathermy)20, static stretching.21 The recent research has found open kinematic chain exercise and closed kinematic chain exercise is best for improving the muscle strength of the quadriceps muscle.22 The Population who does not have any kind of injury to the joint should do exercise regularly to prevent degeneration of weight-bearing joints,23 aerobic exercises,24 isometric exercises,25 Resistance strength training,26 Wobble boards,27,28 Manual therapy, exercise and electrical dry needling techniques,29 massage therapy.30 Non-steroidal anti-inflammatory drugs, hyaluronic acid, Total knee replacement.31
Electrogoniometer (EGM) is a flexible lightweight tool that is reliable for measuring static knee joint angles in supine, sitting and standing positions. Electrogoniometer is an easy non-invasive and cheap method to assess and is considered as a precise way to assess movement capability. It is also proved that the reliability of this instrument is high.32 The advantages of Electrogoniometer are stable, precise, accurate and repeatable in performance. The universal goniometer is easy to be employed, it can be used in the clinical evaluation of patients. still, the electro-goniometer is more accurate and hence it is used in laboratory studies.
The National Institute for Clinical Excellence (NICE) report, in the 2014 guidelines, state that treatment for osteoarthrosis should take a holistic approach. The use of MD and UD wobble board is hypothesized that improves balance and proprioception. So pain, lower extremity muscle power and proprioception are clinically important for the participants' balance control. Hence there is a need to study that the weight-bearing exercise to hip abductor in various balance strategies which may need to achieve joint position sense.
MATERIALS AND METHODS
Ethical clearance
The present study was approved by the Institutional Ethics Committee (IEC), Saveetha Medical College and Hospital(IEC No. 016/02/2017/IEC/SU dated 28th February 2017). The procedure was informed to all the members and higher authorities. The intervention procedure and benefits of the study were well explained to the participants before enrolling on the study. The clinical parameters and other details from the participants were collected after getting informed consent and the information was maintained confidential throughout the study.
Procedure
The participants were taken from the Physiotherapy Outpatient Department, Saveetha Medical College Hospital, Saveetha Institute of Medical and Technical Sciences, Thandalam, Chennai 602 105, Tamil Nadu, India. The Randomised Controlled Trial with three arms (random allocation with sealed envelopes) was used. The sample size estimation was done by using N Master software with the power of 90% and alpha error 5% and arrive the sample size 219 (it includes 10% of dropout), 73 of each group for three groups. The inclusion criteria of OA knee was diagnosed by clinical history and physical examination, each participant met the American College of Rheumatology criteria for OA knee and age of 50 years and above and chronic knee pain for 6 months or more and unilateral knee osteoarthrosis subjects. The exclusion criteria were a history of any recent injury in the lower limbs. Any recent fracture in the lower limb, any neurological weakness in the lower limb, feel difficult in single-limb standing on wobble board, limb length discrepancy and established deformities in the affected knee.
Totally 253 participants diagnosed with unilateral knee osteoarthritis were screened for this study and 219 participants who satisfied the inclusion and exclusion criteria were enrolled. The aim and purpose of the study, hip abductor strengthening procedures on multidirectional and unidirectional wobble board were explained to all the participants and informed consent was taken before enrolling them for the study.
The basic subjective data and clinical measurements were collected for all participants before allotting them into the groups randomly. The basic subjective data and clinical measurements include the age of the patient, gender, body mass index (BMI) after enrolling these data, the participants were randomly allotted into three groups as multidirectional wobble board lateral step-up exercise group (MD EXERCISE GROUP), unidirectional wobble board lateral step-up exercise group (UD EXERCISE GROUP) and control group.
The sensitivity and acuity of peripheral proprioceptors have been investigated by assessing JPS using electrogoniometer by test angle measurement. In a quiet environment, the participants were blindfolded and seated on a high couch with back support and their hips and knees flexed to approximately 90° and their lower leg hanging independently. An electrogoniometer was attached to the lateral aspect of the subject's knee using doubled sided sticky tape. The proximal electrogoniometer block was placed just above the lateral femoral condyle in line with the greater trochanter, and the distal block just below the head of the fibula, in line with the lateral malleolus. In this 'resting position' the electrogoniometer display unit was set to 0. The subjects were instructed to slowly straighten their knee and told to stop at a random angle. This 'test angle' indicated on the display was noted.
For approximately 5 secs the subjects were asked to visualize their knee position. The subjects were then told to relax, allowing their leg to hang freely and return to the resting position, and after 3 secs the subjects were asked to reproduce the test angle. The 'reproduced angle' on the display was recorded. The procedure was performed for 10 test angles chosen randomly by the researcher throughout the range of 90° flexion and full knee extension. The mean error between the 10 test and reproduced angles were calculated and tabulated.33JPS was measured by the physiotherapist who was blinded to the group allotment. These testers were qualified and expertise in making use of the above outcome measures.
The participant's baseline values for JPS were recorded and analyzed with the help of the parametric test, one way ANOVA was used to analyse the baseline homogeneity. Before starting the exercise program the pretest measurements was taken and post-test measurements were measured and tabulated during the 2nd week of the intervention period and 4thof the intervention period for statistical analysis to obtained results. Joint position sense in OA knee was measured and statistically analysed by Electrogoniometer. One way repeated measures of ANOVA (Student Newman Keuls Method) was used to compare within-group significance and the second section deals with one way ANOVA test.
TOTAL of 219 PARTICIPANTS WERE RANDOMLY ALLOCATED INTO THREE GROUPS
CONTROL GROUP
(N = 73)
Interferential therapy in knee vector mode with a sweep frequency of 60-120 Hzs for 12 minutes per day, 3 days a week for 4 weeks
Isometrics quadriceps exercises hold for 10 counts 10 repetitions over 3 sets with 10-15 seconds of rest period between 3 sets for 4 weeks
MULTIDIRECTIONAL WOBBLE BOARD EXERCISE GROUP (N = 73)
UNIDIRECTIONAL WOBBLE BOARD EXERCISE GROUP
(N = 73)
Subjects were asked to stand with both lower extremities shoulder-width apart and then they will perform a lateral step up on the wobble board in the frontal plane and following which keeping the pelvis in a level position
Interferential therapy in knee vector mode with a sweep frequency of 60-120 Hzs for 12 minutes per day, 3 days a week for 4 weeks
Subjects lift the contralateral lower extremity and abduct the leg up to 25?, hold it for 10 counts and return to starting position and repeat.15 reps * 3 sets. 10 to 15 sec rest period between 3 sets,3 days a week / 4 weeks. Bag cuff mass equal to 3% patient body weight was at the contralateral lower extremity.
Figure 1: Flowchart depicting the methodology
RESULTS
The participants' demographic factors like age, gender, body mass index (BMI) analysis done for the following subgroups (Table 1).
The participants' age, gender, body mass index were recorded in this study and was analyzed with the help of a non-parametric Chi-square test.Thec2 value of 0.346 and pEnglishhttp://ijcrr.com/abstract.php?article_id=3687http://ijcrr.com/article_html.php?did=3687
Guccione AA, Felson DT, Anderson JJ, Anthony JM, Zhang Y, Wilson PW. The effects of specific medical conditions on the functional limitations of elders in the Framingham study. Am J Public Health 1994; 84(3):351-358.
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Ashkavand H, Malekinejad BS, Vishwanath.The pathophysiology of osteoarthritis. J Pharm Res 2013;7(1):132–138.
Loyola-Sánchez J, Richardson NJ, MacIntyre. Efficacy of ultrasound therapy for the management of knee osteoarthritis: a systematic review with meta-analysis. Osteoarthr Cartil 2010;18(9):1117-1126. .
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Bruce-Brand RA, Walls RJ, Ong JC, Emerson BC, O’Byrne JM, Moyna NM. Effects of home-based resistance training and neuromuscular electrical stimulation in knee osteoarthritis: a randomized controlled trial. BMC Musculoskeletal Disord 2012;13(1):1
Dwi R, Simadibrata HC, Srilestari A, Wahyudi ER, Hidayat R. Pain Reduction After Laser Acupuncture Treatment in Geriatric Patients with Knee Osteoarthritis: a Randomized Controlled Trial. Indonesian J Intern Med 2016;48(2):114-121.
Rabini DB, Piazzini G, tancredi C, Foti. (2012). Deep heating therapy via microwave diathermy relieves pain and improves physical function in patients with knee osteoarthritis: a double-blinded randomized clinical trial. Eur J Phys Rehabil Med 2012; 48(4):549-559.
Weng MC, Lee CL, Chen CH, Hsu JJ, Lee WD, Huang MH, et al. Effects Of Different Stretching Techniques On The Outcomes of Isokinetic Exercise In Patients With Knee Osteoarthritis. Kaohsiung J Med Sci 2009; 25(6):306-315.
Olagbegi OM, Adegoke BO, Odole AC. Effectiveness of three modes of kinetic chain exercises on quadriceps muscle strength and thigh girth among individuals with knee osteoarthritis. Arch Physiother 2017;7:9:1-11.
Mangione KK, McCully K, Gloviak A, Lefebvre I, Hofmann M, Craik R. The Effects of High?Intensity and Low?Intensity Cycle Ergometry in Older Adults With Knee Osteoarthritis. J Gerontol 1999;54?A(4): M184?M190.
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Dadabo J, Fram J, Jayabalan P. Non-interventional therapies for the Management of Knee Osteoarthritis. J Knee Surg 2019;32(1):46-54.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareBuild Immunity to Beat Corona Virus Infection
English3334Sunita GuptaEnglish Sharda TakEnglish Ashsish AnjankarEnglishTill there is no permanent solution in form of vaccination to this disease called CORONA VIRUS, we can take precautions and stop it from spreading. Since many people got infected from this virus but those who are safe from infection should take ayurvedic treatment daily to make their immunity strong and enable them to fight with virus strongly.
EnglishImmunity, Corona, Decoction, PreventionIntroduction:
At the outset, we must understand Immunity & Corona. According to Ayurveda, Immunity depends on Ojas, the equilibrium state of Kapha and Udana Vata. There are two terminologies used in Ayurveda to discuss the concept of vyadhiksamatwa (immunity) namely Ojas and Bala. In biology, Immunity is the capability of multicellular organisms to resist harmful microorganisms.
Covid-19 is a disease caused by a new strain of coronavirus. ‘CO’ stands for Corona, ‘VI’ for virus and ‘D’ for disease. Let's not fear corona but face it. Because in Ayurveda, various Immunity Promoting Measures have been described. So, we have to build our immunity by taking ayurvedic remedies. It is also said in the textbooks that taking precautions is always better than cure.1,2
There is no permanent solution to this disease called coronavirus shortly, but we can take precautions and stop it from spreading. Since many people got infected from this virus but those who are safe from infection should take ayurvedic treatment on daily basis to make their immunity strong and enable them to fight with virus strongly. To overcome this pandemic situation, each and everyone should have strong immunity, and everyone should take precautions even to avoid cough & cold which arises due to change of weather.
We can keep ourselves healthy by following the proper diet and doing physical activity. The two main objects of Ayurveda are Caring & Curing i.e. to take care of a healthy person and curing the disease. If we follow the 1st aim properly by taking care of a person, we can easily help them to avoid un-wellness.3,4
Remedial Measures
To boost our immunity, we need to take decoction i.e. “Kadha”. The various type of Kadha are described hereunder.
Ayush Kadha I
5 almonds, 5 black pepper, 1 long pepper (after being kept in water overnight), 5-7 holy basil, 5-7 dry grapes (rinse in hot water and take out the seeds from them).
Ayush Kadha II
Grind all these and add 100 ml water, 1 cardamom, ½ teaspoon turmeric powder, ½ teaspoon sugar and boil it properly and afterwards drink it just like tea.
These Kadha can be given to adults @¼ cup and 2 spoons to 5-10-year-old children twice a day.
Guduchi Kadha
The extract of Guduchi (Tinosphora cardifolia) or holy basil can be used by way of as decoction method. For this, 40-50 gm of Guduchi per person to be boiled with 50 ml of water.
Holi Basil Kadha
Take 5 to 7 leaves for each person and boil it with water, add sugar or jaggery. It is very useful when a person is suffering from fever or asthma.
Hot Liquids
All types of hot liquids like Lukewarm water, Milk plain or mixed with turmeric powder, Lemon tea or Ginger Tea etc. are very useful.
Lemon Tea
Take 5-7 holy basil leaves, 4 black pepper, 1 clove, 1 gm cinnamon, 10-15 gm ginger, and boil all these ingredients with 1 cup of water, then add half lemon before drink it.
Ginger Kadha
When the person is suffering from cough or cold, take 15-20 gms Ginger extract & boiled it for few minutes with 100 ml water. Then to add honey or jaggery when the water is lukewarm, then mix it well before drink. This is very useful for a healthy respiratory system.
This Kadha can be given to adults @¼ cup and 2 spoons to 5-10-year-old children twice a day.
Gargle
When the person is suffering from cough because of allergies, gargle with hot water added with one spoon of rock salt is very useful.
Oil-Massage
Boil sesame oil and add rock salt therein, then massage it on the chest gently.
Chayvanprash
Take 10 gm of Chayvanprash daily with 1 glass of plain milk or milk mixed with turmeric. It helps in preventing every type of cough and cold and is very helpful.
Healthy Diet
It is very important to take care of the whole day’s diet as it should be healthy and useful.
- Use fresh and seasonable vegetables.
Not to do
Don't use or drink cold & heavy food because they aren't good for health and according to Ayurveda, all of these are cough promoting.5,6
Conclusion
Ayurveda describes so many dravyas (substance) along with healthy food, to boost up immunity level. By using all these, immunity can be increased to safeguard ourselves from pandemic like Covid-19. Everyone should take necessary precautions, and no one gets afraid of this coronavirus.
Conflict of interest: Nil
Source of funding: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=3688http://ijcrr.com/article_html.php?did=3688
Yadav V, Trikam JI. Acharya Charak Samhita of Agnivesha. Charak and Dridbala. Chaukhamba Sanskrit Sansthan, Varanashi 11th Edition, 2000
Astang Sangrah of Vrddha Vaghbhata with Shashilekha Sanskrit. Chaukhamba Series Office, Varanashi 3rd Edition 2012
Kaviraj Ambikadutta. Susruta Samhita of Maharsi Susruta edited with Ayured-Tatva-Sandipika Shastri published by Chaukhamba Sanskrit Sansthan, Varanashi 11th Edition, 1997
Atharveda Samhita, PrathamaKhanda, ShwetaKushta Naashan Sukta – 23/ 99- 100.
Atharveda Samhita, Divtiya Khanda, Aastrva BhaishjyaSukta – 3/ 166- 168.
Atharveda Samhita, Divtiya Khanda, Kshetriya Roganashana Sukta – 8/ 195.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareOutcome of Induction of Labour: A Prospective Study in a Tertiary Care Centre from Aurangabad, Maharashtra
English3539Lakshmi RachakondaEnglish Savita KadamEnglish Kritika AgrawalEnglish Harshini TEnglishIntroduction: Induction of labour is an intervention carried out to artificially initiate uterine contractions causing progressive dilatation and effacement of the cervix leading to vaginal delivery. There should be a clear medical indication for induction of labour. Induction of labour is a challenge to obstetricians, patients and fetuses.
Objectives: To evaluate the causes of induction of labour and its neonatal outcome
Material and Methods: The prospective observational study was conducted from July 2019 to December 2019 in the Department of Obstetrics and gynaecology, Mahatma Gandhi Mission Medical College and Hospital, Aurangabad, Maharashtra. During this period 1504 patients delivered to our hospital, out of which 174 were induced (11.56%). Foley’s catheter with Dinoprostone gel, only Dinoprostone gel, oral Mifepristone and sweeping of membrane were methods of induction. Written consent was taken of each patient after explaining the procedure in detail to the patient and her relatives.
Results: In our study, the rate of induction in our hospital was 11.56%. 84.48% of patients were between the ages of 19-29 years. We have induced 48.28% booked patients. In our study 44.25% of patients were primigravida. Most of them were between the gestational ages of 37-40 weeks. Most of the patients were induced for postdatism (35.05%) and PROM (28.73%). The average induction delivery interval was 10-20 hours.83.34% of patients delivered vaginally. Only 14.97% of babies required NICU.
Conclusion: Induction of labour is safe and beneficial in high-risk pregnancy. In our study, postdatism and PROM were common indicators of induction with good perinatal outcome. It has to be monitored carefully to avoid complications.
EnglishInduction of labour, Bishop score, Maternal outcome, Perinatal outcomeINTRODUCTION
Induction of labour is an intervention carried out to artificially initiate uterine contractions causing progressive dilatation and effacement of the cervix leading to vaginal delivery of baby.1It is generally done when benefits to mother and fetus will outweigh benefits if pregnancy is continued.1 The World Health Organization recommends that there should be a clear medical indication of induction and it should be practised when benefits outweigh potential harms.2 There is a trend towards rising inductions in the USA and Europe which may lead to increased cesarean delivery.1,3-6 The rate in the U.S ranges from 9.5-33.7%.2 It is seen that elective induction which are inductions in absence of medical or obstetric indications are becoming common and contribute to the overall increasing induction rate.3 This is because of an improved ability to plan the timing of delivery by the patient, her family and obstetrician. Few studies have shown that delivery before 39 weeks of gestation without medical indication is associated with worse perinatal outcomes than delivery at full term.7 Other studies have also concluded that induction of labour beyond 41 weeks varies from country to country.8 There are various methods of induction including pharmacological and mechanical methods. Misoprostol (PGE1) as an inducing agent is less expensive, more stable and easier to store than PGE2.1 Another inducing agent is PGE2 (Dinoprostone) gel which increases hyaluronidase and collagenase levels in the cervix which will cause cervical softening.1
This study was conducted to analyze the various indicators of induction in our hospital along with understanding maternal and neonatal outcomes.
MATERIALS AND METHODS
This study was conducted in MGM Medical College & Hospital, Aurangabad, Maharashtra after obtaining permission from the ethical committee.
The study period was from July 2019 to December 2019. It was a prospective observational study of 6 months duration. Out of 1504 deliveries during that period 174 were induced. Written consent was taken after explaining the details to patients and relatives. Basic requirements and contraindications for induction were assessed. The inclusion and exclusion criteria were pre-decided and accordingly patients were selected. The various methods of induction were Dinoprostone gel, Foley’s catheter with gel and oral Mifepristone. Sweeping and stretching of the membrane was also carried out in some patients. Induction of labour was done using Dinoprostone gel in 163 patients and 5 patients gel was combined with intracervical Foley’s catheter as Bishop Score was less.
The inclusion criteria in our study were post-dated pregnancy, pre-eclampsia, fetal growth restriction, oligohydramnios, PROM, IUFD and others. The patient excluded were patients not willing to give consent and all contraindications for induction.
A detailed proforma was made and details filled out. All patients were monitored in the labour room as per the protocol of labour room monitoring. The patients were monitored in the labour room with NST, auscultation and CTG. Mifepristone was given orally and Dinoprostone gel was inserted in the posterior fornix.
RESULTS
During our study of 6 months, out of the 1504 patients who delivered in that period, 174 patients were induced. The rate of induction in our hospital was 11.56%.
Demographic factors in the study population
Table 1 shows that around 84.48% of patients were in the age group between 19 - 29 years as this is the commonest reproductive age group seen in our hospital.
Table 2 shows that majority of the patients had a BMI in the range of 25 – 30 kg/m2. BMI of >30 kg/m2 also did not influence the route of delivery to much extent. In patients with BMI more > 30 kg/m2, 69.9% underwent LSCS and 38.09% delivered vaginally.
Patients maintaining follow-up in the institute till the time of delivery were considered as booked patients and patients with irregular visits or presented at time of delivery were considered as unbooked patients. As is evidenced by Table 3, the booking status did not influence the induction of labour in our study.
Variables affecting Induction of Labour
Table 4 shows that 44.25% of patients were primigravida. Out of all the primigravida delivered in our study period 15.2% were induced. In 2nd/ 3rdgravida only 7.75% required induction. Nearly 39.3% of patients with 4thgravida and above required induction. This could indicate that more primigravida requires induction as compared to multigravida.
Table 5 shows that 56.33% of the patients were between 37 – 40 weeks of gestation. Though postdatism is a common indication for induction, 76% required induction for a different obstetric indication. As 23.56% of patients were above 40 weeks gestational age, naturally postdatism became the commonest indication of induction. The common reasons for induction in patients with Englishhttp://ijcrr.com/abstract.php?article_id=3689http://ijcrr.com/article_html.php?did=3689
Lamichhane S, Subedi S, Banerjee B, Bhattarai R, Outcome of induction of labour: A prospective study. Ann Int Med Dent Res 2016;2(6):1-5.
Soni, Kavita, K. Subudhi, B. Misra, B. Gouda and S. Chaudhary. Maternal and perinatal outcome in the induction of labour: A comparative study. Sch J App Med Sci 2017;5(1D):273-281.
Dögl M, Romundstad P, Berntzen LD, Fremgaarden OC, Kirial K, Kjøllesdal AM, et al. Elective induction of labor: A prospective observational study. PLoS One. 2018;13(11): e0208098.
Wood S, Cooper S, Ross S. Does induction of labour increase the risk of caesarean section? A systematic review and meta-analysis of trials in women with intact membranes. Bri J Opth 2014;121:674-685.
Chawla S, Singh SK, Saraswat M, Vardhan S, Induction of labour: Our experience. J Marine Med Soc 2017;19:96-98.
Gomathy E, Ramachandra A, Rajan S. Induction of Labor and Risk for Emergency Cesarean Section in Women at Term Pregnancy. J Clin Gynecol Obstet 2019;8:17-20.
Grobman WA, Rice MM, Reddy UM, Alan TN, Yasser Y.Labor Induction versus Expectant Management in Low-Risk Nulliparous Women. N Engl J Med 2018;379:513-523.
Keulen J, Bruinsma A, Kortekaas JC, Dillen J, Bossuyt P, Oudijk M, et al, Induction of labour at 41 weeks versus expectant management until 42 weeks (INDEX): multicentre, randomised non-inferiority trial. Bri Med J 2019;364:1344.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareCentral Corneal Thickness in Diabetics and its Relation with Severity of Diabetic Retinopathy and Hyperglycemia Assessed by Glycosylated Hemoglobin in Central India
English4045Eva Rani TirkeyEnglish Neha AdlakhaEnglish Charudatt ChalisgaonkarEnglish Kailash KhairnarEnglishIntroduction: Diabetes Mellitus is the leading cause of blindness as a result of complications due to diabetic retinopathy. The metabolic status of the cornea is affected by changes in blood glucose levels. Metabolic stress due to hyperglycemia can alter central corneal thickness.
Objective: To compares central corneal thickness (CCT) in diabetics and non-diabetic controls and evaluates the relation of CCT with glycemic status and severity of diabetic retinopathy.
Methods: 180 subjects(93 diabetics and 87 non-diabetics) attending or referred to the Department of Ophthalmology of a tertiary care hospital were included in the study.CCT was measured in all subjects using an ultrasonic pachymeter.
Results: 93 patients were diabetic(Type 1 four and type 2 eighty-nine) of which 35 patients had no diabetic retinopathy,44 patients had non-proliferative diabetic retinopathy and 14 patients had proliferative diabetic retinopathy. Mean CCT in diabetics(563.11μm ±11.40μm)was found to be greater than non-diabetics (529.53±17.91μm)and the difference was statistically significant (pEnglishCentral corneal thickness, Complications, Diabetes Mellitus, Glycosylated Hemoglobin, Keratoplasty, Ultrasonic PachymeterINTRODUCTION
Diabetes mellitus is a metabolic disease that occurs due to an increased level of blood glucose, which can cause microvascular and macrovascular complications.1Failure of pancreatic beta cells to secrete an adequate amount of insulin can cause hyperglycemia, which influences genetic and environmental factors.2 Hyperglycemia has toxic effects on almost all cells in the body.3 Ocular complications of hyperglycemia are most remarkable in the cornea and retina.
Retinal impairment accounts for the majority of visual loss in diabetic patients Diabetic Retinopathy is the most common cause of blindness for people over the age of 50 years.4 Neovascular glaucoma, refractive changes5 and various corneal pathologies may be also seen. These include dysfunction in the corneal endothelium, desensitization,6 stromal and subbasal nerve abnormalities,7 low endothelial cell density and hexagonality,8 increased corneal autofluorescence,9 recurrent epithelial erosions, epithelial oedema, desensitization and neurotrophic ulcers.
Studies show that the eyes of patients with Diabetes Mellitus have a greater central corneal thickness (CCT) and that there is a positive correlation between CCT and the Grading of Diabetic Retinopathy.10 Control of corneal hydration appears to be compromised in corneas of diabetic patients.11 Corneal morphological evaluation is always very crucial in Ophthalmologists clinical practice. Ophthalmologists rely on corneal parameters such as central corneal thickness, anterior and posterior corneal curvature, anterior chamber depth or endothelial cells counts to make the diagnosis, to follow up or to plan treatment for refractive errors or diseases such as glaucoma, keratoconus, corneal ectasia or cataract.
There are varying reports on central corneal thickness (CCT) changes due to DM.12 To the best of our knowledge, there are only a few published studies on CCT in Diabetes Mellitus.13 In our study, we aimed to measure the difference in the mean CCT between diabetes and age-matched non-diabetic controls. Also, we evaluated the correlation between each of these values and the diabetic duration and hyperglycaemia assessed by HbA1C by measuring CCT using an ultrasonic pachymeter.
MATERIALS AND METHODS
Ethical clearance was obtained from the Institutional Ethical Committee ( Ethical clearance number – 138/ 03.06.2017) and an observational cross-sectional case-control study was designed in our tertiary eye care centre. A total of 180 subjects (93 diabetics and 87 non-diabetics) who gave consent were included in the study. Eyes with corneal pathologies like pterygium, corneal dystrophies, contact lens users, receiving treatment for any topical or systemic diseases, any prior history of ocular surgeries or ocular trauma were excluded from the study. Age, gender, duration of diabetes, HbA1c levels, the status of DR, any medical illness and prescribed medical treatment were recorded. All subjects underwent a complete ophthalmological examination that included visual acuity assessment using the Snellen chart, refraction using auto-refractometer, intraocular pressure measurement using applanation tonometry, slit-lamp biomicroscopy, and fundus examination. Grading of Diabetic Retinopathy was done according to the International clinical disease severity scale for DR. Central corneal thickness of all subjects was measured with an ultrasonic pachymeter.
The diabetic eyes were classified into 3 groups according to the status of DR (group without DR, group with non-proliferative DR [NPDR], and group with proliferative DR [PDR]). Also, they were divided into 2 groups according to DM duration (the group with a duration of fewer than 10 years and group with a duration of ≥10 years) and according to HbA1c value (the group with HbA1c less than 7 % and group with HbA1c more than or equal to 7%).
Statistical Analysis
Data were analyzed using SPSS software for windows. The results were expressed as mean ± SD. An independent sample t-test was performed to compare the means of CCT in diabetic and control groups. The differences among 3 or more groups were analyzed by one way ANOVA. Pearson correlation coefficient was done to find the relationship between corneal thickness and DM duration, HbA1c, and DR status. A value of P ≤ 0.05 was considered statistically significant.
RESULTS
The present cross-sectional study was conducted on 180 consecutive subjects in the Department of Ophthalmology in a tertiary care hospital. In this study 93 patients were diabetic (Type 1 four and type 2 eight nine), of which 35 patients had no diabetic retinopathy, 44 patients had non-proliferative diabetic retinopathy and 14 patients had proliferative diabetic retinopathy. Eighty-seven subjects were non-diabetic controls.
The age of all patients in the present study varied from 30 years to 80 years with a mean age of 55.41±10.94 years. The maximum number of patients in the diabetic group were in the age group of 51–60 years (39.7%) and the mean age of diabetic patients was 55.45±10.79 years, while in the non-diabetic control group it was in the age group of 51-60 years (35.6%) and the mean age of the non-diabetic group was 53.48±10.99 years. No significant difference was found between the mean age of diabetics and non-diabetic controls (p=0.227; Figure 1).
In the diabetic group, 47 (50.53%) were males and 46 (49.46%) were females while in the non-diabetic control group 50 (57.47%) were males and 37 (42.52%) were females. In this study, M: F ratio is 1.16:1 (Figure 2).
Out of 93 patients of DM, two patients of type 1 DM and 33 patients of type 2 DM had no diabetic retinopathy. One patient of type 1 DM and 22 patients of type 2 DM had mild NPDR. None of the patients of type 1 DM had moderate NPDR, while 10 patients of type 2 DM had moderate NPDR. Eleven patients of type 2 DM had severe NPDR. One patient of type 1 DM and 13 patients of type 2 DM had PDR. No diabetic retinopathy was the most common grade seen in 35 eyes and moderate NPDR was the least common grade found amongst diabetic patients (Figure 3).
Out of 93 patients of DM, three patients of ≥10 years duration of diabetes and 32 patients of Englishhttp://ijcrr.com/abstract.php?article_id=3690http://ijcrr.com/article_html.php?did=3690
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Sayin N, Kara N, Pekel G. Ocular complications of diabetes mellitus. World J Diabetes 2015;6(1):92-108.
Taylor-Phillips S, Mistry H, Leslie. Extending the diabetic retinopathy screening interval beyond 1 year: a systematic review. Bri J Ophth 2016;100(1):105-114.
Weston BC, Bourne WM, Polse KA, Hodge DO. Corneal hydration control in diabetes mellitus. Invest Ophthalmol Vis Sci 1995;36:586–595.
Saini JS, Mittal S. In vivo assessment of corneal endothelial function in diabetes mellitus. Arch Ophth 1996;114:649–665.
Roszkowska AM, Tringali CG, Colosi P, Squeri CA, Ferreri G. Corneal endothelium evaluation in type I and type II diabetes mellitus. Ophthalmology 1999;213:258-261.
Akinci A, Bulus D, Aycan Z, Oner O. Central corneal thickness in children with diabetes. J Refract Surg 2009;25:1041-1044.
Lee JS, Oum BS, Choi HY, Lee JE, Cho BM. Differences in corneal thickness and corneal endothelium related to duration in diabetes. Eye 2006;20:315–318.
Ozdamar Y, Cankaya B, Ozalp S, Acaroglu G, Karakaya J, Ozkan SS. Is there a correlation between diabetes mellitus and central corneal thickness. J Glaucoma 2010;19:613-616
N Busted T Olsen O Schmitz, Clinical observations on the corneal thickness and the corneal endothelium in diabetes mellitus, Br J Ophthalmol. 1981;65:687-90.
Storr-Paulsen A, Singh A, Jeppesen H, Norregaard JC, Thulesen J.Corneal endothelial morphology and central thickness in patients with type II diabetes mellitus. Acta Ophthalmol 2014;92:158-160.
Larsson LI, Bourne WM, Pach JM, Brubaker RF. Structure and function of the corneal endothelium in diabetes mellitus type I and type II. Arch Ophthalmol 1996;114:9-14
Schultz RO, Matsuda M, Yee RW. Corneal endothelial changes in type 1 and type 2. Diabetes mellitus. Am J Ophthalmol 1984;98:401-410
Sahin, A. Bayer G. ?Ozge A, Mumcuo T . Corneal biomechanical changes in diabetes mellitus and their influence on intraocular pressure measurements. Investig Ophth Vis Sci 2009;50(10):4597–4604.
Toygar O, Sizmaz S, Pelit A, Toygar B, Yaba? Kizilo?lu Ö, Akova Y.. Central corneal thickness in type II diabetes mellitus: is it related to the severity of diabetic retinopathy? Turk J Med Sci 2015;45:651-654.
Solani D. Mathebula, Tshegofatso M. Segoti. Is the central corneal thickness of diabetic patients thicker than that of non-diabetic eyes? Afri Vis Eye Health 2015;74:1-5.
Prempal Kaur, Baljinderpal Singh, Bhavkaran Singh Bal, Inderjit Kaur, Vishal Brar. Central Corneal Thickness in Type 2 Diabetic Patients and its Correlation with Duration, Hba1c Levels And Severity of Retinopathy. J Den Med Sci 2016;15:91-4.
Zengin MO, Ozbek Z, Arikan G, Durak I, Saatci SA. Does central corneal thickness correlate with haemoglobin A1c level and disease severity in diabetes type II? Turk J Med Sci 2010;40:675-680.
Brownlee M. The path biology of diabetic complications. Diabetes 2005;54:1615–1625.
Dabas R, Sethi S, Garg M, Aggarwal R, Lamba S, Bhattacharjee A, et al. Central Corneal Thickness (CCT) in Diabetic Subjects and its Correlation with Disease Duration and Severity. Ann Int Med Den Res 2017;3:4-6.
Abdulghani YS, Ali TO. Correlation between central corneal thickness and diabetes in Sudanese patients. Nat J Med Res 2013;3:309-311.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareFertility Transitions in Qatar: The Dynamics between Women’s Socioeconomic Status and Fertility
English4651Noora Ahmed LariEnglish Noof Abdulhadi Al-RakebEnglishIntroduction: Qatar society has undergone major socio-economic transformations that have eventually promoted female access to education and career opportunities, which has, in turn, impacted fertility preferences.
Objective: This paper examines the determinants of Qatari women’s socioeconomic characteristics on fertility rates and preferences, as well as their policy implications.
Methods: Data from a 2018 fertility survey project with a random sample of 607 Qatari households, collected via personal interviews using a questionnaire programmed into a computer-assisted personal interview system, were examined based on a multi-dimensional model. The data were analyzed using logistic and Poisson regression techniques.
Results: The results demonstrated that the Qatari women’s average fertility rate was 3.2, with the women in the 20–29 age group having the highest fertility rate. An evaluation of the effects of women’s educational attainment and employment status revealed no significant factors influencing the age-specific fertility rate of Qatari women. The use of family planning methods was more prevalent in older women who have had more children than younger women.
Conclusion: The paper concludes with practical family-friendly policy implications for higher authorities in response to the declining fertility rate among Qatari women by elucidating the sustainable development goals concerning Qatari national reproductive health.
EnglishFertility rates, Women, Education, Employment status, QatarINTRODUCTION
The existing literature has presented several factors contributing to the decline in the global total fertility rate and its relevant impact on the number of live births, which has decreased from 4.7 to 2.4. The effect of this decline on demographic transitions, coupled with the prevailing social and economic dynamics of the population, has also been previously discussed.1,2 Unsurprisingly, most of the Gulf Corporation Council (GCC) states have been experiencing high fertility levels, moderate mortality rates, and low contraceptive usage.3,4 It has been posited that Arab Gulf countries will continue to experience exponential population growth in the coming years. In June 2020, it was estimated that the total population in Qatar is 2.7 million,4but the current percentage of Qatari nationals only accounts for approximately 20% of the total national population.5,6 It is expected that the population in Qatar will reach 3.2 million by 2030.7
Nevertheless, Qatari nationals are expected to experience declining fertility rates, reduced number of mortality rates and increased life expectancy over the coming years.3,8 Between 2013 and 2017, the total fertility rate of Qatari women significantly declined, dropping from 3.30 births per woman to 2.94 in 2017.9 Given such projections, the Qatari authorities have considered infertility a national priority, and provided several initiatives to promote the fertility rate among its nationals while working on the reduction of expatriate recruitments as a means to address the imbalance in demographic transitions.10
Traditionally, Qatari society was based on patriarchal behaviours and gender roles, and women were not involved in making marriage decisions, resulting in a substantial number of them getting married off early to potential suitors.11 Although these traditions have not been fully overcome, it is imperative to underscore the fact that much progress has been made towards achieving gender parity and women empowerment in the Arab Gulf region. During the last 20 years, Qatar has undergone major social and economic transformations that have eventually culminated in increased industrialization and high rates of economic growth. This led to a shift toward a sedentary lifestyle that resulted in the promotion of female access to education and career opportunities for women in the labour market.6 Consequently, women have outnumbered their male counterparts in higher education, representing 34% of the total workforce of Qatar.12-14
Due to the aforementioned measures, as well as high rates of economic growth and higher rates of female literacy, declining total fertility rates continue to be recorded.15 The ripple effect is a delayed age of first marriage for women, with others preferring to practice celibacy, and declined fertility and reproduction. For instance, a study observed that uneducated and unemployed women are more likely to have more children compared to their educated counterparts.16 Eventually, this dynamic influences fertility levels in the sense that education becomes a predictive factor about the desired ideal family size, number of marriage years, frequency of contraceptive usage, and level of household income, which directly or indirectly affect fertility and reproduction.17
These dynamics demonstrate that women are increasingly becoming engaged with employment rather than establishing a family. In other words, they are progressively moving “away from home,” leaving limited opportunities for reproduction and shifting their fertility preferences. This is the premise of this paper, which will assess the determinants of Qatari women’s socioeconomic characteristics and fertility rates and their policy implications. This research is guided by the following research question: How and to what extent do women’s socioeconomic characteristics, such as age, level of education, employment status, and income level, contribute to declining fertility rates? Based on the results obtained from this research, it is expected that the practical recommendations will be able to address the implications of women’s fertility decline and raise the quality of family–work policies as a means to provide the possibility of a better reconciliation between childbearing and career responsibilities.
MATERIALS AND METHODS
This paper utilized a national survey on a representative sample consisting of 607 Qatari women conducted by the Social and Economic Survey Research Institute in 2019. The data were collected via personal interviews with a questionnaire programmed into a computer-assisted personal interview (CAI) system (BLAISE). The data were analyzed using the Statistical Software Package (STATA). Means with their corresponding standard deviations (SDs) were calculated for the continuous variables and proportions for the categorical variables. Potential variables (age, marital status, educational level, employment status, and the number of children) were incorporated in the univariate model, and their corresponding p-values were recorded. The model used these variables, which have been categorized as social and demographic variables that are likely to affect women’s fertility rates. All variables in which the p-value was less than 0.05 were considered for the Poisson and regression analysis.
Sample Characteristics
A total of 607 Qatari women were selected and interviewed. The age group from 33–40 years old constituted the largest percentage (36%), followed by the 41–49 years and 25–32 years’ age groups with a ratio of about one third each, and, finally, the younger age group from 18–24 years (the lowest percentage in the sample, 8%). The sample included Qatari women who were married or previously married. Most of the women who participated in the study were married (88%). The percentage of divorced women was 7%, that of widows was 3%, and that of separated women was 2%. The results indicated that 96% of the sample married once and a small percentage married twice (4%). The percentage of pregnant women who participated in the survey was 14% of the total sample. Table 1 presents the sample characteristics.
In terms of educational level and employment status, the percentage of Qatari women who achieved a higher education level than secondary constituted the largest percentage in the sample (41%), followed by those with an education lower than the secondary level (32%), and, finally, those with a high school diploma, who constituted about a quarter of the sample (26%). The percentage of employed Qatari women was 46%, those who were unemployed constituted about a third (31%), female students constituted 5%, and the retired women 2%. The percentage of Qatari women working in the professional jobs category comprised the largest percentage (38%), followed by the women working in the office jobs category with 23%, and, finally, 16% in the senior employees’ category (legislators, senior management employees, directors).
RESULTS
Total Fertility Rate
The data were analyzed statistically using fertility equations, as well as Poisson and logistic regression analysis. In this sample, the total fertility rate of Qatari women was three births per woman on average. The Age-Specific Fertility Rate (ASFR) was calculated using the equation below:17
Age-Specific Fertility Rate = the number of live births per woman at a specific age/number of women at that specific age
Sociodemographic Factors Associated with Fertility
Table 2 depicts the fertility rate according to the women’s age groups. Based on the sample characteristics, the women in the 20–29 age group had the highest fertility rate, after which it declined in the older groups. Meanwhile, the percentage of women who have not given birth was 12%, with the majority coming from the age group 18–24 years.
Poisson regression analysis was performed to measure the associations between the age-specific fertility rate and women’s educational level, employment status, and income level. The results revealed that the age-specific fertility rate decreased as the educational level of Qatari women increased (above secondary), which means that there is no relationship between age-specific fertility rate and women’s educational level. No associations were found between age-specific fertility rate and women’s employment status (Table 3).
Also, logistic regression analysis was performed to measure the desire of non-pregnant women (the sample consisted of 86% non-pregnant women during the time of the survey) to have another child relative to their employment status and educational level. The findings in Table 4 indicate that the women with a higher educational level (above secondary) had a greater desire to bear a child compared to the women with lower than secondary level education. This supports the findings in Table 1, as the women with a higher educational level (above secondary) desired to have one or more children since their age-specific fertility rate is low.
On the other hand, when Poisson regression analysis was performed, a direct relationship between women’s fertility rate and level of income was found. The age-specific fertility rate for high-income Qatari women was higher than that for low-income women because the age-specific fertility rate increased as the women’s income increased (Figure 1).
Family Planning Methods
To assess their fertility preferences, the prevalence of contraceptive usage was measured among the respondents, and a positive association was found between women’s access to employment and their level of income. The respondents were asked about their “intention to use family planning methods to postpone or prevent pregnancy shortly.” Almost 48% reported that they are currently using a contraceptive method as a means to postpone or prevent pregnancy (i.e., during the survey period).
As depicted in Figure 2, pills constitute the most widely used method for postponing or preventing pregnancy among Qatari women (29%), followed by IUD (25%), condom (10%), safe period (8%), and breastfeeding (5%). A study conducted to measure the prevalence of contraceptive use among Qatari women also found that IUD and pills are among the most common contraceptive methods used by Qatari women .18
More than half of the employed women in full- or part-time jobs indicated that they were using contraceptive methods (53%) compared to 43% of the women who were not employed. In terms of the type of employment, the Qatari women who had administrative jobs (secretary, administrative assistant) tended to use contraceptive methods of postponement or contraception more than those with professional jobs (engineer, doctor, lawyer, teacher, accountant, and journalist). Figure 3 demonstrates that the use of postponement methods was more prevalent among older women than in the younger age groups. It was expected that the older women would have more children compared to the younger age group. This indicated that there was a significant association between the women’s age and the number of living children and the current use of contraceptive methods.
DISCUSSION
In the changing socio-economic dynamics, women have gone beyond regressive social constructs, such as being constrained to domestic chores and blindly following male orders.20,21 Several cross-country studies have stated that the dimensions of women’s education and empowerment compel women to have fewer children to raise their quality of life, as opposed to traditional times when childbearing was considered the norm in society.19,22,23 This is in line with the postulations of the theory of demographic transition, which argue that the main cause of fertility decline is the changing status of women (through access to employment and education, their assumption of important positions in society and decision-making, etc.), amongst other major developments.24
Since changes in social norms have taken place in Qatari society, where childbearing was once considered the norm, the country has been grappling with the issue of declining total fertility rates.15,25 One study found that Qatari women’s desire to have children decreases as they become increasingly empowered with expanded access to employment and education opportunities.13 This study contradicts our results, as we found that women’s reproductive preferences have not changed due to their educational level and that they are not associated with fertility differentials or decline. Rather, our analysis revealed that Qatari women with low age-specific fertility rate and higher education desire to have more children. These findings are consistent with the results of previous studies carried out in other Arab Gulf states, such as Oman and the UAE.17,26On the other hand, it indicated that the participation of women in the workforce leads to a decline in their fertility due to several reasons, including the inability to achieve the required balance between childcare and work duties, thereby leading to a delay in reproductive age.26,27
The results primarily demonstrated that an increase in the age of first marriage and prevention or delay in childbearing through the prevalent use of contraceptive methods by women have emerged as consequences. For instance, it was demonstrated that almost half of the non-pregnant women use contraceptives to postpone or prevent pregnancy (during the survey period), and more than half of those who work are currently using contraceptive means (53%) compared to 43% of those who do not work. Consistent with previous studies, Algur et. al.26, indicated that in terms of family planning preferences, females’ respondents were in favour of the use of contraceptives and birth control methods more than males’ respondents. The high level of usage of contraceptive methods among married working women is ascribed to the lack of family-friendly policies that contribute to balancing family responsibilities, parenting, childcare, and work duties. Several studies have indicated that employed women tend to use contraceptive methods to delay their pregnancy to a later time.28-31
Based on the results, it was also determined that age is a predictive factor for the decreased fertility in Qatari women.3,32 In fact, our empirical findings revealed that age may directly contribute to reduced fertility rates for women, as the use of postponement methods of contraception is more prevalent among older women who have given birth to many children compared to the younger age group. It follows that there is a strong positive correlation between old age and quality of life with the increased necessity for long-term care needs. The fact that the older generation has a higher dependency ratio means that the ageing population will be less willing to conceive and procreate.3 The Qatari authorities have increased the implementation of interventions to improve access to healthcare services and provided improvements in overall sanitation as a means to help reduce the mortality rates among older generations.10
CONCLUSION
Similar to most other Arab Gulf countries, Qatar has undergone major social and economic transformations, both of which have significantly influenced the level of fertility and birth rates in the country. This paper has presented the key socioeconomic determinants influencing fertility rates among Qatari women (e.g., education, employment, age, etc.). In light of research results and to increase the total fertility rate, several initiatives have been adopted in Qatar to encourage procreation, facilitate the establishment of families, mitigate child mortality rates, and increase live births while reducing or possibly averting stillbirths.
The following policy recommendations are considered as partial solutions to the existing ones: providing family-friendly initiatives to encourage working Qatari married women to increase their family sizes, such as subsidized childcare support and services, and strengthening the provision of paid maternity leave. Moreover, sufficient incentives in the workplace that would motivate Qatari women to have children, such as part-time jobs, flexible working hours, work-from-home options, and nursing rooms for children in the workplace should be implemented. The authorities should also regulate and promote the provision of high-quality family planning services, including the use of contraceptives. Finally, governmental plans for enhancing health services and addressing fertility-related issues can ensure an increase in the total fertility rate.
ACKNOWLEDGMENTS: The authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to the authors, editors, and publishers of all the articles, journals, and books that have been reviewed and discussed in this article.
Conflict of Interest: The authors declare that they have no conflict of interest to report.
Source of Funding: This publication was made possible by Program grant # NPRP9-190-5-022 from the Qatar National Research Fund (a member of the Qatar Foundation). The findings herein reflect the views of the authors alone and are solely the responsibility of the authors.
Compliance with Ethical Standards
All procedures performed in studies involving human participants were following the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The research protocol was approved by the institutional review board of the Qatar University, QU-IRB 597-EA/16, under which the Social and Economic Research Institute (SESRI) operates.
Englishhttp://ijcrr.com/abstract.php?article_id=3691http://ijcrr.com/article_html.php?did=3691
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Slaiby W. New Population Policy Seeks a Balanced Demographic Growth. Qatar Tribune. 2017. http://www.qatar-tribune.com/news-details/id/93490
Al–Thani MH, Sadoun E, Al-Thani A, Khalifa SA, Sayegh S, Badawi A. Change in the Structures, Dynamics and Disease-related Mortality Rates of the Population of Qatari Nationals: 2007–2011. J Epidemiol Global Health 2014;4(4):277–287.
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Planning and Statistics Authority. Births and Deaths in the State of Qatar 2017 – Presentation and Analysis. Planning and Statistics Authority. 2018. https://www.psa.gov.qa/en/statistics/Statistical%20Releases/Population/BirthsDeaths/2017/Birth_death_2017_AR.pdf
Alharahsheh MM, Mohieddin ST, Almeer FK. Marrying Out: Trends and Patterns of Mixed Marriage amongst Qataris. Int J Soc Sci Studies 2015;3(6):211–225.
Klasen S. What Explains Uneven Female Labor Force Participation Levels and Trends in Developing Countries? World Bank Res Observer 2019;34(2):161–197.
Khraif RM, Salam AA, Al-Mutairi A, Elsegaey I, Jumaah, A. Education’s Impact on Fertility: The Case of King Saud University Women, Riyadh. Middle East Fert Soc J 2017;22(2):125–131.
Young KE. Women’s Labour Force Participation Across the GCC. The Arab Gulf States Institute in Washington. Washington, DC. 2016. https://agsiw.org/wp-content/uploads/2016/12/Young_Womens-Labor_ONLINE-2.pdf
Zauner G, Girardi G. Potential Causes of Male and Female Infertility in Qatar.
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Al-Awad M, Chartouni C. Explaining the Decline in Fertility among Citizens of the GCC Countries: The Case of the UAE. Educ Busi Soc Contemp Middle Eastern Issues, 2014;7(2/3), 82–97.
Arbab AA, Bener A, Abdulmalik M. Prevalence, Awareness and Determinants of Contraceptive Use in Qatari Women. Eastern Mediterranean Health J 2011;17(1), 11–18.
Atake EH, Ali PG. Women’s Empowerment and Fertility Preferences in High Fertility Countries in Sub-Saharan Africa. BMC Women’s Health, 2019;19(1):54.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcarePrevalence of Psychiatric Morbidity in Undergraduate Medical Students in a Rural Medical College of Central India using Global Mental Health Assessment Tool - Primary Care (GMHAT-PC)
English5258Prakash B BehereEnglish Anweshak DasEnglish Aniruddh P BehereEnglish Amit B NagdiveEnglish Richa YadavEnglish Rouchelle FernandesEnglishBackground: Many studies report that medical education is one of the toughest courses and that life in a medical college can be quite engaging, demanding and straining to lead to stress both physically and emotionally. It is also observed that many medical students even if having mental health issues would hesitate to contact help providers, especially psychiatrists. It may be due to stigma, negative criticism and discrimination attached to mental illness or due to negative opinions regarding mental illness. Medical students hesitate to seek help from their college and instead prefer to go to another psychiatrist in a different town. It has been time and again stated that early detection and treatment improves the prognosis and reduces lifelong negative consequences.
Objective: To find the prevalence of psychiatric morbidity in undergraduate students of a private medical college in Central India.
Methods: Students were assessed using GMHAT-PC, which is a computer-based diagnostic tool designed to be used in the primary health care setting.
Results: Female participants were significantly more than male participants. Female participants also had a significantly higher prevalence of mental illness compared to their male counterparts.
Conclusion: Medical schools need to give priority to student welfare and not merely focus on student distress. Academic stress has a significant correlation with the prevalence of mental illness. Apart from academic studies, students must also be given the knowledge to improve their coping skills, manage their anger, skills on emotional regulation, impart them skills on conflict resolution and also give them some knowledge to improve their resiliency. These can be possible through Life Skill education and also Social Emotional Training Program.
EnglishGMHAT-PC, Help-seeking behaviour, High prevalence of anxietyINTRODUCTION
Globally medical colleges or medical schools strive to usher in an environment where all their students (both undergraduates and post-graduates) become both skilful enough and knowledgeable enough to better serve the society in their profession as a doctor. These problems hamper academic development, learning of clinical skills and professional abilities.1 Many studies report that medical education is one of the toughest courses and that life in a medical college can be quite engaging, demanding and straining to lead to stress both physically and emotionally.2
Life in a Medical college starts around the age of 18. This is the transition phase of late adolescence and early adulthood. Most of us start taking adult roles taking major social roles and responsibilities. Students learn for the first time in their lives to live on their own, maintaining a balance of demands of course work and social life, adjusting to roommates, hostel life, making new relations, cooking food at times, maintaining finances which are challenging and stressful. Although some students can weather this stormy and stressful stage, many students buckle under this stress, cannot cope with the changes and experience emotional maladjustment and psychological problems. Seventy-five per cent of mental illnesses start before age of 24 years which is the prime age of medical education.3 The goals of medical education is to train physicians who are prepared to serve the fundamental purposes of medicine – with requisite knowledge, skills, attitudes, values and responsiveness, so that they may function appropriately and effectively as a basic doctor, physicians of the first contact for the community in the primary care setting both in urban as well as rural areas of our country.4 The Bachelor of Medicine and Bachelor of Surgery (MBBS) course in India like in other countries is very demanding and rigorous, taking a toll emotionally in many students leading to depression, anxiety and the unfortunate incidents of suicide or suicidal attempts by the students. The most commonly observed sources of stress were fear of failure, inability to cope with the expectations of parents and peers, lack of peer support, competitive environment, long working hours, difficulty in adjusting, relationship issues, residency uncertainty, family history of mental illness are few reasons of stress.5-7
Gender differences differ from study to study. While some studies have reported that female medical students suffer more. Symptoms suggestive of neuroticism, depression, anxiety, and somatic symptoms were more in female students; other reports have found no sex differences in stress perception.8 For many students the first year is found to be more stressful. Other reports have however suggested that the 2nd and 3rd year is stressful. Surprisingly, the psychological morbidity of the first year and fourth year is similar. The however stressful period during the MBBS course has differed from study to study.5
Studies worldwide have reported high levels of anxiety, stress and depression in medical students. A study in Saudi Arabia reported the prevalence of severe stress was 25% in medical students.9 In another cross-sectional study in the medical school of New Delhi, the prevalence of provisionally diagnosed depressive disorder was 21.5.10 One of the studies on undergraduate medical students in the rural area of North-West India, 43% showed psychological distress.11 Another cross-sectional study of 400 medical students from Rural Medical College, Loni reported prevalence of psychiatric morbidity stood at 29.75%.12 A study done in a private medical college in Uttar Pradesh found significant stress and anxiety and depression in medical students of the college.13 Another study was done on medical students in a medical college of Bangalore reported 42.38% had some form of depression, 54.96% had some form of anxiety and 45.69% had some form of stress.14 The prevalence of depression among medical students in India was found to be 71.25%.15 Anxiety and depression were found to be present in 70% according to a Pakistani study.7 In an Egyptian study 44% of medical students were diagnosed to have mood and anxiety symptoms.16,17
It is also observed that many medical students even if having mental health issues would hesitate to contact help providers, especially psychiatrists. It may be due to stigma, negative criticism and discrimination attached to mental illness or due to negative opinions regarding mental illness. Medical students hesitate to seek help from their college and instead prefer to go to another psychiatrist in a different town. It has been time and again stated that early detection and treatment improves the prognosis and reduces lifelong negative consequences.8,18 This would also contribute to the reduction of the global burden on health and social care systems caused by mental disorders.19 So it is of utmost importance that we give impetus on early identification and prevention of mental health issues. Modern technology especially computer-assisted methods can be used to augment the available human resources in the health and social well-being sector, especially in low to middle-income countries.19 GMHAT-PC screening is an easy to use screening method that can be used in the community. It can be used by other mental health professionals as it gives the diagnosis along with its differentials as per the ICD-10 criteria.
In this study, the main aim was to find out the prevalence of psychiatric morbidity in undergraduate students of Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha and whether the frequency of morbidity changes in subsequent years of education.
MATERIALS AND METHODS
The study was conducted in Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha. It was a cross-sectional study with a single evaluation was done. Subjects were selected as random sampling. A total of 650 MBBS students were selected. Electronically data was collected on the GMHAT-PC.
Institutional Ethics Committee approval was taken vide letter number DMIMS (du)/IEC/2012-2013/957. Confidentiality was ensured. They were informed that if any mental illness was detected the help will be provided.
The following were the inclusion criteria:
Undergraduate students from the first to fourth years were included.
Both sexes were included.
Students who were willing to give written informed consent.
Those students who did not give their consent were not interviewed and were excluded from the study. The instrument used was Global Mental Health Assessment Tool – Primary Care Version (GMHAT – PC) – Computer Software. It gives at the end, ICD-10 diagnosis and also, the differential diagnosis. A summary report consisting of symptoms along with their scores is generated and the GMHAT/PC diagnosis is given. The part on history has six sections: presenting problems, past mental health, physical health, family history, personal and social history and substance misuse. There are then sections on mental state examination, assessment of unmet needs and risk assessment. Further sections focus on diagnosis, an overall summary, relevant investigations required, a care plan and a section to gather third party information and to detail the progress on the ward. Finally, there is a checklist of items of explanation to the service-user and the caregivers.
RESULTS
A total of 390 students were enrolled in the study. Two hundred sixty students were excluded from the analysis as 140 did not provide consent to participate in the study, 63 were previously diagnosed to have a psychiatric disorder and 57 students were unavailable to interview. The remaining 390 students were assessed using GMHAT-PC.
Female students were significantly higher in number in the sample, compared to male students. There were 158 (40.5%) male students and 232 (59.5%) female students. This statistically significant difference was seen in 3rd year M.B.B.S. students as well (27.4% vs 72.6%, p=0.001). However, there was no statistically significant difference between males and females in 1st, 2nd, and 4th-year students. These findings are shown in Table 1.
Out of 390 students assessed using GMHAT-PC, 144 (36.92%) were found to have a mental illness. A total of 38 (9.7%) male students and 106 (27.2%) female students were found to have a mental illness. Among these students, the majority were from the final year (40.2%), followed by 2nd-year students (38.6%), 1st year students (35.9%) and 32.1% from the 3rd year of M.B.B.S. There was no statistically significant difference between students from different phases of their education, However, a statistically significant difference was seen between male and female students, with mental illness being significantly higher in female students compared to males. These findings are depicted in Table 2.
Out of 390 students 144 (36.92%) students were diagnosed as having a mental illness. Females were significantly higher than males to have a mental illness. Among these students (n=144), anxiety disorder was the most commonly diagnosed mental illness. Forty-four (10.8%) students were found to have an anxiety disorder. Depression was the next common mental illness which was diagnosed in a total of 39 (10%) students. Phobia which was mainly social phobia was diagnosed in 21 (5.38%) students. stress was found in 14 (3.42%) of students. Hypochondriasis was found in 5 (2.29%) students of which 4 students were female. They were mostly concerned about their weight. OCD was reported in 3 students (0.77%). The eating disorder was found in 2 (0.51%) students. Both these students were females. 3 (0.77%) students were diagnosed to have psychosis with depression of which 1 student had bipolar disorder. There was 1 (0.26%) student who had schizophrenia who was diagnosed as having psychosis. No statistically significant difference was found in illness wise distribution among boys and girls as shown in Table 3.
DISCUSSION
In the study out of 650 undergraduate medical students, 390 gave their willingness to participate in the interview (response rate was 60%). Some of the students who failed to pass the annual exams and were not in the regular batch of students were also lost. Overall, there were 158 (40.51%) male students and 232 (59.48%) female students which were statistically significant. In the 1st MBBS, there were 45 (43.46%) males and 58 (56.31%) females. In 2nd MBBS there were 45(44.55%) males and 56(55.45%) females. In the 3rd MBBS, there were 23 (27.38%) males and 61(72.62%) females and in the final MBBS, there were 45 (44.12%) males and 57 (55.45%) females. The only significance in gender-wise yearly distribution was found in the 3rd MBBS students. Males were less in the third year as most of them were not in the hostel when the interview sessions were conducted.
Out of 390 students 144 (36.92%) students were diagnosed as having a mental illness. A total of 38(9.74%) male students and 106 (27.18%) female students were diagnosed to have a mental illness. The reported prevalence of mental illness was 20.9%20, 43%11, 29.75%21, 55%22, 16%.23 Out of 144 students diagnosed as having some mental illness, 41 (40.20%) were from final year followed by 39 (38.61%) from 2nd year, 37(35.92%) from 1st year and 27 (32.14%) from 3rd year. There was no significance found in the distribution of illness from 1st year to final year students. However, in the gender-wise distribution of mental illness, it came out to be significant with females having more mental illness than males. Other studies9,22 reported a higher prevalence of emotional distress in females than males. In one study males showed a greater prevalence of mental illness than females.11 In this study females were statistically significant than males. This may be the reason for the increased prevalence of mental illness in females than males. Also, coping strategies were found to be less in females as compared to males. Females react more to a particular situation while males distract. In a small town like Wardha recreational facilities were less for females as compared to males. These factors also contributed to the increased prevalence of mental illness in female students as compared to their male counterparts.
There was no significance found in the distribution of illness from 1st year to final year students. This was in contradiction to other studies. Most of the studies showed statistically significant variation of mental illness with years of study. 9,10,21,24 One study found more emotional disturbances in 2nd year and 3rd-year students than 1st-year students. 25 Most of these studies quoted higher emotional distress in first-year students as they have to adjust to the new environment, cope up with the academic pressure and stay away from home. Final year students also showed a higher prevalence of mental illness mostly emotional distress due to academic pressure, stress of examination, highly competitive environment, uncertain future and pressure of getting into a post-graduation course. In this study first-year, students were interviewed within one or two months of their admission, when they were still new to the medical academics, without exposure to the vast courses of medicine, exam pressure, patient and clinical postings. Most of them were happy and still excited to get admitted to a medical school whereas, the final year students had high stress levels as they had to pass their final MBBS exams. They had their seminar presentations, clinics, pressure to do well in exams and a very rigorous and high competitive routine to follow. Most of them stated that even after passing their final MBBS their future was uncertain as they had to get into a post-graduate course which is very difficult in India due to limited seats for M.D/M.S.
In this study 44 (10.77%) students had anxiety which was the highest diagnosed mental illness. Depression was the next common mental illness to be diagnosed with a total of 39 (10%) students having depression. Also, stress was found in 14 (3.42%) of students. This was concerning other previous studies which reported high levels of anxiety, stress and depression in undergraduate medical students.25-29 Although in all previous studies the prevalence rate of anxiety, depression and stress varied. In previous studies, the commonest factor responsible for stress and anxiety were academic and professional factor.30-32 The present study also has found the same factors responsible for anxiety and stress. Study-related stress was the most common factor. The other factors were relationship problem, difficulty in adjusting to new friends or roommates, family issues. A very few quoted financial reasons as a stressor. Anxiety was mostly associated with a mild degree of panic symptoms. Depression was mostly associated with decreased concentration, easy fatigue. However, sleep disturbances, loss of appetite and feeling of hopelessness were not very common. GMHAT also gave a comorbid diagnosis of stress and anxiety in 10 students. In most of the students diagnosed with depression, GMHAT also gave anxiety and stress as the other possible diagnosis. Another finding in this study was 69 students, 23 (9.35%) male and 46 (18.70%) female had some anxiety features and these students showed some score in the anxiety domain, but the score was not enough for them to be diagnosed as having mental illness by GMHAT. Similarly, 35 students, 12(4.88%) male and 23(9.35%) female had depressive symptoms and the 31 students 9(3.66%) were male and 22(8.94%) females have symptoms of stress. These students were not diagnosed as having mental illness by GMHAT.
Phobia which was mainly social phobia was diagnosed in 21 (5.38%) students. These students mainly had fear of public speaking, speaking in front of the whole class, presenting a seminar or presenting a case. Hypochondriasis was found in 5 (2.29%) students (M: F= 1:4). They were mostly concerned about their weight. OCD was reported in 3 students (0.77%). Eating disorders were found in 2 (0.51%) students. Both these students were females. Eating disorders were found in other previous studies also.33-35 There was 1 (0.26%) student who was diagnosed as having schizophrenia, GMHAT gave the diagnosis as psychosis. Three (0.77%) students were diagnosed to have psychosis with depression of which 1 student had bipolar disorder. This low prevalence of psychosis was concerning the earlier study. 22 2 out of 14,600 students registered with the Leeds Student Medical Practice had a recorded diagnosis of Schizophrenia.36
Thirty-four (23.61%) students out of 144 students having mental illness had the risk of self-harm or suicidal ideation. Out of these 34 students, 28 students had a mild degree of self-harm ideation and 6 had a moderate degree of self-harm ideation. Out of 246 students who were diagnosed to have no mental illness 2 students showed a mild degree of suicidal ideation. There was no student found to be having a severe degree of suicidal ideas. Also, no one has attempted suicide till now.
An interesting finding in this study was that one student being diagnosed as having alcohol abuse. Many of the students reported having an addiction to nicotine (cigarette smoking) (it cannot be diagnosed by GMHAT). Although many students, including females, do take alcohol almost everybody denied taking alcohol. This may in fear of getting punished by the college administration even though they were earlier intimidated that confidentiality will be maintained. Many of them cited that it was difficult to get alcohol, Wardha being a dry district. The same was with illicit drug use as no student admitted having or taking any illicit drug.
It was seen out of 144 students diagnosed to having mental illness only 29 (20.13%) students are seeking help from a psychiatrist and have visited the Psychiatry OPD for treatment. In a previous study, it was seen that only 22% of students having psychological distress seek help or use health services for treatment.28 In another study done in India reported 4.7% of students seeking help from a counsellor.10
CONCLUSION
Medical schools need to give priority to student welfare and not merely focus on student distress. The present study reports a high prevalence of anxiety, depression and stress in medical students which is comparable with studies done around the globe. Academic stress has a significant correlation with the prevalence of mental illness. The Year of the study did not have an impact on the prevalence of mental illness. Females showed more susceptibility towards having a mental illness. Apart from academic studies, students must also be given the knowledge to improve their coping skills, manage their anger, skills on emotional regulation, impart them skills on conflict resolution and also give them some knowledge to improve their resiliency. These can be possible through Life Skill education and also Social Emotional Training Program which should be made part of the medical education curriculum. Students in the medical fraternity are disinclined to ask for help for their mental illness. Initiatives must also be taken to improve their help-seeking behaviour. This calls for collective responsibility in a holistic and integrated manner and a coordinated effort from their parents, teachers, and friends and most importantly the policymakers and management of the medical college they are studying.
CONFLICT OF INTEREST: None declared.
SOURCE OF FUNDING: None
ACKNOWLEDGEMENT: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript and also acknowledge the contribution of our study participants.
Englishhttp://ijcrr.com/abstract.php?article_id=3692http://ijcrr.com/article_html.php?did=3692
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareA Study of Skin Infections Following Percutaneous K Wire Fixation of Distal Radius Fractures in Elderly
English5962S Panakkal AjayEnglish V Rajiv ShwethaEnglish Kumar K V AneeshEnglishIntroduction: Lower end radius fractures are one of the most common fractures that we deal with in the Department. Almost one-third of the cases in here are these. Elderly patients are more commonly involved in these fractures. The mode of treatment depends upon many factors. But the commonest employed is the K-Wire fixation. But we found that in the elderly population the rate of infections was higher. So this study puts in a sincere effort to find the pattern in the above-mentioned cases.
Objectives: To find the incidence of skin infections following the percutaneous k wire fixation of distal radius fractures in the elderly.
Methods: Seventy-three patients were taken as the sample size for the study. Out of these forty one were male and the rest were females. A careful history of the subjects was taken. Co-morbidities and other conditions if any were noted.
Results: Staph aureus was found to be the most common pathogen which was involved. And the incidence was more observed in females.
Conclusion: With proper and timely management we can save the patient from unnecessary complications. But one has to be vigilant and know these facts.
EnglishSkin infections, K-wire fixation, Elderly, Complications, Radius, FractureINTRODUCTION
Around 15 to 2000 % of all fractures admitted in the Orthopedic ward are of the distal end of the radius.1 The treatment depends on age and several other demographic factors. The treatment includes both conservative and surgical options.2 For a very long time the conservative treatment has been used but many studies indicate the fact that it would be associated with collapse and would not be the choice of treatment in the elderly. So the open reduction and fixation is the choice of treatment especially in the elderly.1,3
Usually, the treatment is very safe and a very less number of cases is reported to have complications.4 There are many types of surgery followed by the operating surgeons in different geographical locations and the complications depend on the surgery and also the operating surgeon.5 Also the complications depend upon the patient's age, lifestyle, associated co-morbid conditions and other factors. Many studies have pointed out the fact that the increase in age and non-compliance with treatment leads to an increased number of complications.6 The surgeon should weigh in proper risk factors and then take the action for the best mode of treatment. This study puts in a sincere effort to identify the incidence of skin infections following the percutaneous k wire fixation of distal radius fractures in the elderly. This study also tries to find the culture and sensitivity pattern and also the management and outcomes of such cases.
MATERIALS AND METHODS
This study was done in the Department of Orthopaedics in collaboration with the Department of Dermatology in Malabar Medical College, Calicut, India. This study was done from August 2018 to July 2020.
Inclusion Criteria: Patients above 65 years.
Exclusion criteria:
The patients who were on immunosuppressant therapy
Patients who were on chemotherapy
Patients who were on radiotherapy.
Open fractures and patients with polytrauma.
Procedure
Seventy-three patients were taken as the sample size for the study. Out of these forty one were male and the rest were females. A careful history of the subjects was taken. Co-morbidities and other conditions if any were noted. A pre-Anaesthetic evaluation was done. Pre-surgical prophylactic antibiotics were started and then taking all anti-septic precautions the patients were operated on. Post-operative prophylactic antibiotics were continued.
The patients were followed up after a week and then after three weeks. The inspection of the surgical site was conducted and no infection was reported. Then a swab was taken and the specimen was transferred to the Department of Microbiology. Culture and sensitivity were done. After the reports, the patients have managed accordingly. In the end, the outcome of the patients was reported.
Results
DISCUSSION
Many studies have reported that the infection rate after k wire fixation is more when compared to the other procedures.7,8 There are a plethora of signs and symptoms that will be displayed by the patients. The commonest symptoms are fever and pain. Then around the surgical site redness, tenderness and even discharge can be noticed. Many studies have pointed out that the infections are very common with K-Wire fixation than in other procedures7,8. According to a study conducted by Esposito et al.9, the infection was reported in around ten per cent which was very much high when compared to that of other procedures.9 Another study conducted by Margaliot Z, et al. reported that the infection rate was found to be around 0.8 per cent when treated with internal fixation. All these statistics have to be considered when the treatment plan is considered for a particular patient. One common practice is to leave the K- wire outside the skin. Such practise should not be considered and followed as many studies have reported that the K wire has to be kept under the skin to minimize the chances of infection.12
Any of the invasive techniques will be associated with the risk of having infections. Egol et al. 11 in their study tried to differentiate the rate of infections using chlorhexidine and hydrogen peroxide-based dressings compared to that of other common dressings but did not find any difference between the two. They also observed that the rate of infections at the site increased with age. A contaminated wound is known to be associated with more chances of infections. So this has to be kept in mind before the line of treatment opted.12 Even though in our country the prophylactic antibiotics have been used extensively some studies have indicated that the use of prophylactic antibiotics will be of no much difference.13
If the infection is there then the next management lines should depend on the extent of infection. Mild to moderate does not need the removal of the K wire. 14,15. Corrective osteotomy, removal of the K wire and debridement may be needed if the infection would be extensive.16
CONCLUSION
This study is a result of a sincere effort to find the frequency of skin infections following percutaneous k wire fixation of distal radius fractures in the elderly. The number of incident cases increased as the patient's age increased. The incidence was observed more in females. All the patients had co-morbidities. Staph aureus was found to be the most common pathogen involved. All the cases were found to be effectively treated as no mortality was found.
ACKNOWLEDGEMENT: We thank the Department of dermatology for the immense help that they have shown.
Conflict of Interest: Nil
Authors Contribution:
Dr S Panakkal Ajay: Lead investigator
Dr V Rajiv Shwetha: Lead investigator
Dr Kumar K V Aneesh: Lead investigator, compiling and statistics.
Englishhttp://ijcrr.com/abstract.php?article_id=3693http://ijcrr.com/article_html.php?did=3693
Ilyas AM, Jupiter JB. Distal radius fractures, classification of treatment and indications for surgery. Orthop Clin North Am 2007;38(2):167–73.
Davis DI, Baratz M. Soft Tissue Complications of Distal Radius Fractures. Hand Clin 2010;26(2):229.
Schneppendahl J, Windolf J, Kaufmann RA. Distal radius fractures: current concepts. J Hand Surg Am 2012;37(8):1718–25.
McKay SD, Assessment of complications of distal radius fractures and development of a complication checklist. J Hand Surg Am 2001;26(5):916–22.
Rhee PC, Dennison DG, Kakar S. Avoiding and treating perioperative complications of distal radius fractures. Hand Clin 2012;28(2):185–98.
Chung KC, Kotsis SV, Kim HM. Predictors of functional outcomes after surgical treatment of distal radius fractures. J Hand Surg Am 2007;32(1):76–83.
Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires. J Hand Surg Br 2004;29(4):374–6.
Ahlborg HG, Josefsson PO. Pin-tract complications in external fixation of fractures of the distal radius. ActaOrthop Scand 1999;70(2):116–118.
Esposito J, External fixation versus open reduction with plate fixation for distal radius fractures: a meta-analysis of randomised controlled trials. Injury 2013;44(4):409–16.
Margaliot Z, A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am 2005;30(6):1185–99.
Egol KA, Treatment of external fixation pins about the wrist: a prospective, randomized trial. J Bone Joint Surg Am 2006;88(2):349–54.
Glueck DA, Charoglu CP, Lawton JN. Factors associated with infection following open distal radius fractures. Hand 2009;4(3):330–4.
Subramanian P, Complications of Kirschner-wire fixation in distal radius fractures. Tech Hand Up Extrem Surg 2012;16(3):120–3.
Hargreaves DG, The role of biofilm formation in percutaneous Kirschner-wire fixation of radial fractures. J Hand Surg Br 2002;27(4):365–8.
Santy J. A review of pin site wound infection assessment criteria. Int J Orthop Trauma Nurs 2010;14(3):125–131.
Turner RG, Faber KJ, Athwal GS. Complications of distal radius fractures. Orthop Clin North Am 2007;38(2):217–28.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareRole of Body Mass Index, Mean Arterial Pressure, and Uterine Artery Doppler at 11-14 Weeks in Prediction of Pregnancy-Induced Hypertension in Low-Risk Population
English6370Kumari MEnglish Das SEnglish Chanania KEnglish Panda AKEnglishIntroduction: Hypertensive disorders of pregnancy represent the most common medical complications with increased maternal and perinatal morbidity. Prediction in the first trimester and prevention with aspirin can help to reduce complications.
Objective: To find out the ability of uterine artery pulsatility index along with mean arterial pressure (MAP) and body mass index (BMI) for prediction of pregnancy-induced hypertension.
Methods: This is a prospective observational study conducted in the Institute of Medical Sciences & SUM Hospital. 200 low-risk pregnant women included at 11-14 weeks of gestation to calculate MAP, BMI. Uterine artery doppler of both arteries are performed during the Nuchal Translucency scan. The average uterine artery pulsatility index was calculated.
Result: 7/200 (3.5%) population developed Pregnancy Induced Hypertension( PIH). Mean Arterial Pressure was significantly higher in early-onset Pre-eclampsia (86.65 ± 3.86) in comparison to normal subjects (80.19 ± 7.37) with (p= 0.040).BMI was not significantly higher (22.50 ± 2.32) compared to normal subjects (22.32 ± 2.02) (p= 0.863). Uterine artery pulsatility index was significantly higher in early-onset pre-eclampsia(pEnglishPre-eclampsia, Prediction, Mean Arterial Pressure, Body Mass Index, Uterine Artery Pulsatility IndexIntroduction
Hypertensive disorders represent the most common medical complication of pregnancy affecting between 2-10% of all gestations and account for approximately a quarter of all antenatal admissions.1 Prediction of pregnancy-induced hypertension is difficult by a single test due to its heterogeneous nature.
It can be assessed to some extent by clinical risk factors (primigravida, PIH in a previous pregnancy, chronic hypertension and renal disease, family history of preeclampsia, type 1 and 2 Diabetes Mellitus, Systemic Lupus Erythematosus, advanced maternal age (>40years), BMI> 30, multi-fetal gestation, In Vitro Fertilization pregnancies, biophysical factors ( mean arterial pressure, body mass index, rollover test and uterine artery doppler in 1st and 2nd trimester )and biochemical markers like serum level of Pregnancy Associated Plasma Protein-A, placental growth factor in 1st trimester.2
A prevalent theory for the development of preeclampsia relates to abnormal vasculature maturation of the arteries within the placenta. Incomplete trophoblastic invasion is the main cause leading to pre-eclampsia.3,4 Doppler imaging permits non-invasive evaluation of uteroplacental circulation. During pregnancy, the normal uterine artery Doppler waveform shows low-resistance flow during diastole with the peak end-diastolic flow increasing as gestational age increases. Assessment of the uterine artery waveform can give indirect evidence of abnormal placentation by displaying a persistently high-resistance flow pattern. Among all parameters, the pulsatility index (PI) performs best.3 Singleton pregnancies identified at 11–13 weeks gestation by combined screening with maternal factors and biomarkers as being at high risk for pre-eclampsia (PE), administration of aspirin (150 mg/day from 11–14 to 36 weeks of gestation) can reduce preterm PE, reduces the rate of delivery at Englishhttp://ijcrr.com/abstract.php?article_id=3694http://ijcrr.com/article_html.php?did=36941. World Health Organization. Report of a WHO technical consultation on birth spacing: Geneva, Switzerland 13-15 June 2005.
2. ACOG Committee on Obstetric Practice. ACOG practise bulletin. Diagnosis and management of preeclampsia and eclampsia. Am Colle Obstet Gynecol Int J Gynecol Obstet 2002;77(1):67-75.
3. Salem MA, Ammar IM. First-trimester uterine artery pulsatility index and maternal serum PAPP-A and PlGF in the prediction of preeclampsia in primigravida. J Obstet Gynaecol Ind 2018;68(3):192-6.
4. Poon LC, Wright D, Rolnik DL, Syngelaki A, Delgado JL, Tsokaki T, et al. Aspirin for Evidence-Based Preeclampsia Prevention trial: effect of aspirin in the prevention of preterm preeclampsia in subgroups of women according to their characteristics and medical and obstetrical history. Am J Obstet Gynecol 2017; 217(5):585-591.
5. Gómez O, Figueras F, Fernández S, Bennasar M, Martínez JM, Puerto B, et al. Reference ranges for uterine artery mean pulsatility index at 11–41 weeks of gestation. Ultrasound Obstet Gynecol 2008;32(2):128-132.
6. Frese EM, Fick A, Sadowsky HS. Blood pressure measurement guidelines for physical therapists. Cardiopulm Phys Ther J 2011;22(2):5.
7. Abrams B, Parker J. Overweight and pregnancy complications. Int J Obes 1988;12(4):293-303.
8. Sood N, Simon P, Ebner P, Eichner D, Reynolds J, Bendavid E, et al. Seroprevalence of SARS-CoV-2–specific antibodies among adults in Los Angeles. J Ame Med Ass 2020; 323(23):2425-2427.
9. Lyall F. The human placental bed revisited. Placenta 2002; 23(8-9):555-562.
10. Kim YM, Bujold E, Chaiworapongsa T, Gomez R, Yoon BH, Thaler HT, et al. ailure of physiologic transformation of the spiral arteries in patients with preterm labour and intact membranes. Am J Obstet Gynecol 2003;189(4):1063-9.
11. Khalil A, Nicolaides KH. How to record uterine artery Doppler in the first trimester. Ultras Obstet Gynecol 2013;42(4):478-9.
12. MacKay AP, Berg CJ, Atrash HK. Pregnancy-related mortality from preeclampsia and eclampsia. Obst Gynecol 2001;97(4):533-8.
13. Osungbade KO, Ige OK. Public health perspectives of preeclampsia in developing countries: implication for health system strengthening. J Pregnancy 2011;5(3):234-238.
14. Duley L. The global impact of pre-eclampsia and eclampsia. Seminars in perinatology J Pregnancy 2009;33(3):130-137.
15. Poon LC, Staboulidou I, Maiz N, Plasencia W, Nicolaides KH. Hypertensive disorders in pregnancy: screening by uterine artery Doppler at 11–13 weeks. Ultrasound Obstet Gynecol: Off J Int Soc Ultras Obstet Gynec 2009;34(2):142-148.
16. Syngelaki A, Bredaki FE, Vaikousi E, Maiz N, Nicolaides KH. Body mass index at 11–13 weeks’ gestation and pregnancy complications. Fetal diagn Ther 2011;30(4):250-265.
17. Anderson NH, Sadler LC, Stewart AW, Fyfe EM, McCowan LM. Ethnicity, body mass index and risk of pre?eclampsia in a multiethnic New Zealand population. Obstet Gynaecol 2012;52(6):552-558.
18 . Mrema D, Lie RT, Østbye T, Mahande MJ, Daltveit AK. The association between pre-pregnancy body mass index and risk of preeclampsia: a registry-based study from Tanzania. BMC Pregn Childbirth 2018;18(1):1-8.
19. Caritis S, Sibai B, Hauth J, Lindheimer M, VanDorsten P, Klebanoff M, et al. Predictors of pre-eclampsia in women at high risk. Am J Obstet Gynecol 1998;179(4):946-951.
20. Gallo D, Poon LC, Fernandez M, Wright D, Nicolaides KH. Prediction of preeclampsia by mean arterial pressure at 11-13 and 20-24 weeks' gestation. Fetal Diagn Therap 2014;36(1):28-37.
21. Quaas L, Wilhelm C, Klosa W, Hillemanns HG, Thaiss F. Urinary protein patterns and EPH-gestosis. Clin Nephrol 1987;27(3):107-110.
22. Kuc S, Koster MP, Franx A, Schielen PC, Visser GH. Maternal characteristics mean arterial pressure and serum markers in early prediction of preeclampsia. PloS One 2013; 8(5):e63546.
23. Cnossen JS, Vollebregt KC, De Vrieze N, TerRiet G, Mol BW, Franx A, Khan KS, Van Der Post JA. Accuracy of mean arterial pressure and blood pressure measurements in predicting pre-eclampsia: systematic review and meta-analysis. Br Med J 2008 15;336(7653):1117-1120.
24. Öney T, Kaulhausen H. The value of the mean arterial blood pressure in the second trimester (MAP-2 value) as a predictor of pregnancy-induced hypertension and preeclampsia. A preliminary report. J Hypert Pregn 1983;2(2):211-216.
25. Rogers MS, Chung T, Baldwin S. A reappraisal of the second trimester mean arterial pressure as a predictor of pregnancy-induced hypertension. J Obstet Gynaecol 1994;14(4):233-236.
26. Kuc S, Koster MP, Franx A, Schielen PC, Visser GH. Maternal characteristics mean arterial pressure and serum markers in early prediction of preeclampsia. PloS One 2013; 8(5):e63546.
27. O’Gorman N, Wright D, Syngelaki A, Akolekar R, Wright A, Poon LC, et al. Competing risks model in screening for preeclampsia by maternal factors and biomarkers at 11-13 weeks gestation. Am J Obstet Gynecol 2016; 214(1):103-e1.
28. Gomez O, Martinez JM, Figueras F, Del Rio M, Borobio V, Puerto B, Coll O, Cararach V, Vanrell JA. Uterine artery Doppler at 11–14 weeks of gestation to screen for hypertensive disorders and associated complications in an unselected population. Ultrasound Obstet Gynecol 2005;26(5):490-494.
30. Pilalis A, Souka AP, Antsaklis P, Daskalakis G, Papantoniou N, Mesogitis S, et al. creening for pre?eclampsia and fetal growth restriction by uterine artery Doppler and PAPP?A at 11–14 weeks' gestation. Ultras Obstet Gynecol2007 Feb;29(2):135-140.
31. Khong SL, Kane SC, Brennecke SP, da Silva Costa F. First-trimester uterine artery Doppler analysis in the prediction of later pregnancy complications. Dis Mark 2015; 2015.
32. Velauthar L, Plana MN, Kalidindi M, Zamora J, Thilaganathan B, Illanes SE, et al. First?trimester uterine artery Doppler and adverse pregnancy outcome: a meta?analysis involving 55 974 women. Ultras Obst Gynecol 2014;43(5):500-507.
33. Erdo?du E, Ar?soy R, Kumru P, Ard?ç C, Pekin O, Tu?rul S. The role of first trimester uterine artery Doppler in the prediction of preeclampsia. Perinat J Perinatoloji Derg. 2014;22.
34. Gómez O, Figueras F, Fernández S, Bennasar M, Martínez JM, Puerto B, et al. Reference ranges for uterine artery mean pulsatility index at 11–41 weeks of gestation. Ultras Obstet Gynecol 2008;32(2):128-32.
35. Poon LC, Nicolaides KH. First?trimester maternal factors and biomarker screening for preeclampsia. Prenat Diagn 2014;34(7):618-27.
36. Akolekar R, Syngelaki A, Poon L, Wright D, Nicolaides KH. Competing risks model in early screening for preeclampsia by biophysical and biochemical markers. Fetal Diagn Ther 2013;33(1):8-15.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareKnowledge and Awareness of Children Towards Parental Tobacco Consumption in Central Maharashtra- An Epidemiological Questionnaire-based Study
English7174Sourabh R JoshiEnglish Gowri S PendyalaEnglish Shridhar ShettyEnglish Gargi S SarodeEnglish Sachin SarodeEnglish Kiran JadhavEnglishIntroduction: Changes in an individual’s lifestyle, not only affects the individual but also his or her surroundings. Parents are generally not aware of the ill effects of their tobacco consumption on the psyche of the child. The affected children are also not generally aware of the ill effects of the passive habit.
Objective: The present study was designed to determine the knowledge and awareness of children towards parental smoking.
Methods: A total of 500 children, between the ages of 10 and 15 years belonging to a similar socio-economic status, from the rural schools in and around Loni were selected for the present study. Information, from these children, was obtained by giving them a questionnaire in the local Marathi language. A Chi-square test was applied to the data obtained and the results were derived.
Results: The obtained results showed that children were highly influenced by parental tobacco use to the extent that they showed the signs of developing the habit themselves.
Conclusion: This study concludes that parental tobacco chewing and/or tobacco habits have a direct detrimental influence on their children.
EnglishChildren’s attitudes, Parental influence, Tobacco chewingIntroduction
During childhood and adolescence, most people develop and establish lifestyles that determine their future health.1 The influence of parental lifestyles is very great on children, since they are at an impressionable age of their lives. Parental Tobacco Chewing is associated with a higher possibility that the child will chew tobacco as well.2 Usage of tobacco products with alcohol and marijuana have been seen among the adolescents.3,4 Associations between use of either tobacco product and corresponding use amongst peers, siblings and parents has also been reported.4,5 Tobacco Chewing is one habit which is dangerous to the health of a person. Since past three decades there has been increasing interest in the effects of passive smoking on children’s health. As children spend much of their early life in the presence of their parents, children whose parents chew tobacco or have any other tobacco habit will have prolonged exposure to tobacco. More than 4000 different components have been identified in cigarette smoke itself.6 Of these, nicotine is a highly toxic alkaloid that is both a ganglionic stimulant and a depressant. Carbon Monoxide, released in tobacco smoke is known to interfere with oxygen transport and supply.6 Tobacco Chewing not only affects the quality of life but also the social well being of an individual. The International Agency for Research on Cancer (IARC) has reviewed that parental tobacco exposure has been associated with prenatal damage to the fetus, adverse respiratory outcomes like asthma, atopy, and allergies among children, coronary heart disease. It also affects the oral health status of children.7,8 WHO estimates 4.9million deaths are annually attributed to tobacco (WHO report 2002). This figure is expected to rise to 10 million in 2030, with 7 million of these deaths occurring in developing countries, mainly, India and China.9 India is home to one-sixth of the global population. Currently about one-fifth of all worldwide deaths attributed to tobacco occur in India, more than 8,00,000 people die and 12 million people become ill due to tobacco. The death rate due to tobacco are expected to rise from 1.4% in 1990, to 13.3% in 2020.9 It is estimated that 5,500 adolescents, inspired by their parents start using tobacco every day in India, joining the 4 million young people under the age of 15 who already regularly use tobacco. Changes in the lifestyle of an individual affect not only his/ her life but also their respective surroundings. Parents may not be aware of the ill effects of tobacco habits on the child’s health as well as his/her psychological development.10 Children are also not very knowledgeable about the same. Thus, this present study was designed to determine the knowledge and awareness of children towards parental tobacco chewing.
MATERIALS AND METHODS
A total of 500 children, between the ages of 10 and 15 years belonging to the same socioeconomic status, from the rural schools in and around Loni were selected for the study, following a simple random sampling method. The study was approved by the Institutional Ethical Committee (PIMS/IEC/DR/2014/180). The demographics of these children are explained in Table 1. Information, from these children, were obtained by giving them a questionnaire in the local Marathi language. A total of 7 questions were framed out of which 3 questions were framed to assess the Knowledge of the students and 4 questions were framed to assess the Awareness of the students towards parental tobacco chewing. Questions were added to include parental tobacco use in the form of smokeless or smoked tobacco and bidi smoking. The questionnaire was presented among young boys and girls in Loni. Data on age, gender, grade, parent’s education and occupation, current use of tobacco products among students, knowledge, and awareness regarding the use of tobacco and tobacco products were obtained using a semi-structured questionnaire. The sequencing of the questions was logical. The questions were administered without any identifying information, skipping or branching pattern. The contents of the questionnaire were validated by a trained Medical Health Professional. The responses collected were kept confidential to the authors themselves. Informed consent was obtained by the guardians (teachers) of the school.
Statistical analysis
Chi-square test was applied to the data received and the results were formulated.
Results
The subjects eligible for the survey were 500 children between the ages of 10 and 15 years. In the following study, all the questionnaires given were returned with the required information (100%). Out of 500, 292 were boys (58.4%) and 208 were girls (41.6%). The mean age of the children was about 11.49 years (Table 1). After obtaining all the required data, the Chi-Square test was applied and the following results were obtained regarding the Knowledge and awareness of the children towards familial tobacco habits. The highest percentage of adults with tobacco habits were the Fathers at 35.8% and Grand Fathers at 42% (Figure 2). The most common type of smoking tobacco in the chosen area was seen to be Bidi at 33% and the most common smokeless form was tobacco with lime at 38.2% (Figure 1). It was seen that about 81.84% of boys and 76.44% of girls knew that a tobacco habit was harmful to health (Figure 3). It was also noted, that around 64.72% of boys and 48.8% of girls knew that passive tobacco inhalation was equally harmful to their health as well. About 98.29% of boys and 95.67% of girls had not discussed the ill effects of tobacco with their parents/guardians (Figure 3). The questionnaire covered the children’s perspective towards familial tobacco habits as well, as the obtained results are as follows;
More than 30% of the children tried to prevent the tobacco habit at home but nearly 70% couldn’t prevent their parents from tobacco consumption (Figure 3). Almost all the children agreed and were aware that public smoking or practising any form of tobacco smoking or smokeless should be banned (Figure 3). Less than 4% of the children also had friends practising the habit (Figure 3).
Discussion
Consistent with previous studies on tobacco use risk factors, this study supports the importance of addressing awareness and, knowledge of children regarding familial tobacco use. From this study, it was clear, that the children were well aware of their parents and relatives have a tobacco habit and were greatly influenced by the same. In our study, most children were heavily and negatively influenced, as it was seen that most have developed the habit themselves due to prolonged exposure passively. Prior research by Murray et al.4 has shown that both general parenting behaviours and smoking-specific parenting practices contribute to adolescent smoking behaviours. A study done by Horn et al. 5 and Chassin et al. 5,11 showed that inadequate knowledge about tobacco and health, tobacco use among family and friends, favourable attitude towards tobacco use were important determinants of tobacco use among adolescents. The 2013 survey done in India also observed that favourable parental tobacco use was a significant risk factor for the uptake of the habit in children.12 In our study, it was clear that the tobacco habit was practised more in front of the boys as compared to the girls. It was also seen that they had more information and were relatively easily influenced by their parents and relatives. A study carried out by Ballal et al. 13 among 13 to 19 years, found knowledge among females to be better than males about tobacco consumption habits. From our study, we could conclude that boys and girls were aware of tobacco chewing habits. One of the positive outcomes of this study was the awareness of the children towards practising the tobacco habit. Almost all of the children agreed that it was imperative to ban public smoking or practising any form of tobacco habit. Children also tried to prevent the habit among their relatives but a very less percentage could attempt it. There was also a visible attempt to prevent and control this habit taken up by the children themselves, which goes to show that the children were better aware of the ill effects of tobacco due to external influences such as school and their peers. It was also clearly seen that there was no significant relationship between the influences of practising tobacco amongst friends.
Conclusion
Many of the parents, guardians and relatives had an excessive habit and the ill- effects were not openly discussed with the children. Despite the children trying to prevent this habit, no clear action was taken in the family to stop or control the habit. This study concludes that parental tobacco chewing and/or tobacco habits have a direct influence on children. Pro-tobacco behaviour of the parents and relatives has a heavy negative influence on the child since the child picks up on the habit and develops the habit for himself/ herself as well. It is thus advisable for parents and guardians to terminate the habit and lead by example to prevent their children from getting addicted to tobacco.
Future Perspectives
The present study highlights the effects of tobacco consumption by parents on children. Though this study highlights childrens’ knowledge and awareness about parental tobacco consumption, more studies are required to understand children's awareness towards parental tobacco consumption.
CONFLICT OF INTEREST: None
FINANCIAL DISCLOSURE: This is a self-funded project.
AUTHORS CONTRIBUTION:
Dr Sourabh Joshi helped in carrying out the study by visiting the schools.
Dr Gowri Pendyala helped in collecting the data.
Dr. Gargi Sarode contributed to creating the concept.
Dr. Sachin Sarode contributed by designing the study.
ACKNOWLEDGEMENT: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed."
Englishhttp://ijcrr.com/abstract.php?article_id=3695http://ijcrr.com/article_html.php?did=36951. Rossow I, Rise J. Concordance of parental and adolescent health behaviours. Soc Sci Med 1994;38(9):1299–1305.
2. Tyas SL, Pederson LL. Psychosocial factors related to adolescent smoking: a critical review of the literature. Tob Control 1998;7(4):409–420.
3. Simon T, Sussane S, Dent C. Correlates of exclusive or combined use of cigarettes and smokeless tobacco among male adolescents. Addict Behav 1993;18(1):623-634.
4. Murray DM, Roche LM, Goldman AI, Whitebeck J. Smokeless tobacco use among ninth graders in a north-central metropolitan population: Cross-sectional and prospective associations with age, gender, race, family structure, and other drug use. Prev Med 1988;17(4):449–460.
5. Horn KA, Gao X, Dino GA, Kamal-Bahl S. Determinants of youth tobacco use in West Virginia: a comparison of smoking and smokeless tobacco use. Am J Drug Alcohol Abuse 2000;26(1):125–138.
6. Raherison C, Pénard-Morand C, Moreau D, Caillaud D, Charpin D, Kopfersmitt C, et al. In utero and childhood exposure to parental tobacco smoke, and allergies in schoolchildren. Respir Med 2007;101(1):107–117.
7. Barnes DE, Bero LA. Why review articles on the health effects of passive smoking reach different conclusions. J Am Med Assoc 1998;279(19):1566–1570.
8. Fleming P, Blair PS. Sudden Infant Death Syndrome and parental smoking. Early Hum Dev 2007;83(11):721–725.
9. Patel DR. Smoking and children. Indian J Pediatr 1999;66(6):817–824.
10. Rainio SU, Rimpelä AH. Home smoking bans in Finland and the association with child smoking. Eur J Public Health 2007;18(3):306–311.
11. Chassin L, Presson CC, Sherman SJ, Edwards DA. Parent educational attainment and adolescent cigarette smoking. J Subst Abuse 1992;4(3):219–234.
12. Dhawan A, Pattanayak RD, Chopra A, Tikoo VK, Kumar R. Pattern and profile of children using substances in India: Insights and recommendations. Natl Med J India. 2017;30(4):224–9.
13. Ballal K, Kulkarni M, Agrawal A, Kamath A, Kumar M. Knowledge and attitude regarding tobacco and its use among adolescent students. Natl J Community Med 2016;79(5):519-513.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareProximal Femoral Nail Versus Dynamic Hip Screw in Unstable Peritrochanteric Fractures of Femur,
A Comparative Clinical Study
English7581Nagesh CherukuriEnglish Raja Ramesh BadavathEnglish Srikanth EEnglishIntroduction: Trochanteric fractures constitute one of the commonest fractures encountered in the elderly. Operative management which allows early rehabilitation and offers the patient the best chances for functional recovery is the treatment of choice for virtually all trochanteric fractures.
Objective: To compare the clinical, functional and radiological outcome of unstable intertrochanteric fractures femur treated randomly with proximal femur nail(PFN) and Dynamic hip screw(DHS). Functional and clinical outcome measurement using harris hip score.
Methods: This prospective randomized study compared the outcome of elderly patients with pertrochanteric fracture and carried out in Nizam`s institute of medical sciences Hyderabad in the year 2018 and 2019. 60 patients with unstable intertrochanteric fractures were included. 30 patients were operated on by the Proximal Femoral Nail (PFN) and 30 patients were operated on by Dynamic hip screw (DHS). Functional outcome was assessed by Modified Harris Hip Score.
Results: The rate of union was similar in both groups. The mean Harris hip Score in the DHS group was 82.1 compared to 83.5 in PFN. Effective results were seen in 63.3% of cases in the DHS group and 73.3% cases in the PFN group. The mean surgery time for DHS (76 min) was marginally higher than that for PFN (76 min) which is non-significant (P=0.281). The blood loss was also marginally lower in the IM Nail group (264ml) compared to the DHS group (354 ml) which was also not statistically significant (P=0.14).
Conclusion: The implant-related complications were much lesser in the patients treated with Dynamic Hip Screw(DHS). We did not encounter any secondary femoral fracture in patients managed by proximal femoral nails though this is one of the common complications reported in other studies.
EnglishDynamic Hip Screw(DHS), Proximal Femoral Nail, Peritrochanteric Fractures, femoral fracture, Functional outcome, Modified Harris Hip ScoreINTRODUCTION
Intertrochanteric fractures are one of the commonest fractures especially in the elderly with osteoporotic bones and are usually due to low energy trauma like simple fall. It occurs most commonly in the age group above 70 years. Hip fractures have a bimodal age distribution. Approximately 97% occur in patients over 50 years of age (the incidence increases with age), and only 3% in patients under the age of 50. In the latter group, they occur most commonly between 20 and 40 years of age, usually in men, and are due to high-energy trauma associated with sports and industrial and motor vehicle accidents. In this young group, most hip fractures are subtrochanteric or basic cervical.
Intertrochanteric hip fractures account for nearly half of the hip fractures in the elderly; out of this more than 50 per cent of fractures are unstable. The unstable pattern occurs more frequently with increased age and with low bone mineral density. By 2025, the incidence of hip fracture is estimated to be doubled worldwide. Fractures in the elderly are serious injuries, often occurring in the terminal years of life and they have a major impact on society, our health care system and the cost of care. Fractures in the young age group lead to long-lasting elimination from working process or even loss of job thus causing socio-economic problems.1
The overall increase in the incidence of trochanteric fracture can be attributed to two factors: increased life expectancy which increases the aged population and high energy trauma which victimizes more young adults. Fractures of the hip in patients between 40 and 50 years of age usually occur in alcoholics or patients with multiple medical diseases, whose fractures are related to osteoporosis. The goal of treatment of an intertrochanteric fracture is to restore mobility safely and efficiently while minimizing the risk of medical complications and technical failure and to restore the patient to preoperative status.1 Moreover as this fracture occurs in elderly patients the risks from prolonged immobility and recumbency arise. Thus, treatment should be designed in a way that promotes union without deformity and enables early mobilisation at the same time. Since then a variety of different implants has been used either extramedullary or intramedullary.
The most commonly used implant is a sliding hip screw with a side plate (DHS), it is currently considered the gold standard for fixation of extracapsular hip fractures. DHS has been shown to produce good results, however, complications are frequent particularly in unstable fractures.2 Nailing has the advantage of providing rotational as well as axial stability in cases of trochanteric fractures allowing a faster postoperative restoration of walking ability when compared with DHS. The nails are load-sharing implants, whereas extramedullary devices are load-bearing. Proximal femoral nailing creates a shorter lever arm, which translates to a lower bending moment and a decreased rate of mechanical failure.
Potential disadvantages are related to a greater risk of jamming the sliding mechanism and stress risers at the site of the tip of the nail and distal locking bolts.3 Intramedullary implants have been associated with an increased risk of intraoperative and postoperative femur fractures compared with sliding hip screws. The increased peri-implant fracture incidence has been linked to stress concentration at the tip of the nail, stress concentration at the distal locking bolt, and reaming of the proximal femur to accommodate the wider proximal diameter of the nail necessary to allow a large diameter lag screw to pass through the nail.
Data published so far confirm that PFN is a reliable implant, producing results similar to those obtained with the DHS for unstable trochanteric fractures. However, some authors have reported a screw cut-out of the femoral head and a higher incidence of PFN intra-operational difficulties. For unstable trochanteric fractures and reverse oblique fractures, therefore controversy continues regarding the optimum choice of implant. The purpose of the present study is to compare outcome and complications between the PFN and DHS in the treatment of patients with an unstable pertrochanteric fracture.
MATERIALS AND METHODS
The present thesis work involves a prospective randomized study of 60 patients with unstable intertrochanteric fractures treated surgically in the Department of orthopaedics, Nizam`s institute of medical sciences, Hyderabad. Institutional ethical clearance was obtained (EC/NIMS/2237/2018).
Inclusion criteria: Patients with unstable intertrochanteric fractures femur which include
Inclusion criteria: Age 20 to 90 years, posterior medial large separate fragment (unstable), Failure to reduce fracture before internal fixation, Reverse oblique pattern and Fractures with subtrochanteric extension
Exclusion criteria: Stable fractures i.e fractures with intact posterior medial cortex, Pathological fractures, Patients with significant hip or knee arthritis and Compound fractures
Patients with unstable intertrochanteric fractures are taken into the study, a note of age, sex, occupation and mechanism of injury is made. The patient’s ambulatory status before the injury is considered. Clinical features do not contribute much to the assessment of type and comminution of fracture. Patients underlying past or present medical conditions are noted which have a bearing on the management and outcome. Measures taken in the acute stage for hemodynamic stabilization of the patient due to the fracture or due to other reasons are not taken in to account. Immediate immobilization of the injured limb with Buck`s skin traction is done to prevent further soft tissue damage and give comfort to the patient.
After the limb is immobilized radiographs are taken to confirm the diagnosis, delineate the fracture pattern, its obliquity and quality of bone present. All the fractures are classified according to Evan`s, Boyd & Griffin classification, AO classification system based on roentgenograms. All routine investigations are done for anaesthetic fitness. If operative treatment is undertaken, the following fractures determine the strength of fracture – Implant assembly, namely the 1) bone quality 2) fragment geometry 3) reduction. 4) implant design and 5) implant placement will be stressed upon. Once anaesthetic fitness is obtained routine preoperative preparation is carried out. Each patient is given antibiotic prophylaxis of injection cefotaxime 1gm just before surgery. The anaesthesia employed is left to the anaesthetist`s choice.
RESULTS
In our study, the maximum number of cases were in the age group of 50-70 years.
Males are more in number compared to females in our present study. Most of our patients were 50 years and above and in the domestic fall (fall at home) and trivial trauma was the main reason behind fracture while in young patients road traffic accident (RTA) was the main cause.c58% of the patients in our study were right-sided. Average time-lapse for surgery: 7 days in our study
43.3% of patients in the DHS group belongs to the 31A2 type. Similarly, 38.3% of PFN patients belong to the 31A2 type.
The mean duration of operation (in minutes) in our study was 72min in the PFN group and 76 min in the DHS group. Mean blood loss in the DHS group was 354 ml and mean blood loss in the PFN group was 264 ml
Mean duration of radiation exposure in sec was 61.5 in the PFN group and 58.3 in the DHS group.
The average shortening in the P.F.N group was 8.4 mm as compared to 9.4 mm in the D.H.S group.
Mean Harris hip Score in the DHS group was 82.1 compared to 83.5 in PFN.
Excellent and good results were seen in 63.3% of cases in the DHS group and 73.3% cases in the PFN group.
DISCUSSION
The present study was carried out in Nizam`s institute of medical sciences Hyderabad in the year 2018 and 2019. 60 patients with unstable intertrochanteric fractures were included. 30 patients were operated on by the Proximal femoral nail(PFN) and 30 patients were operated on by the Dynamic hip screw (DHS).
In our study, the maximum number of cases were in the age group of 50-70 years. The average age was 59.2 years, the average age for males was 56.8years and for females was 62 years. The mean age in years for the group operated by PFN was 57.6 years. The mean age in years for the group operated by DHS was 60.9 years. The youngest patient was 21 years old and the oldest patient was 84 years old. In a study done by Adeel K et al mean age of patients in PNF was 59.32±2.39 years and in DHS was 60.88±12.49 years.4 Dorotka et al. reported in their series of 182 patients, the mean age of 77.1 years.5 Moran et al in a mega study of 2903 cases, reported the mean age of 80 years for hip fractures.6 In the present study, the mean age was found to be 71.1 years. The lower peak age as compared to the West may simply be linked to a shorter life span, as also to the inclusion of traumatic/ non-fragility fractures in the analysis.
Most of the patients from the present study were males. There was a slight male preponderance in our patients. The ratio of males to female was 1.1:1. In western countries, women suffering from osteoporosis far outnumber men, and this is largely thought to be due to the effects of menopause.7 The men: women ratio may be distorted in India because men are more likely to be brought for hospital care. Moran et al. reported 76% females with male to female ratio of 1:3.1.6 While Gardner et al. reported 78% females with male to female ratio of 1:3.5 in his series of 80 patients But in our study male to female ratio was 1.5:1.8 This sex distribution is against most of the international data but is following different local studies. The majority of the patients in the series were male as they are more outgoing and engaged in activities like agriculture, driving motor vehicles and are more likely to be involved or prone to accidents/fall. Females play a more dormant role and are involved more in household activities.9
Most of our patients were 50 years and above and in the domestic fall (fall at home) and trivial trauma was the main reason behind fracture while in young patients road traffic accident (RTA) was the main cause. 90% of hip fractures in the elderly result from a simple fall.10 In the cases treated by PFN, there were 18 cases(60%) due to domestic fall and 12 cases(40%) due to road traffic accident(RTA) while there were no cases due to assault. In the patients treated with DHS, there were 23 cases(76.6) where the mode of injury was due to domestic fall, while 7 cases(23.3%)were due to Road traffic accident (RTA). There were nil assault cases. Young patients with intertrochanteric fractures sustained trauma either as a result of a road traffic accident or fall from height, thereby reflecting the requirement of high-velocity trauma to cause a fracture in the young. Whereas in elderly people trivial trauma caused the hip fracture.
We have studied 60 cases of different types of intertrochanteric fractures in our present study. Among the 30 cases operated by PFN, 11(36.6%) patients were found to have proximal femoral fractures on the left side while 19 (63.3%) patients were having fracture on the right side. Among the 30 cases operated by DHS,14 (46.6%) patients were found to have proximal femoral fractures on the left side while 16 (54.4%) patients were having fracture on the right side.
The majority of patients in the present study series were operated on within 10 days following admission to the hospital (52/60). But in some patients (8/60) operative procedure was delayed due to medical problems (Hypertension and Diabetes) of patients. Average time-lapse for surgery: 7 days. Amongst patients who had a delay in operative intervention, 6 patients came to the hospital following 10 days of trauma. The delay in surgery was attributed to two major reasons. The first was the time lag between injury and hospitalization. The second reason for the delay was the time lag between hospitalization and surgery. This was attributed to the poor general condition of the patient towards requiring further workup for fitness for anaesthesia and surgery and associated injuries.
The most commonly used classification currently is the AO/OTA classification, which classifies IT fractures into three types: 31A1, 31 A2 and 31A3 with increasing instability as the grade increases. In A1 and A2 fractures, axial loading leads to fracture impaction, whereas in A3 fractures such impaction does not occur, and medial displacement of the distal fragment of the fracture is common due to the instability. All the fractures in our study were unstable intertrochanteric fractures and were classified according to the AO classification for peritrochanteric fractures. 49 (81.6%) patients were AO type 2 in both DHS and PFN group while 11(18.3%)patients were AO type 3 in both DHS and PFN group
In patients with domestic fall, distal radius fracture was seen in 2 patients which were treated conservatively, 1 patient had iliac wing fracture treated conservatively. 1 patient had an L2 wedge compression fracture which was treated conservatively. Associated injuries seen in patients with fall from height are distal end radius fracture in 1 patient treated conservatively.
In patients who sustained high energy trauma is as the head injury was seen in 2 patients, CT brain study was normal in one and the other had cerebral oedema and was treated conservatively. Blunt injury abdomen was seen in 1 patient CT scan showed Grade 1 liver laceration and was treated conservatively. 1 patient had radius fracture and patella fracture, 1 patient had a shaft femur fracture and patella fracture,1 patient had both bones leg fracture. Associated injuries were more common in the high-velocity trauma group. In our study 23 patients had hypertension, 10 patients were diabetic,7 patients had CAD, 1 patient with post CABG status, 4 patients had hemiparesis, 1 patient undergone PTCA, 2 patient had bronchial asthma,3 patients had COPD and 2 patients had CKD.
The majority of the patients were diabetic and hypertensive in our group.
In our study, we considered various intraoperative parameters like radiographic exposures, duration of surgery and amount of blood loss. Radiographic exposure was more for PFN where the closed reduction was done and for comminuted fractures with difficult reduction. Duration of surgery was more for DHS compared to PFN. Blood loss was measured by mop count and collection in suction. Blood loss was more for DHS compared to the PFN group. Operating time and blood loss in various other studies are as follows.11
Mean blood loss of our study was comparable with that of Pan et al.12 Mean duration of surgery was comparable with that of Saudan et al. Mean operating time was more when compared to Giraud et al because most of the fractures were unstable pattern which required more radiation exposure for closed reduction.13 Superficial wound infection was seen in 4 cases in total. 3 cases were seen in those operated by DHS. The 3 cases operated by DHS had superficial wound infection at the suture site. This may be attributed to the long duration of surgery because of difficulty reduction& more soft tissue exposure, which is more in cases operated by DHS. In all the cases infection was treated by removal of skin sutures and antibiotics were continued. The wound healed by secondary intention. One case operated by PFN had a superficial infection which was treated with removal of skin sutures, antibiotics and regular dressing. In all the cases the wound healed in the end. In the series of patients operated by DHS by Dr. G.S Kulkarni, there were two cases of deep infections which were treated by removal of the implant.14 The infected sinuses thus healed after implant removal.
Two cases of fascia lata pain were noted due to the laterally protruding plate in the DHS group. No incidence of anterior thigh pain was noted in our study. In 4 cases (13.3%) operated cases by Proximal Femoral Nailing (PFN), there was ill-fitting of the jig. Due to the corresponding holes of the jig and nail was not matching at times. In 3 cases treated by PFN, we encountered difficulty in distal locking of the nail due to mismatch of corresponding holes of jig and nail. While in those cases operated by Dynamic Hip Screw (DHS) we encountered 2 cases (6.6%)having difficulty in reduction. This was due to excessive comminution and displacement. There is no incidence of crewcut out or breakage of the implant or femoral shaft fracture noted in the follow-up period in our study.
Varus angulation was noted in one operated case in the DHS group due to the pull of the muscle the distal shaft fragment tends to migrate upwards thus resulting in varus deformity. The other reason that patients had coxa vara deformity was due to inadequate reduction and failure to maintain neck-shaft angle preoperatively, however, varus angulation was less than 10 ? and there was no incidence of screw cut out. In the series by K.D Harrington, out of 72 cases, there were 4 cases of coxa vara and 56 cases of limb shortening at an average of 1.5 cms. The average shortening in the PFN group was 8.4 mm as compared to 9.4 mm in the D.H.S group. So, shortening is less in the PFN group which is not statistically significant, p-value 0.21.
In the present study, in the cases that we operated by PFN, we have not encountered the ‘Z’ effect or reverse ‘Z’ effect. In patients with unstable intertrochanteric fractures treated with proximal femoral nailing, technical or mechanical complications seem to be related to the fracture type, operating technique, and time to weight-bearing rather than the implant itself.
The range of movement calculated by the Harris Hip Scoring system treated by both the implants i.e PFN and DHS was good, Mean Harris hip Score in the DHS group was 82.1 compared to 83.5 in PFN. Excellent and good results were seen in 63.3% of cases in the DHS group and 73.3% cases in the PFN group, however, results were not statistically significant(P value>0.05). Mean union time for fracture union in PFN group was 13.7 weeks while in DHS group was 14.8 weeks however results were not statistically significant (p-value >0.05) (Range:12 to 18 weeks). We have used criteria for the union as the presence of bridging callus at the fracture site. Most of the fracture circumference with a density similar to adjacent cortical bone. Clinically, absence of pain at the fracture site. Kevin D. Harrington11 in his series reported the average radiological time of fracture union as 16 weeks.
A randomized post-op rehabilitation study by Pajarinen et al. comparing peritrochanteric femoral fracture treated with DHS or PFN suggested that the use of PFN may allow faster postoperative restoration of walking ability when compared to DHS.16 Preservation of ambulatory function is the most important issue in the treatment of hip fractures. Larsson et al also showed that severe loss in ambulatory function would increase the risk of having socioeconomic problems.17 The level of ambulation achieved in the post-op period is a function of the pre-operative mobility status and medical condition, associated skeletal injuries, the quality of fracture stabilization, perioperative complications and early ambulation.
CONCLUSION
Both the implants PFN and DHS are excellent modalities in the management of pertrochanteric fractures of the femur. Functional outcome was assessed by Modified Harris Hip Score. Mean Harris hip Score in the DHS group was 82.1 compared to 83.5 in PFN. Results were excellent and good in 63.3% of cases in the DHS group and 73.3% cases in the PFN group, however, results were not statistically significant. The incidence of wound infection was found to be lower with intramedullary implants. 10% in DHS vs 3% in PFN. Non-union of trochanteric fracture is a rare entity, no case was found in our series of patients. The implant-related complications were much lesser in the patients treated with Dynamic Hip Screw(DHS). We did not encounter any secondary femoral fracture in patients managed by proximal femoral nails though this is one of the common complications reported in other studies. Since the sample size of this study was small the outcome cannot be generalised. However, a longer follow-up period and further study with a larger number of patients is required to confirm the results of our study
ACKNOWLEDGEMENT: The 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.
Conflict of interest-Nil
Financial support-Nil
Englishhttp://ijcrr.com/abstract.php?article_id=3696http://ijcrr.com/article_html.php?did=3696
Babhulkar SS. Management of trochanteric fractures. Indian J Orthop 2006;40(4):210-218.
Gupta SKV, Valisetti VS. Comparative study between dynamic hip screw vs proximal femoral nailing in inter-trochanteric fractures of the femur in adults, Int J Orthop Sci 2015;1(1):07-11.
Maniscalco P, Rivera F, D’Ascola J, Del Vecchio EO: Failure of intertrochanteric nailing due to distal nail jamming. J Orthop Traumatol 2013:14:71–7.
Adeel K, Nadeem RD, Akhtar M, Sah RK, Mahy-Ud-Din I. Comparison of the proximal femoral nail (PFN) and dynamic hip screw (DHS) for the treatment of AO type A2 and A3 pertrochanteric fractures of the femur. J Pak Med Assoc 2020;70(5):815-819.
Dorotaka R, Schoechtner H, Buchingerw. The influence of immediate surgical treatment to proximal femoral fractures on mortality and quality of life within six hours of the fracture versus late than six hours. J Bone Joint Surg 2003;85:1107-13
Moran CG, Wennrt, Sikand M. Early mortality after hip fracture: Is delay before surgery important. J Bone Joint Surg 2005;87:483-9.
McCarus DC. Fracture prevention in postmenopausal osteoporosis: A review of treatment options. Obstet Gynecol Surv 2006; 61:39-50.
Gardner MJ, Brophy RH, Demetrakopoulos D. Interventions to improve osteoporosis treatment following hip fracture: A prospective, randomized trial. J Bone Joint Surg 2005;87:1-7.
Sengodan VC, Elangovan S, Kumar JS. Management of ipsilateral fracture of hip and shaft of the femur. Int J Curr Res Rev 2017; 07(17):7-14.
Koval KJ, Chen AL, Aharonoff GB, Egol KA, Zuckerman JD. Clinical pathway for hip fractures in the elderly: the Hospital for Joint Diseases experience. Clin Orthop Relat Res 2004;4(25):72-81.
Windoff J, Hollander DA, Hakimi M, Linhart: Pitfalls & complications in the use of proximal femoral nail. Lagenbecks Arch Aurg 2005:3901(1):234.
Pan X, Xiao D, Lin B, Huang G. Dynamic hip screws (DHS) and proximal femoral nails (PFN) in treatment of intertrochanteric fractures of the femur in elderly patients. Chin J Orthop Trauma 2004:6(7):785–789.
Saudan M, Lübbeke A, Sadowski C, Riand N, Stern R, Hoffmeyer W. Petrochanteric fractures: is there an advantage to an intramedullary nail? A randomized, prospective study of 206 patients comparing the dynamic hip screw and proximal femoral nail. J Orthop Trauma 2002:16(6):386–393.
Kulkarni GS, Miraj AW. Treatment of trochanteric fractures of hip by modified Richard's compression and collapsing screw. Indian J Orthop 1984:18(1):30.
Domingo LJ, Cecilia D, Herrera A, Resines C. Trochanteric fractures treated with a proximal femoral nail. Int Orthop 2001;25:298-301.
Pajarinen J, Lindahl J, Michelson O, Savolainen V, Hirvensalo E. Pertrochanteric femoral fractures treated with dynamic hip screws or a proximal femoral nail: A randomized study comparing post-operative rehabilitation. J Bone Joint Surg Br 2005;87(1):76–81.
Larsson S, Friberg S, Hansson LI. Trochanteric fracture; Influence of reduction and implant position on impaction and complication. Clin Orthop 1990;259:130-139.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareStudy of Renal Adverse Effects of Nsaids Used in Spondyloarthritis Patients
English8287Chaudhary GKEnglish Das CEnglish Dash SEnglish Sahu SEnglishIntroduction: Clinical history, symptoms, lab parameter along with radiological investigation help in the diagnosis and management of spondyloarthritis (SpA). However, spondyloarthritis manage mainly by NSAIDs.NSAIDs can cause subclinical renal injury which is not manifest in routine renal function tests (like serum creatinine). Published case series among ankylosing spondylitis patients have shown the prevalence of renal complication 72% higher than the general population. A limited number of studies are present on evaluating the effect of NSAIDs on changes in the level of cystatin-c. So here we studied the change in parameters of serum creatinine and cystatin-c level after the use of NSAIDs in the setting of SpA.
Objective: To study the relation of the duration of use of NSAIDs in Spondyloarthritis patients and the incidence of subclinical kidney injury by comparing serum creatinine with serum cystatin-c.
Methods: A hospital-based prospective observational study carried out over one year in IMS and SUM hospital over 31 patients on spondyloarthritis patients. Where the level of serum creatinine and cystatin-c level calculated on the baseline, four weeks and twelve-week.
Results: Patients using a different type of NSAIDs there is no significant change in serum creatinine value (p=0.546).while a significant change in serum cystatin-c level (pEnglishSpondyloarthritis, NSAIDs, Subclinical renal injury, Ankylosing spondylitisINTRODUCTION
Spondyloarthritis is a diverse group of arthritis feature by inflammation in the axial skeleton and enthesis.1 Spondyloarthritis comprises ankylosing spondylitis, reactive arthritis, arthritis, or spondylitis associated with Psoriasis, arthritis, or spondylitis related to inflammatory bowel disease.2 Spondyloarthritis may manifest with vague symptoms. Mostly present with back pain and stiffness.3 The prototype of Spondyloarthritis is ankylosing spondylitis. Ankylosing spondylitis is one of the most prevalent diseases among young adult males presenting in the outpatient department. The most common complaint is that of back pain. The most common causative factor is a genetic association with HLA B-27.4 Recent studies also reveal an association with tissue necrosis factor-alpha (TNF-α) and interleukin (IL-6, IL-17, and IL-23) and IL-37.5 Ankylosing spondylitis is diagnosed by clinical features, radiographic changes, and genetic analysis.6
The mainstay of treatment is a different type of NSAIDs like Aceclofenac, Indomethacin, Naproxen, Etoricoxib and biologicals, Disease-modifying antirheumatic drugs, glucocorticoids.7Although biological treatment is used frequently in western countries, NSAIDs are still the first-line treatment in our country considering the high cost of biologicals. NSAIDs can cause many side effects including renal, cardiac, gastrointestinal etc. NSAIDs can cause subclinical renal injury which is not manifested in routine renal function tests. Overt or clinical renal side effects of non-steroidal anti-inflammatory drugs (NSAIDs) like raised serum creatinine is seen in very few cases of patients with spondyloarthritis.
Here we have studied the change in levels of serum creatinine and change in levels of cystatin-c as sensitive biomarkers of NSAID induced kidney injury in spondyloarthritis patients.
MATERIALS AND METHODS
This is a hospital-based Prospective observational study carried in IMS & SUM Hospital Bhubaneswar after approval from the institutional committee over one year from November 2018 to October 2019. Assuming an error of 5% and considering the sample size of the thirty-one patient. A total of 31 patients aged between 22 and 54 years (all are male). All spondyloarthritis patients who came into the outpatient department and in-hospital in our tertiary care hospital over 1 year have been included in this study. Diagnose spondyloarthropathy(Axialspondyloarthropathy, Peripheral spondyloarthropathy or axial+peripheral spondyloarthropathy) based on different criteria and Radiological investigation. According to Amor criteria, every clinical feature is given a score of 1-2, and a score of 6 or more consider as “spondyloarthropathy”. A clinical feature like Lumbar pain at night or lumbar morning stiffness, Nongonococcalurethritis/cervicitis within 1 month of onset, Acute diarrhoea within 1 month of arthritis onset,
Buttock pain has a score of 1. If Clinical feature like bilateral alternating buttock pain, Asymmetric oligoarthritic, Sausage-like toe or digit(s), Heel pain or other well-defined enthesitis, Iritis, Psoriasis, balanitis or inflammatory bowel disease (Crohn’s or ulcerative colitis), Sacroiliitis (bilateral grade 2 or unilateral grade 3), human leukocyte antigen HLA-B27(+) or (+) family history of a spondyloarthropathy, Rapid less than 48 hours respond to NSAIDs having a score of 2.8 Other criteria Assessment in spondyloarthritis international society for Axial spondyloarthropathies which include sacroiliitis on imaging plus one of spondyloarthropathy feature or HLA-B27 and two other spondyloarthropathy feature.Spondyloarthropathy feature like-sausage digit (dactylitis), psoriasis-positive family history of spondyloarthropathy, inflammatory back pain ,NSAID good response, enthesitis (heel), Arthritis, Crohn’s/colitis disease-elevated C-Reactive Protein (CRP), human leukocyte antigen (HLA-B27), Eye (uveitis). How to diagnose sacroiliitis on X-ray bilateral Grades2-4 or Unilateral Grades 3-4 according to the modified new criteria, MRI Active (acute) inflammation on MRI.9 All spondyloarthritis patients included in the study except spondyloarthritis patients with psoriasis and inflammatory bowel disease, Spondyloarthritis patients using biological like sulfasalazine, methotrexate, a corticosteroid. Spondyloarthritis Patients with a known case of diabetes mellitus, hypertension, hypothyroidism, pre-existing medical renal disorder, use of NSAID for any other cause like migraine are excluded from the study. Informed consent was taken from all the patients. Based on all these criteria 31 patients have been selected and a blood sample collected at baseline, four weeks, and twelve-week for estimation of serum creatinine and serum cystatin-c level.
Statistical analysis
Statistical analysis will be carried out with the help of SPSS (version 25). The description of the data will be done in form of mean +/- SD for quantitative data while in the form of % frequency and % proportion for qualitative (categorical) data. For quantitative data Student’s t-test will be used to test the statistical significance of the difference between two independent group means. Chi-square test (or Fisher’s exact test in case of small frequencies in a cell) will be used to examine the association between patients of spondylarthritis with the use of NSAID and effect on kidney biomarkers. The univariate analysis will be done to identify the candidate variables for multiple logistic regression analysis. To determine the impact of NSAID on kidney biomarkers. Multivariate logistic regression analysis will be performed to determine risk factors associated with acute kidney injury. Analysis of Variance (ANOVA) test was performed to find out the association of quantitative variables with different NSAIDs used. The p-value was set to Englishhttp://ijcrr.com/abstract.php?article_id=3697http://ijcrr.com/article_html.php?did=3697
Shukla A, Rai MK, Prasad N, Agarwal V. Short-term non-steroid anti-inflammatory drug use in spondyloarthritis patients induces subclinical acute kidney injury: biomarkers study. Nephrologist 2017;135(4):277-286.
Akgul O, Ozgocmen S. Classification criteria for spondyloarthropathies. World J Orthop 2011;2(12):107.
Terenzi R, Monti S, Tesei G, Carli L. One year in review 2017: spondyloarthritis. Clin Exp Rheumatol 2018;36(1):1-4.
Tam LS, Gu J, Yu D. Pathogenesis of ankylosing spondylitis. Nat Rev Rheumat 2010 Jul;6(7):399-405.
Chen B, Huang K, Ye L, Li Y, Zhang J, Zhang J, Fan X, Liu X, Li L, Sun J, Du J. Interleukin-37 is increased in ankylosing spondylitis patients and associated with disease activity. J Trans Med 2015;13(1):36.
McVeigh CM, Cairns AP. Diagnosis and management of ankylosing spondylitis. Br Med J 2006;333(7568):581-585.
Braun JV, Van Den Berg R, Baraliakos X, Boehm H, Burgos-Vargas R, Collantes-Estevez E, et al. 2010 update of the ASAS/EULAR recommendations for the management of ankylosing spondylitis. Ann Rheumat Dis 2011;70(6):896-904.
Amor B, Dougados M, Mijiyawa M. Criteria of the classification of spondylarthropathies. Revue du rhumatisme et des maladies osteo-articulaires. 1990;57(2):85-89.
Lipton S, Deodhar A. The new ASAS classification criteria for axial and peripheral spondyloarthritis: promises and pitfalls. Int J Clin Rheumat 2012;7(6):675.
Malakar A, Kakati S, Barman B, Dutta A. Clinical presentation and subtypes of spondyloarthritis patients in North East India. Egyp Rheum 2020;23(6):721-724.
Fan M, Liu J, Zhao B, Wu X, Li X, Gu J. Indirect comparison of NSAIDs for ankylosing spondylitis: Network meta-analysis of randomized, double-blinded, controlled trials. Exp Therap Med 2020;19(4):3031-3041.
Lafrance JP, Miller DR. Selective and non?selective non?steroidal anti?inflammatory drugs and the risk of acute kidney injury. Pharmacopoeia. Drug Safety 2009;18(10):923-931.
Rexrode KM, Buring JE, Glynn RJ, Stampfer MJ, Youngman LD, Gaziano JM. Analgesic use and renal function in men. JAMA 2001;286(3):315-321.
Herget-Rosenthal S, Marggraf G, Hüsing J, Göring F, Pietruck F, Janssen O, et al. Early detection of acute renal failure by serum cystatin C. Kidney Int 2004;66(3):1115-1122.
Esson ML, Schrier RW. Diagnosis and treatment of acute tubular necrosis. Ann Int Med 2002;137(9):744-752.
Ronco C, Bellomo R. Prevention of acute renal failure in the critically ill. Nephr Clin Pract 2003;93(1):c13-20.
Molitoris BA. Transitioning to therapy in ischemic acute renal failure. Journal of the Clin J Am Soc Nephrol 2003;14(1):265-267.
Chertow GM, Levy EM, Hammermeister KE, Grover F, Daley J. Independent association between acute renal failure and mortality following cardiac surgery. Am J Med 1998;104(4):343-348.
Joannidis M, Metnitz PG. Epidemiology and natural history of acute renal failure in the ICU. Crit Care Clin 2005;21(2):239-249.
Clermont G, Acker CG, Angus DC, Sirio CA, Pinsky MR, Johnson JP. Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes. Kidney Int 2002;62(3):986-996.
Levy EM, Viscoli CM, Horwitz RI. The effect of acute renal failure on mortality: a cohort analysis. J Am Med Ass 1996 May 15;275(19):1489-1494.
Haase-Fielitz A, Bellomo R, Devarajan P, Story D, Matalanis G, Dragun D, et al. Novel and conventional serum biomarkers predicting acute kidney injury in adult cardiac surgery—a prospective cohort study. Crit Care Clin 2009;37(2):553-560.
Lagos-Arevalo P, Palijan A, Vertullo L, Devarajan P, Bennett MR, Sabbisetti V, et al. Cystatin C in acute kidney injury diagnosis: early biomarker or alternative to serum creatinine. Pediatr Nephrol 2015;30(4):665-676.
Briguori C, Visconti G, Rivera NV, Focaccio A, Golia B, Giannone R, et al. Cystatin C and contrast-induced acute kidney injury. Circulation 2010;121(19):2117.
Vaidya VS, Ferguson MA, Bonventre JV. Biomarkers of acute kidney injury. Ann Rev Pharmacol Toxicol 2008;48:463-493.
Hoek FJ, Kemperman FA, Krediet RT. A comparison between cystatin C, plasma creatinine and the Cockcroft and Gault formula for the estimation of glomerular filtration rate. Nephrol Dial Transplant 2003;18(10):2024-2031.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareAssociation of Anti-TPO Antibodies with Insulin Resistance and Dyslipidemia in Hashimoto’s Thyroiditis: An Observational Study on South Indian Population
English8894Rajarajeswari REnglish Sumathi SEnglish Asmathulla SEnglish Srinivasan AREnglish Girija SEnglish Maithili Karpaga Selvi NEnglishIntroduction: Hashimoto’s Thyroiditis (HT) is a frequently observed autoimmune thyroid disease and the commonest cause of hypothyroidism. Although the association of hypothyroidism with cardiovascular risk is a well-documented fact, it is still not clear as to whether thyroid autoimmunity is an independent risk factor for atherosclerosis, a cardiometabolic risk factor.
Objective: In this study, we attempted to elicit the probable association of Anti –Thyroid peroxidase (Anti-TPO) antibodies with cardiometabolic factors (insulin resistance and dyslipidemia) in patients.
Methods: In this observational study, sixty-five healthy controls and sixty-eight HT patients were enrolled. Serum concentrations of TSH, FT4, FT3, (Anti-TPO), Total Cholesterol (TC), Triglycerides (TG), HDL-Cholesterol (HDL-C), Very Low-Density Lipoprotein (VLDL), Fasting Blood Glucose (FBG) and Fasting Insulin levels were measured. LDL-Cholesterol (LDL-C), HOMA-IR and Atherogenic Index of Plasma (AIP) were calculated.
Results: There was a significant increase in TC, TG, LDL, VLDL, AIP, Fasting Insulin and HOMA-IR among the HT group (P < 0.001) compared to healthy controls. Despite a significant positive correlation between Anti-TPO antibodies and TC, LDL, Fasting Insulin, HOMA-IR, Anti-TPO was found to be independently associated with AIP as revealed in Regression analysis, which unequivocally demonstrates the cardiovascular risk in HT.
Conclusion: The findings of the present study point to the implication of thyroid autoimmunity in insulin resistance and dyslipidemia, independent of thyroid function in patients with HT. Thus, the assessment of lipid profile variables and insulin resistance possess value in the treatment and management of HT patients.
EnglishHypothyroidism, Thyroid autoimmunity, Anti-Thyroperoxidase antibodies, Hyperlipidemia, Insulin resistance, Cardiovascular disease riskIntroduction
Hashimoto’s Thyroiditis (HT) is a genetic autoimmune disease, characterized by the destruction of thyroid cells by cell- and antibody-mediated immune responses1 and is regarded as the commonest cause of hypothyroidism. HT has a prevalence rate of 1-4% and found to be more common in women and increases with age.2,3 Elevated circulating antibodies to thyroid antigens is a characteristic feature in HT patients, of which anti-thyroid peroxidase antibodies (anti-TPO) being the most specific and sensitive for the diagnosis of the disease.2 Several studies have found that hypothyroidism is associated with insulin resistance, dyslipidemia and chronic inflammation and in turn, increases the risk for atherosclerosis.4,5 Though the exact mechanism of the atherosclerotic process in hypothyroidism remains to be delineated, few studies suggest the role of thyroid autoimmunity in atherosclerosis, independent of thyroid function.6-8 Inflammation observed in HT may induce alterations in lipid metabolism, contributing to the increased risk of atherosclerosis.9 Few studies have reported insulin resistance in hypothyroid state10,11, whereas, a few other studies failed to demonstrate the relationship.12,13 The mechanism connecting hypothyroidism to insulin resistance is not clear. Mazaheri et al suggested that an imbalance between pro-inflammatory and anti-inflammatory cytokines resulting from chronic inflammation can be one of the mechanisms behind insulin resistance in HT. They had studied in euthyroid HT patients on levothyroxine treatment, which was believed to attenuate the inflammation in HT and might mitigate the study results.14 Thus, in this study we aimed to study the association of thyroid autoimmunity with cardiometabolic factors in newly diagnosed Hashimoto’s Thyroiditis subjects, at a tertiary care hospital from South India, which is, to our knowledge, one among the few studies.
MaterialS and Methods
This observational study was designed to include sixty-eight newly diagnosed and untreated HT patients and sixty-five age and gender-matched healthy controls who had attended the clinics at a tertiary care hospital in South India. The patients who had elevated serum TSH levels, with or without elevated fT3 and fT4, high serum anti-TPO and enlarged rubbery thyroid were categorized as Hashimoto’s thyroiditis.14 Patients with diabetes mellitus, cardiovascular disease, pregnancy, thyroid cancer and any other autoimmune disease such as lupus erythematosus and rheumatoid arthritis were excluded from the study. All the participants were enrolled for the study following written informed consent. The study was conducted following the Declaration of Helsinki and was approved by the institute ethics committee (IEC letter no.: SMVMCH-EC/DO/AL/817/2018).
Anthropometric measurements and laboratory assessments were carried out on all the participants, as per established protocol. Bodyweight and height were measured with a calibrated digital scale and stadiometer respectively. Body Mass Index (BMI) was calculated as weight (kg) divided by height (m) squared. Waist circumference (WC) was measured midway between the lowest rib and iliac crest at umbilicus level and Hip circumference (HC) was measured at the widest girth of the Hip using a measuring tape in centimetres. Waist to Hip Ratio (WHR) was calculated by WC divided by HC. Blood pressure values were measured in the sitting position. Demographic information and family history of diabetes, hypertension and any thyroid disorder were obtained from the participants.
Blood was collected from all the participants in the fasting state and subjected to centrifugation at 3000 rpm. The serum separated was used for the estimation of biochemical parameters. Glucose was measured by Glucose oxidase – peroxidase method, total cholesterol (TC) was measured by cholesterol oxidase method and triglyceride (TG) levels were measured by glycerol kinase- peroxidase method, high-density lipoprotein cholesterol (HDL-c) was measured by divalent cation precipitation method using the reagents adapted to Biolis 50i, Tokyo BoekiMedisys, Japan. Very low-density lipoprotein cholesterol (VLDL) level was computed from triacylglycerol concentration and low-density lipoprotein cholesterol (LDL-C) level was calculated using Friedwald’s formula. Atherogenic Index of Plasma (AIP) is the logarithmically transformed ratio of TG to HDL-C.15
Serum concentrations of fT3, fT4 and TSH were measured using the Chemiluminescence (CLIA) method adapted to Advia Centaur XP, Siemens, USA. Anti-TPO was determined by Medizym Anti-TPOEnzyme Linked Immunosorbent Assay (ELISA) kit, Berlin, Germany. Insulin was measured using DRG Insulin ELISA kit, Germany and Insulin Resistance (IR) was assessed by Homeostasis Model assessment index (HOMA-IR = Fasting Insulin (µIU/mL) x Fasting Glucose (mg/dL)/405.
Statistical Analysis
Statistical Analysis was performed using licenced SPSS software 20.0 version. Data were presented as mean ± standard deviation (SD) or median (inter-quartile range), wherever appropriate. Differences between the two groups were tested using Independent Student ‘t’ test for normally distributed variables and the Mann-Whitney U test for non-normal distributed variables. Spearman’s correlation was used to determine the correlation of TSH and Anti-TPO with other variables. Based on Anti-TPO levels, the HT group was further divided into two groups and the between-groups comparison of continuous variables among the control group and two subgroups of HT was performed by Oneway ANOVA. P-value < 0.05 was considered to be statistically significant.
Results
A total of 133 subjects including sixty-five healthy controls (three males and sixty-two females) and sixty-eight Hashimoto’s Thyroiditis patients (two males and sixty-six females) were enrolled in this study. Anthropometric parameters and Thyroid profile of the two groups were compared in Table 1.
Based on the data obtained, there was a significant difference between the mean values of the HT group and the control group in terms of BMI, WC, WHR, fT3, fT4, TSH and Anti – TPO antibodies (Table 1).
Table 2 represents the comparison of cardiometabolic factors between HT group and healthy controls. Correlation analyses of TSH and Anti-TPO with other biochemical parameters were enabled.TSH was found to be positively correlated with Anti-TPO (r value = 0.813, P value = 0.000), LDL (r value = 0.275, P value = 0.023), TC/HDL (r value = 0.256, P value = 0.035) and LDL/HDL (r value = 0.302, P value = 0.012).
Table 3 represents the correlation of anti-TPO with cardiometabolic factors. On correlation analysis, HOMA-IR was found to be correlated only with Anti-TPO. But when HOMA-IR was subjected to Linear Regression analysis, it was found to be independently associated with WHR (Standardized Co-efficient ‘Beta’ = 0.039, P-value < 0.05). On Linear Regression analysis, TSH, TC/HDL and AIP were found to be independently associated with Anti-TPO antibodies (Table 4). Based on Anti-TPO levels, the HT group was subdivided into two (HT Group I: HT patients with Anti-TPO level less than 1000 IU/L and HT Group II: HT patients with Anti-TPO level more than or equal to 1000 IU/L). Patients with Anti TPO antibody levels of more than 1000 IU/ml were classified as having highly positive antibodies. Anthropometric and Biochemical parameters were analyzed among controls, HT Group I and HT Group II, the data of which is shown in Table 5.
Discussion
Studies have demonstrated that HT is the primary cause of non- iatrogenic hypothyroidism. Hypothyroidism has been observed to enhance the risk for cardiovascular disease and atherosclerosis. Though reports are available on metabolic indices in euthyroid subjects with HT, the results are inconsistent and at times paradoxical. Furthermore, it remains to be seen as to whether thyroid autoimmunity is an independent risk factor for atherosclerosis. Thus, in this observational study, we aimed to compare the anthropometric parameters, lipid profile variables and Insulin resistance between the newly diagnosed HT subjects and healthy controls, among the South Indian population.
The findings of the present study depict a higher prevalence of insulin resistance and dyslipidemia in patients with HT when compared to healthy controls. In our study, we found a significant increase in the levels of fasting Insulin as well as Insulin resistance in HT patients when compared to controls. Though this result is in line with previous studies16,17, several other studies have not shown any significant difference between the HT patients and healthy controls.18,19 A study conducted by Mazaheri et al., demonstrated a significant increase in fasting insulin only in HT subjects with highly positive Anti-TPO antibodies, whereas it failed to demonstrate any difference in fasting Insulin and HOMA-IR between patients with and without HT.14 There was no correlation between TSH and HOMA-IR in all the patients with HT. However, Anti-TPO antibody concentrations were found to be positively correlated with HOMA-IR in HT subjects. However, in the present study when HT subjects were subdivided into two groups based on Anti-TPO levels and analyzed, the HT group with highly positive Anti-TPO antibody showed a significant increase in HOMA-IR when compared to the HT group with Anti-TPO concentration less than 1000 IU/L. These findings suggest that thyroid autoimmunity may be associated with insulin resistance independent of thyroid function, as reported earlier in the Iranian and Chinese populations.14,16 The anti-TPO antibodies in all probability might possess a destructive effect on thyrocytes by activating T helper 1 cells, and resultant production of proinflammatory cytokines such as TNF-α and IL-6 resulting in inflammation.20 The monocytes, macrophages, lymphocytes in association with the proinflammatory cytokines – particularly, TNF-α and IL-6, may contribute to insulin resistance and atherosclerotic plaques.21,22 Insulin resistance may impair the PI3-K/AKt pathway, decreasing the bioavailability of Nitric Oxide, which might contribute to endothelial dysfunction.16 The present study also exhibits an association between HOMA-IR and WHR in Linear regression analysis, which would explain the fact that insulin resistance and central adiposity would co-exist14 which is another risk factor for cardiovascular diseases.
The relationship between thyroid function and serum lipids had been investigated in previous studies. In a study conducted by Tamer et al, HT subjects were found to have higher TC, LDL-C, TG and non-HDL-C levels as compared to healthy controls. The same study did not reveal any difference in the levels of TC and LDL-C between overt hypothyroid and euthyroid patients with HT. Though there was no correlation between TSH and any other lipid parameters, Anti-TPO antibodies were found to be positively correlating with TG levels in HT subjects, suggesting the association of thyroid autoimmunity with dyslipidemia, independent of thyroid function.23 In a previous report, the subclinical hypothyroid patients manifested an increase in atherosclerotic cardiovascular disease despite having low TC levels than controls.24 In the present study, serum TC, TG, LDL-C and VLDL levels were found to be significantly elevated in HT subjects when compared to healthy controls. In contrast to the previously reported studies, a positive correlation was found between TSH and LDL – C levels in HT subjects. Anti-TPO antibodies were also correlating positively with TC and LDL – C levels. The result of our study has been augmented by the HUNT study and Tagami et al., where a positive correlation was observed between TSH and lipid levels.25,26
Being an autoimmune disease, HT itself may be a risk factor for the development of cardiovascular disease. According to Volpe’s hypothesis, in HT, due to defective suppressor T cells, the helper T cells are not suppressed leading to a production of various cytokines such as IFN – γ, IL-2 and TNF– α27 which might cause weight gain and hyperlipidemia.28 Taddei et al29 demonstrated that endothelial dysfunction and impaired NO availability were associated with atherosclerosis rather than the thyroid function itself. Tamer et al.23, also reported the association of thyroid autoimmunity with hyperlipidemia, independent of thyroid function. The data from the present study reveals that although TSH demonstrated a positive correlation with LDL-C, it lost its significance on regression analysis. Also, in Linear Regression analysis, Anti-TPO antibodies were found to be independently associated with AIP. Being a surrogate marker of, small dense LDL (sdLDL), the AIP, has been indicated as a superior predictor of cardiovascular risk than the other lipid parameters.30 Since sdLDL is more susceptible to oxidation and glycation and exhibits decreased clearance attributed to the reduced affinity for LDL receptor, the predominance of sdLDL indicates an increased risk for atherogenesis.31,32
To the best of our knowledge, this is among the few studies to show the association of anti-TPO with insulin resistance and dyslipidemia among the south Indian population. The main limitations of the present study are the lack of a euthyroid and hypothyroid group without elevated anti-TPO and small sample size. Further studies, including subjects at different thyroid function levels with and without elevated anti-TPO and larger sample size, may throw more light and provide a deeper insight into the relationship of anti-TPO with hyperlipidemia and insulin resistance - the risk factors for cardiovascular disease. Significance of the study: The study opens up newer vistas in biochemical pharmacology and clinical endocrinology, especially concerning combinatorial drug therapy that could help in the effective and rational management of cardiovascular morbidity, in the light of insulin resistance, thyroid autoimmunity and dyslipidemia.
Conclusion
To conclude, the present study has demonstrated that thyroid autoimmunity might possess effects on insulin resistance and hyperlipidemia, thus increasing the risk for cardiovascular disease. Therefore, it is imperative to objectively determine the lipid levels and insulin resistance that would aid in the management of accompanying cardiovascular disease in patients with Hashimoto’s thyroiditis.
Acknowledgement: The authors would like to acknowledge Mr. Srinivasan for extending his technical support in conducting this study.
Financial support and Sponsorship: None declared.
Conflict of interest: Nil
BMI : Body Mass Index, WC: Waist Circumference, HC : Hip Circumference, WHR : Waist Hip Ratio, TSH : Thyroid Stimulating Hormone
The data are represented as mean ± S.D / Median (inter-quartile range)
P value calculated by Independent ‘t’ test for normal distributed parameters and Mann-Whitney U test for Non-normal distributed parameters
TC : Total Cholesterol, TG : Triglyceride, HDL : High Density Lipoprotein, LDL : Low Density Lipoprotein, VLDL : Very Low Density Lipoprotein, HOMA-IR : Homeostatic Model Assessment of Insulin Resistance, AIP : Atherogenic Index of Plasma
The data are represented as mean ± S.D
P value calculated by Independent ‘t’ test for normal distributed parameters and Mann-Whitney U test for Non-normal distributed parameters
TC : Total Cholesterol, HDL : High Density Lipoprotein, LDL : Low Density Lipoprotein, TSH : Thyroid Stimulating Hormone, HOMA-IR : Homeostatic Model Assessment of Insulin Resistance
P value calculated by Spearman correlation method
HT Group I : Anti-TPO < 1000 IU/mL, HT Group II : Anti-TPO ≥ 1000 IU/mL
P value less than 0.05 = ‘*’ :in comparison to Controls , ‘†’ : in comparison to HT Group II
Englishhttp://ijcrr.com/abstract.php?article_id=3698http://ijcrr.com/article_html.php?did=36981. Yang M, Du C, Yinpingwang, Liu J. CD19+CD24hiCD38hi regulatory B cells are associated with insulin resistance in type I Hashimoto's thyroiditis in Chinese females. Exp Therap Med 2017;14:3887-3893.
2. Cunha CA, Neves C, Neves J, Oliveira SC, Sokhatska O, Dias C, et al. Cardiovascular risk factors in patients with autoimmune thyroiditis. Rev Port Endocrinol Diabetes Metab 2017;12:133-141
3. Sood N, Nigam JS. Correlation of fine needle aspiration cytology findings with thyroid function test in cases of lymphocytic thyroiditis. J Thyroid Res 2014;2014:430510.
4. Yang N, Yao Z, Miao L, Liu J, Gao X, Fan H, et al. Novel clinical evidence of an association between homocysteine and insulin resistance in patients with hypothyroidism or subclinical hypothyroidism. PLoS One 2015;10(5):e0125922.
5. Lu M, Yang CB, Gao L, Zhao JJ. Mechanism of subclinical hypothyroidism accelerating endothelial dysfunction (review). Exp Ther Med 2015;9:3–10.
6. Bastenie PA, Vanhaelst L, Neve P. Coronary artery disease in hypothyroidism. Lancet 1967; 2:1221-1222.
7. Bastenie PA, Vanhaelst L, Bonnyns M, Neve P, Staquet M. Preclinicalhypothyroidism: a risk factor for coronary heart disease. Lancet 1971;1:203-204.
8. Bastenie PA, Vanhaelst L, Golstein J, Smets P. Asymptomatic autoimmune thyroiditis and coronary heart disease. Cross-sectional and prospective studies. Lancet 1977;2:155-158.
9. van Diepen JA, Berbee JF, Havekes LM, Rensen PC. Interactions between inflammation and lipid metabolism: relevance for the efficacy of anti?inflammatory drugs in the treatment of atherosclerosis. Atherosclerosis 2013;228:306-315.
10. Rochon C, Tauveron I, Dejax C, Benoit P, Capitan P, Fabricio A, et al. Response of glucose disposal to hyperinsulinaemia in human hypothyroidism and hyperthyroidism. Clin Sci (Lond). 2003;104:7–15.
11.Stanicka S, Vondra K, Pelikanova T, Vlcek P, Hill M, ZamrazilV.Insulin sensitivity and counter-regulatory hormones in hypothyroidism and during thyroid hormone replacement therapy. Clin Chem Lab Med 2005;43:715–720.
12. Owecki M, Nikisch E, Sowinski J. Hypothyroidism has no impact on insulin sensitivity assessed with HOMA-IR in totally thyroidectomized patients. Acta Clin Belg 2006;61:69–73.
13. Harris PE, Walker M, Clark F, Home PD, Alberti KG. Forearm muscle metabolism in primary hypothyroidism. Eur J Clin Invest 1993;23:585–8.
14. Mazaheri T, Sharifi F, Kamali K.Insulin resistance in hypothyroid patients underLevothyroxine therapy: a comparison between those with and without thyroid autoimmunity. J Diab Metab Disor 2014;13:103.
15. Dobiásová M, Frohlich J. The plasma parameter log (TG/HDL-C) as an atherogenic index: correlation with lipoprotein particle size and esterification rate in apoB-lipoprotein-depleted plasma (FER(HDL)). Clin Biochem 2001;34(7):583-588.
16. Liu J, Duan Y, Fu J, Wang G. Association between thyroid hormones, thyroid antibodies and cardiometabolic factors in non-obese individuals with normal thyroid function. Front Endocrinol 2018;9:130.
17. Dimitriadis G, Mitrou P, Lambadiari V, Boutati E, Maratou E, Panagiotakos DB, et al. Insulin action in adipose tissue and muscle in hypothyroidism. J Clin Endocrinol Metab 2006;91: 4930?4937.
18. Mousa U, Bozku? Y, Kut A, Demir CC, Tutuncu NB. Fat distribution and metabolic profile in subjects with Hashimoto’s Thyroiditis. Acta Endocrinologica (Buc). 2018;14(1):105-112.
19. Amouzegara A, Kazemiana E, Gharibzadeha S, Mehran L, Tohidib M, Azizia F. Association between thyroid hormones, thyroid antibodies and insulin resistance in euthyroid individuals: A population-based cohort. Diabetes Metab. 2015. Front Endocrinol (Lausanne) 2018;9: 130.
20. Nielsen CH, Brix TH, Leslie RQ, Hegedus LA. Role for autoantibodies in the enhancement of pro-inflammatory cytokine responses to a self-antigen, thyroid peroxidase. Clin Immunol 2009;133(2):218–227.
21. Wei Y, Chen K, Whaley-Connell AT, Stump CS, Ibdah JA, Sowers JR. Skeletal muscle insulin resistance: role of inflammatory cytokines and reactive oxygen species. Am J Physiol Regul Integr Comp Physiol 2008;294:673–680.
22. Wilson HM, Barker RN, Erwig LP. Macrophages: promising targets for the treatment of atherosclerosis. Curr Vasc Pharmacol 2009;7:234–243.
23. Tamer G, Mert M, Tamer I, Messi B, DamlaK?l?c, Ar?k S. Effects of thyroid autoimmunity on abdominal obesity and hyperlipidaemia. Polish J Endocrinol 2011;62:421-428.
24. Hak AE, Pols HA, Visser TJ, Drexhage HA, Hofman A, Witteman JC. Subclinical hypothyroidism is an independent risk factor for atherosclerosis and myocardial infarction in elderly women: The Rotterdam Study. Ann Intern Med. 2000;132: 270-278.
25. Asvold BO, Vatten LJ, Nilsen TI, Bjoro T. The association between TSH within the reference range and serum lipid concentrations in a population-based study. The HUNT study. Eur J Endocrinol 2007;156:181-186.
26. Tagami T, Tamanaha T, Shimazu S. Lipid profiles in untreated patients with Hashimoto’s thyroiditis and the effects of thyroxine treatment on subclinical hypothyroidism with Hashimoto’s thyroiditis. Endocrine J 2010;57:253-258.
27. Volpe R. Autoimmune Thyroiditis. Braverman LE, Utiger RD (ed). Werner and Ingbar’s. The Thyroid. JB Lippincott Co, Philadelphia.1991; 921-941.
28. Sultan A, Strodthoff D, Robertson AK. T cell-mediated inflammation in adipose tissue does not cause insulin resistance in hyperlipidemic mice. Circ Res 2009;104:961-968.
29. Taddei S, Caraccio N, Virdis A, Dardano A. Low-grade systemic inflammation causes endothelial dysfunction in patients with Hashimoto’s thyroiditis. J Clin Endocrinol Metab 2006; 91:5076-5082
30. Baliarsingh S, Sharma N, Mukherjee R. Serum uric acid: a marker for atherosclerosis as it is positively associated with "atherogenic index of plasma. Arch Physiol Biochem 2013;119:27-31.
31. Berneis KK, Kraus RM. Metabolic origins and clinical significance of LDL heterogeneity. J Lipid Res 2002;43:1363–1379.
32. Austin MA, King MC, Vranizan KM, Krauss RM. Atherogenic lipoprotein phenotype. A proposed genetic marker for coronary heart disease risk. Circulation 1990;82:495–506.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareAssociation between Quality of Sleep and Body Mass Index: A Brief Narrative Review
English9598Darshana NariyaEnglish Subhash KhatriEnglishIn the short term, a lack of adequate sleep can affect judgment, mood, ability to learn and retain information, and may increase the risk of serious accidents and injury. In the long term, chronic sleep deprivation may lead to a host of health problems including obesity, diabetes, cardiovascular disease, and even early mortality. These days, the treatment of sleep impediment speaks to a new challenge for health systems. So evaluation of factors affecting the quality of sleep has extreme significance. Previous studies have demonstrated the negative impact of high BMI on the quality of sleep. It was also stated that sleep deprivation is associated with obesity. Obesity and sleep disturbances are two major problems that adversely affecting the quality of life of humans worldwide. So this review aims to explore the association of Body Mass Index (BMI) with quality of sleep. Studies on the topic of quality of sleep and BMI will be reviewed so the findings of those articles will be used to explore the association between BMI and quality of sleep.
EnglishSleep quality, BMI, ObesityINTRODUCTION
Sleep is defined simply as an absence of wakefulness. It is an active, regulated and metabolically different state needed for health and wellbeing.1,2 Normally, adults sleep about 7 to 9 hours per night. According to National Sleep Foundation, key determinants of good quality sleep are,3
Sleeping more time while in bed (at least 85 %t of the total time)
Falling asleep in 30 minutes or less
Waking up no more than once per night; and
Being awake for 20 minutes or less after initially falling asleep.
The Pittsburgh Sleep Quality Index (PSQI) is a self-rated questionnaire that assesses sleep quality and disturbances. The score ranges from 0-21. A score of more than 5 indicates poor sleep quality. It has a reliability of 0.85 and a validity of 0.81.4,5
“Obesity is defined as anomalous or extreme fat accumulation that presents a health risk. A measure of obesity is the body mass index (BMI), a person’s weight (in kilograms) divided by the square of his or her height (in meters)”. A person with a BMI of thirty or additional is mostly thought of as obese.6Prevelence of obesity in India is varies from 11.8% to 31.3%. In Gujarat prevalence of obesity are 19.7% in males and 23.7% in females.7So this review aims to explore the link between the quality of sleep and BMI.
MATERIALS AND METHODS
A computer-based literature search was done using the PUBMED, PUBMED CENTRAL, and GOOGLE SCHOLAR. Relevant articles with a full text published in English between the years 2011 to 2020 were screened and included. Editorials, Commentaries, Discussion papers, Conference abstracts, Reviews, and Duplicates were excluded. We included only cross-sectional studies with full-text articles. After the screening through articles, 7 relevant articles were included in the review. Figure 1 shows the searching strategy for this review. Characteristic of the reviewed article was summarized in table 1. All studies have examined the association between quality of sleep and BMI.
Out of 7 cross-sectional studies, 6 studies demonstrated that higher BMI is associated with poor quality of sleep in adolescents, adults, older adults. Only one study demonstrated that there is no association between quality of sleep and BMI in long-lived subjects (870 participants, ≥90 years) (p=0.554). 5 cross-sectional studies with a total of 20300 participants have demonstrated the association between sleep quality and BMI in the age group 16-54 years and found a significant association between sleep quality and BMI (p Englishhttp://ijcrr.com/abstract.php?article_id=3699http://ijcrr.com/article_html.php?did=3699
Cooper CB, Neufeld EV, Dolezal BA, Martin JL. Sleep deprivation and obesity in adults: a brief narrative review. BMJ Open Sport Exerc Med 2018;4(1);1-5.
Carley DW, Farabi SS. Physiology of sleep. Diabetes Spectr. 2016;29(1):5-9.
National sleep foundation. What is good quality sleep? [Cited 2020 April 2]. Available from: https://www.sleepfoundation.org/press-release/what-good-quality-sleep.
Buysse DJ, Reynolds CF, Monk TH. The Pittsburgh sleep quality index: a new instrument for psychiatric practice and research. Psychiatry Res 1989;28(2):193–213.
Backhaus J, Junghanns K, Broocks A, Riemann D, Hohagen F. Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. J Psychosom Res 2002;53(3):737-40.
WHO. Obesity and Overweight. [Cited 2020 April 2]. Available from: /detail/obesity-and-overweight.
Ahirwar R, Mondal PR. Prevalence of obesity in India: a systematic review. Diabetes Metab Syndr 2019;13(1):318-21.
Vargas PA, Flores M, Robles E. Sleep quality and body mass index in college students: the role of sleep disturbances. J Am Coll Health 2014;62(8):534-41.
Peltzer K, Pengpid S. Sleep duration, sleep quality, body mass index, and waist circumference among young adults from 24 low-and middle-income and two high-income countries. Int J Environ Res Public Health 2017;14(6):566.
Wang J, Chen Y, Jin Y, Zhu L, Yao Y. Sleep quality is inversely related to body mass index among university students. Rev Assoc Med Bras 2019;65(6):845-50.
Mirdha M, Nanda R, Sharma HB, Mallick HN. Study of Association between Body Mass Index and Sleep Quality among Indian College Students. Indian J Physiol Pharmacol 2019;63(1):8-15.
Shochat T, Shefer-Hilel G, Zisberg A. Relationships between body mass index and sleep quality and duration in adults 70 years and older. Sleep Health 2016;2(4):266-71.
Yan Z, Chang-Quan H, Zhen-Chan L, Bi-Rong D. Association between sleep quality and body mass index among Chinese nonagenarians/centenarians. Age 2012;34(3):527-37.
Ha CR, Kim SH, Na SB, You JS, Chang KJ. Advances in Experimental Medicine and Biology. Taurine 9. In: Marcinkiewicz J., Schaffer S. editors. The Association among Dietary Taurine Intake, Obesity and Quality of Sleep in Korean Women. 2015;803:725-733.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareA Study on Clinical Spectrum, Laboratory Profile, Complications and Outcome of Pediatric Scrub Typhus Patients Admitted to an Intensive Care Unit from a Tertiary Care Hospital from Eastern India
English99102Kumar SEnglish Prusty JBKEnglish Priyadarshini DEnglish Choudhury JEnglish Dash MEnglish Rath DEnglish Praveen SPEnglishIntroduction: Scrub typhus is an emerging mite born infectious febrile illness in children caused by Orientia tsutsugamushi. This study overviews the various clinical, laboratory characteristics, complications outcome of scrub typhus patient.
Objective: Scrub typhus is a common differential diagnosis of fever of unknown origin in children. It is often associated with complications involving many organ systems needing admission to the pediatric intensive care unit (PICU). It affects healthy children of all age groups and a delay in diagnosis can prove fatal. The study was conducted to study clinical spectrum, laboratory profile, complications and outcome of scrub typhus patients admitted to pediatric intensive care unit, to estimate the burden of scrub typhus as a cause of admission to PICU.
Methods: It was a prospective, observational study conducted on all pediatric patients admitted to PICU with a diagnosis of scrub typhus over a period from Aug 2018 to July 2019. Clinical, laboratory data along with complications and outcome were studied in all cases.
Results: Out of the total of 122 scrub typhus patients, 30(24.59%) patients were admitted to PICU. Scrub typhus contributed to 8.24% of total PICU admission. Shock (40%) was the most common complication followed by meningoencephalitis(13.33%) and acute respiratory disease syndrome (ARDS) (13.33%).
Conclusion: Scrub typhus is an emerging cause of intensive care admission in recent times. Timely diagnosis and early treatment can prevent complications and reduce the financial burden to a great extent.
EnglishScrub typhus, Complications, Shock, Acute respiratory disease syndrome (ARDS), Meningoencephalitis, Pediatric intensive care unit (PICU) admissionIntroduction
Scrub typhus is an emerging mite born infectious febrile illness in children caused by Orientia tsutsugamushi.1 The spectrum of clinical manifestation of scrub typhus is very broad. Though most of the infections are mild to moderate in severity, the mortality rate is quite high in untreated patients ranging from 0 % to 30 % 2 As the clinical features of scrub typhus mimic many of the common viral, protozoal and bacterial infections, the diagnosis is often delayed leading to complications and damage to vital organs and admission to the intensive care unit. The classical presentation of fever, headache, lymphadenopathy, organomegaly, rash and typical eschar are not seen so often in children posing a diagnostic dilemma.3,4 Though it can be diagnosed by relatively inexpensive tests like IgM ELISA and can be treated easily with drugs like doxycycline and azithromycin, delayed presentation leads to complications like meningoencephalitis, myocarditis, shock, respiratory distress, renal failure and multiple organ dysfunction syndromes (MODS) leading to admission to admission to a pediatric intensive care unit.5 Considering the simple and cheap modality of treatment and the good outcome it is often necessary to start empiric therapy for scrub typhus in pediatric cases presenting as an undifferentiated febrile illness with multisystem involvement.6 we aimed to study the various clinical, laboratory characteristics, complications outcome of scrub typhus patient.
MATERIALS AND METHODS
This was a prospective observational study in children below 14 years of age admitted to the Department of Pediatrics of IMS and SUM HOSPITAL, during the period between August 2018 and July 2019, with a clinical diagnosis of scrub typhus. The ethical committee approval was taken from the institutional ethical committee. Those patients who were laboratory confirmed by IgM ELISA as scrub typhus were studied after taking parental consent and patients needing admission to PICU were followed and evaluated in detail.
The clinical diagnosis of cases was based on Rathi – Goodman Aghai scoring for scrub typhus.6 Laboratory confirmation of cases was done by Scrub IgM ELISA. Those serologically confirmed patients who needed admission in PICU were the study participants and were followed up in detail.
The clinical data, complete blood counts along with other laboratory profile, treatment details, complications, the outcome were noted in each case. Multi-organ dysfunction was defined as the involvement of 2 or more system simultaneously.7 The need for inotrope support, mechanical ventilation, transfusion of blood products and other interventions were noted. Thrombocytopenia was defined as a total platelet count less than 1.5 lakh/mm3. Hyponatremia was defined as serum sodium less than 135meq/L, hypoalbuminemia was defined as serum albumin less than 3.5 gm%.
All patients were treated with intravenous doxycycline at a dose of 4 mg/kg/day in two divided doses followed by an oral continuation of doxycycline once the child was able to take orally for a total duration of 7 to 10 days. Various complications like myocarditis, respiratory distress syndrome, meningoencephalitis were treated as per need on case to case basis. The outcome was noted as death, survival, and the meantime for fever defervescence and mean duration of PICU stay were recorded. Qualitative variables were described as number and percentage. Quantitative variables were expressed as mean (SD), median (IQR) wherever applicable.
Results
From August 2018 to July 2019 a total of 151 cases were admitted with a clinical diagnosis of scrub typhus. Out of them, 125 cases were serologically positive for scrub typhus. Three cases were excluded from the study due to confection with malaria (1case) and dengue fever in (2 cases ).122 number of lab-confirmed IgM ELISA positive cases were studied. Out of these 122 cases, 30 (24.59%) cases were admitted to PICU for various complications. Scrub typhus contributed to9.96 % of total PICU admission during the study period. The mean age of presentation was 5.68(± 3.42) years. The male to female ratio was 2:1(Table 1).
Out of various clinical signs, Hepatomegaly has seen in 18 (60%) cases followed by oedema 12 (40%), splenomegaly in 11(36.6%) cases and lymphadenopathy (26.6 %). Eschar was found only in 2(6.66%) cases (Table 2). Among the laboratory parameters, thrombocytopenia with a total platelet count less than 1.5lakhs/ cm was seen in 8(26.6%) cases, deranged liver function test was seen in 20(66.66 %) cases. Hypoalbuminemia with Serum albumin Englishhttp://ijcrr.com/abstract.php?article_id=3700http://ijcrr.com/article_html.php?did=3700
Batra HV. Spotted fevers and typhus fever in Tamil Nadu Commentary. Indian J Med Res 2007;126:101?3.
Rathi N, Rathi A. Rickettsial infections: Indian perspective. Indian Pediatr 2010;47:157?64.
Takhar RP, Bunkar ML, Arya S, Mirdha N, Mohd A. Scrub typhus: A prospective, observational study during an outbreak in Rajasthan, India. Natl Med J India 2017;30:69-72
Jayaram Paniker CK. Ananthanarayan and Paniker’s Textbook of Microbiology. 7th ed. University Press Pvt. Ltd.; 2008. p. 412?21.
Pavithran S, Mathai E, Moses PD. Scrub typhus. Indian Pediatr 2004;41:1254?7.
Rathi NB, Rathi AN, Goodman MH, Aghai ZH. Rickettsial diseases in central India: A proposed clinical scoring system for early detection of spotted fever. Indian Pediatr 2011;48: 867?72.
Goldstein B, Giroir B, Randolph A. International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: Definitions for sepsis and organ dysfunction in paediatrics. Pediatr Crit Care Med 2005;6:2?8.
Meena JK, Khandelwal S, Gupta P, Sharma BS. Scrub typhus meningitis: An emerging infectious threat. IOSR J Dent Med Sci 2015;14:26?32.
Gurunathan PS, Ravichandran T, Stalin S, Prabu V, Anandan H. Clinical profile, morbidity pattern and outcome of children with scrub typhus. Int J Sci Stud 2016;4:247?50.
Christal A, Boorugu H, Gopinath KG, Prakash JA, Chandy S, Abraham OC, et al. Scrub typhus: An unrecognized threat in South India-Clinical profile and predictors of mortality. Trop Doct 2010; 40:129?33.
Palanivel S, Nedunchelian K, Poovazhagi V, Raghunandan R, Ramachandran P. Clinical profile of scrub typhus in children. Indian J Pediatr 2012; 79:1459?62.
Sivaraman S, Viswamohanan I, Krishna GR, Jithendranath A, Bai R. Serological prevalence of scrub typhus among febrile patients from a tertiary care hospital in South Kerala. J Acad Clin Microbiol 2020; 22:41-3.
Kumar Bhat N, Dhar M, Mittal G, Shirazi N, Rawat A, Prakash Kalra B, et al. Scrub typhus in children at a tertiary hospital in north India: clinical profile and complications. Iran J Pediatr 2014;24(4):387–392.
Narayanasamy DK, Arunagirinathan AK, Kumar RK, Raghavendran VD. Clinical-laboratory profile of scrub typhus - an emerging rickettsiosis in India. Indian J Pediatr 2016;83(12–13):1392–1397.
Kumar M, Krishnamurthy S, Delhikumar CG, Narayanan P, Biswal N, Srinivasan S. Scrub typhus in children at a tertiary hospital in southern India: clinical profile and complications. J Infect Public Health 2012;5(1):82–88.
Masand R, Yadav R, Purohit A, Tomar BS. Scrub typhus in rural Rajasthan and a review of other Indian studies. Paediatr Int Child Health. 2016;36(2):148–153.
Krishna MR, Vasuki B, Nagaraju K. Scrub typhus: audit of an outbreak. Indian J Pediatr 2015;82(6):537–540.
Giri PP, Roy J, Saha A. Scrub Typhus - A Major Cause of Pediatric Intensive Care Admission and Multiple Organ Dysfunction Syndrome: A Single-Center Experience from India. Indian J Crit Care Med 2018;22(2):107-110.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareComparative Genomic Analysis of Strains Belonging to Two Different Pathovars of Pseudomonas syringae van Hall
English103109Krishna BaruahEnglish Sushmita KalitaEnglish Debasish B. KrishnatreyaEnglishEnglishComparative genomics, Gene order, Pathovars, Synteny, Phylogeny, Pseudomonas syringaeINTRODUCTION
Pseudomonas syringae is a gram-negative rod-shaped gamma?proteobacterium with phytopathogenic habits but can occur also as a saprotroph when conditions are not favourable for the development of disease.1 It causes bacterial canker and leaf spot disease in more than 180 plant species including kiwifruit, beet, tomato, wheat, barley, pea etc. and is an oxidase and arginine dihydrolase-negative fluorescent bacteria.2,3 The species is found worldwide geographically, but the wet and cool temperature is mostly favourable for this bacterium. P. syringae can infect plants through natural openings, such as stomata in leaves, and lenticels in woody tissues.4
Due to the presence of flagella and pilli, they can enter the plant through wounds and then infiltrate using some virulence factors called type III secretion system (T3SS) effector proteins. Effector molecules are used by both prokaryotes and eukaryotes to transport proteins, DNA and chemical molecules (e.g. toxins) across cell walls and membranes into host tissues.5 Gram-negative bacteria have six major secretion systems, the most extensively studied of which is the Type III secretion system (T3SS). T3SS is central to the pathogenesis of many pathogens in infection of economically and ornamentally important crops. In P. syringae, hrp/hrc genes encode the Hrp (type III secretion) system, while avirulence (avr) and Hrp dependent outer protein (hop) genes encode effector proteins.6 The type III secretion system (T3SS) is required for the pathogenesis of P. syringae and forms a specialized delivery system functioning in the translocation of effector proteins directly into the cytoplasm of plant cells.7 This suppresses the defence system of the plant and establish infections that result in plant cell death and release of nutrients for the invading pathogen.
The bacterium can change its pattern of expression of genes when comes in contact with the host and starts expressing virulence-related genes. It can produce highly viscous compounds like polysaccharides which create a protective environment for it to grow in.8 The species P. syringae is best known for its ice nucleation activity.9 The bacterium occurs in non-agricultural habitats like flooded areas, snow, alpine streams and lakes, and is responsible for frost damages in plants.10 Some strains of these bacteria have ice-making proteins on their surface which help in the formation of ice crystals. The ice crystals grow and create more wounds to the injured plant surface through which the bacterium can further infiltrate the plant tissues.
This study is focused mainly on the comparative genomics of the two most common pathovars of P.syringae, viz. P. syringae pv. Actinidiae and P. syringae pv. syringae. Pathovaractinidiaeis the causal agent of bacterial canker in kiwifruit11 and causes leaf spots, dieback, and canker that sometimes lead to plant death in vines.12 P. syringae pv. syringae is a common pathogen of several crop plants, which invades parenchymatous tissues causing leaf spots and stem cankers.13 It mainly attacks Syringa, Prunus and Phaseolus species with some reports of infection also in case of beans, millet, mango etc.14,15 The pathovar is known for the production of syringomycin, a peptide-containing phytotoxin that is not host-specific but biocidal to a wide spectrum of organisms.16 In this study we have tried to create a projection towards the comparative analysis of genomic features of the two pathovars, using both analytical and visualization tools for representation.
MATERIALS AND METHODS
Pathogenic strains belonging to two different pathovars
The strains which have been considered in this study belong to two different pathovars of Pseudomonas syringae (syringae and actinidiae) (Table 1). All genomes included, have been collected from NCBI Database (https://ncbi.nlm.nih.gov), and only the ones with complete sequences have been selected (including chromosome and megaplasmids). This is because the inclusion of scaffold and contigs might lead to undiscovered anomalies due to the omission of some genomic characteristics.
The MAFF212063 strain, belonging to the pathovar actinidiae has been used as the reference strain in this comparative genomics study, due to its widespread popularity and availability of complete molecular details of its genome. The 6.69347 megabases (Mb) genome of MAFF212063 is divided into 3 replicons: a 6.56 Mb chromosome and two plasmids of about 0.07 Mb. The MAFF212063 strain has a chromosome of 6,556,999 bp and two plasmids of 68,316 bp (pMAFF212O63-A) and 68,156 bp (pMAFF212063-B). The MAFF212063 is copper resistant variety, with copper resistance genes present on plasmid pMAFF212063-A. It carries a copper resistance encoding operon withCopA, CopB, CopC, CopD, and the regulatory CopRS pair.17The genome also contains many proteins which are associated with pathogenicity. Basic genomic features of the reference strain, as collected from the NCBI database, have been included in Table 2.
Sequence-based comparative analyses
Sequence comparisons can be done by using different sequence alignment programs. Multiple sequence alignment programs (e.g. ClustalW, Muscle) can find similarities between several sequences using more complex algorithms.18 EDGAR (Efficient Database framework for comparative Genome Analyses using BLAST score Ratios) is an online tool that supports the functional analysis based on the comparison of the closely related genome. Algorithms for sequence alignment analyses (Muscle) have been assimilated into it in a user-friendly manner.19 The strains used for our study were integrated into a single project in the EDGAR web-server using the help of the server administrators. The whole-genome sequences of the selected strains were then used for various sequence-based analytical programs like calculation of genomic subsets, genesets in the form of Venn diagrams, synteny plots, and genome browser for detecting the presence/absence and order of orthologous genes among the compared strains.
The genomic subsets calculation includes the core genome, pan-genome and the singleton genes calculation, with the reference genome as the starting base. The pan-genome is the entire gene set of all the strains of a species. It includes the genes present in the complete family of selected strains. The core genome represents the common set of genes present in all the strains. Whereas a singleton can be defined as a gene-specific to only a single strain, i.e, exhibiting no hits in any other genome but it's own. Venn diagrams allow an easy inspection of the size of the core genome and the number of genes in each of the dispensable subset of the genome. A synteny plot shows the conservation of gene order among compared genomes as it describes the co-localization of genes on a stretch of DNA. We designed separate synteny plots for each strain against the reference to gain an insight into the possible evolutionary events like genome rearrangements and inversion in the gene order. Stop positions of two orthologous genes of two bacterial strains are used as coordinates and plotted to a diagram with the sequence length of the compared strains serving as x and y-axis.
Phylogenetic analysis
Multiple sequence alignments for all the genome sequences were carried out using MEGA7 software.20 The sequences were aligned using the MUSCLE algorithm and a phylogenetic tree was generated using the neighbour-joining method, based on the Jones-Taylor-Thorton (JTT) model and bootstrap of 1000 replicates. The tree was squared to scale, with the number of substitutions per site represented by branch lengths.
Visualization of LCBs
MAUVE (Multiple Alignment of Conserved Genomic Sequence with Rearrangements) is genome comparison software that aligns the conserved genomic sequence by identifying the Locally Collinear Blocks (LCBs). Each LCB is a homologous region of sequence shared by two or more genomes and does not contain any rearrangements within itself.21 The genome sequences of the selected strains were aligned by ‘Progressive MAUVE’, to generate the comparative profiles for order of arrangement of the LCBs. Two separate alignment sets were created for strains belonging to actinidiae and syringae pathovars; each set against the reference strain MAFF212063.
RESULTS
Calculation of genomic subsets
The number of genes in the core and pan-genome for all the strains together was 3,777 and 8535 respectively. Additionally, the number of genes in the core genome and pan-genome was calculated in two sets each i.e., actinidiae strains + reference and syringae strains + reference. The core genome for actinidiae strains consists of 4566 CDS (coding sequences), whereas the core genome for syringae strains along with the reference shows 3916 CDS. This indicates the presence of a much greater number of common genes amongst the actinidiae strains. Similarly, the pan-genome for the actinidiae group consists of 6942 CDS, while that of the syringae + reference group consists of 7468 CDS. Pan-genome represents the sum-total of core genes, singletons (genes present in only one strain of analysed set) and dispensable (genes present in more than one strain but not a part of core genome). In other words, the pan-genome represents the total set of conserved, dispersed and unique genes. The fraction of singletons were found to be higher when four strains of pathovar syringae were analysed along with the reference strain, than that when strains of pathovar actinidiae were analysed (Figure 1). This indicates that on the gene level, a significantly greater degree of commonness is exhibited by the strains of actnidiae strains together with reference, as compared to syringae strains with the reference genome.
Core and pan-genome sizes are calculated by starting with one genome and then iteratively adding other genomes- one at a time- to the comparison in a user-defined order. Hence, in this manner, core genome size gradually keeps on reducing as the number of genes found to be conserved in sequentially added genomes keeps on decreasing. On the other hand, as the total number of encountered genes keeps on amassing with the addition of new strains, the pan-genome size keeps on increasing. The core and pan-genome development plots signify this trend (Figure 2). The corresponding increase and decrease of core and pan-genome sizes by gradual addition of particular strains in the analysis have been revealed in Table 3.
Visualization of overlapping gene sets within the compared groups
Venn diagrams are visual representation tools. They demonstrate the number of genes for the possible combinations of a selection of genomes. In any subset of the dispensable genome, they make a simple visual inspection of the core genome size and the gene numbers. The Venn diagrams were created in two sets, first is the actinidiae strains with the reference MAFF212063, and the second is for syringae strains with reference MAFF212063 (Figure 3). Each region signifies the number of common genes between the strains that overlap that region. The resultant Venn diagram also indicated more number of common genes when the reference was compared with actinidiae strains, than with the syringae strains.
Generating synteny plots for analysis of conservation in gene order
The synteny plots for each of the strains were developed against the MAFF212063 as the reference strain. The plots show the position of each CDS of the chromosome specified (with its genome on the Y-axis in terms of percentage of size), against the position of its homologue in the second chromosome (reference strain) given on the X-axis (Figure 4). It can be seen that B301D, B728a and Pss9097 strains show large scale inversion in their gene order. This proves to be an important distinctive feature on gene-level for strains belonging to a different pathovar than that of the reference genome. However, HS191 as an exception, despite being a syringae strain, shows a significant amount of conservation in its gene order with reference strain belonging to pv. actinidiae. Moreover, actinidae strains NZ-47, ICMP 18708 and ICMP 18884 when plotted against the reference genome, can be said to mainly exhibit large scale rearrangements in their gene order.
Phylogenetic Analysis
To define the homology between the analysed strains, a rooted phylogenetic tree was constructed after aligning the sequences using MUSCLE algorithm. The resulting tree produced well-resolved phylogeny with two separate clusters (Figure 5). The strains belonging to two different pathovars viz. actinidiae and syringe formed two separate well defined phylogenetic groups, with varying branch lengths based on the degree of evolutionary substitutions. HS191 however formed a separate branch from the rest of the strains of pv. syringae and was the closest syringae strain to the reference genome MAFF212063, in terms of parental node and branch length.
Sequence alignment of genomes against the reference strain for visualization of relative gene order
The MAUVE software was used for the visualization and alignment of the LCBs (representation conserved stretch of genes) of the different strains. The analysis was carried out in two separate sets for pv. actinidae and pv. syringae, with reference strain taken as the first sequence in both the cases (Figure 6). The results showed similar trends with that of synteny plot analysis. The actinidiae strains NZ-47, ICMP 9853, ICMP 18884 and ICMP 18708 show rearrangements in their gene order, whereas the syringae strains Pss9097, B301D and B728a show large scale inversion. HS191 despite being a syringae pathovar shows some amount of conservation in its gene order with the reference. The progressive MAUVE alignment also helps to visualize the difference in the size of genomes for actinidiae and syringae strains.
DISCUSSION
Comparative genomics is an exciting field of biological research in which researchers use a variety of tools including computational analyses, to compare the complete genome sequences of different species.22 Whole-genome sequence alignments have become more important day by day because the comparison between different genomes often leads to rapid identification of distinct mechanisms underlying pathogenicity.23 Through this type of study, scientists can devise new strategies to plan for the development of resistant crop varieties and biocontrol techniques. In this present study, we have tried to expound the basic genomic differences between strains of P. syringae belonging to two different pathovars, which exhibit different habits of pathogenicity and ensuing symptoms in the infected plants.
The first conspicuous genomic difference between the two pathovars lies in the size of the genomes of included strains. The genome sizes for pv. syringae strains are around 6 megabases, whereas, the sizes of actinidiae strains are greater than 6.5 megabases. The genomic architecture and gene order also correspondingly show greater similarity within the same pathovar, than with strains of another pathovar. The core and pan development plots generated more than 95% upper and lower confidence limits, thus ensuring that consistent and reliable genomic data has been used for carrying out the sequence-based analyses. The number of unique genes in the reference genome is found to be 1086 when pooled with the syringae strains, and is nearly half the value at 538 genes when compared with the rest of the actinidiae strains. The strain MAFF212063 belongs to biovar?5 of P. syringae. It is popularly known as ‘kiwifruit canker pathogen’ based on its host and pathogenicity patterns. In 2017, the first complete sequence of this copper resistant biovar-5 strain was published.17
The synteny plots however did not give a comprehensive demarcation between the two distinct pathovars. Even though the gene order for B301D, B728a and Pss9097 showed inversion in respect to the genome of reference strain, but HS190 contrastingly showed significant conservation in its gene order. In other words, the position of the orthologous genes was conserved to a great extent in HS191 strain (pv. syringae) and MAFF212063 strain (pv. actinidiae). Moreover, actinidiae strains ICMP9853, ICMP18707, ICMP1884 and NZ?47 showed rearrangements in their gene order concerning the pathogen. This can be considered as an unexpected observation, given that these strains are much closer to the reference, in terms of their phylogeny. Furthermore, the orthologous genes involved in the Type-III secretion system such as the Hrp genes often showed differences in their gene lengths in the strains of two pathovars. For instance, the length of the YopN family T3SS gatekeeper subunit is 1,107 bp in actinidiae strains whereas it is 1,182 bp in pv. Syringae strains. Similarly, the lengths of HrpQ and HrpZ1 genes were 993 bp and 1,104 bp in actinidiae strains, but 975 bp and 1,032 bp in syringae strains, respectively. However, the lengths of some genes like HrpB and HrpE were conserved in all the strains (375 and 582 bp respectively).
This comparative genome analysis identified the similarities and differences between the two most common pathovars of P. syringae. The gene order exhibits rearrangements between the actinidiae strains whereas the syringae strains show inversion in their gene order except for HS191 which formed a separate branch in the phylogenetic tree. This study helps to predict that geographic isolation of different strains of P. syringae from each other and variation in the pathogenic habits have most probably resulted in their genomic distinction. This further enhances the need for carrying out detailed research on the extent of correlation existing between the genomic organization and host specificity among the pathogenic strains of Pseudomonas syringae. Availability of complete genome sequences will further facilitate elucidating the differences in the genetic make-up of pathogenic strains as well as their pathogenicity and specificity towards host plants.
ACKNOWLEDGEMENT: The authors would like to acknowledge the University of Science and Technology, Meghalaya and Gauhati University, Guwahati, Assam. They also acknowledge their contemporaries whose works have been cited in this manuscript. The authors express their gratitude to Dr.NirajAgarwala, Assistant Professor, Department of Botany, Gauhati University for his guidance and motivation.
CONFLICT OF INTEREST: The authors declare they have no conflict of interest.
AUTHOR CONTRIBUTIONS: Krishna Baruah: Software, Writing - Original draft, Formal Analysis; Sushmita Kalita: Writing - Review & Editing, Data Curation; Debasish B. Krishnatrey: Supervision, Validation.
FUNDING: No source of financial support was available for this study.
Englishhttp://ijcrr.com/abstract.php?article_id=3701http://ijcrr.com/article_html.php?did=3701
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareImmediate Heart Rate Response to Standing in Pregnancy: A Case Control Study from India
English110113Balasaheb B. VikheEnglish Shashikant B SabadeEnglish Muktpal M. BhaleraoEnglishEnglish Heart rate, Parasympathetic function, Pregnancy, CANWININTRODUCTION
Pregnancy is one of the most beautiful and enriching experiences in a woman's life. It is characterized by various changes in the functions of the various regulatory system of the human body. These changes are initiated by ovarian and placental hormones during the first trimester and get modified as gestational age advances. Significant physiologic adaptations take place in the body long before they are necessary. By the seventh week of pregnancy significant changes observed in overall body compositions as well as cardiopulmonary and metabolic functions.1 The decline in systemic vascular resistance may be due to gestational hormones, increased concentrations of prostaglandins, and increased heat production due to developing fetus and development of a low-resistance circulation in the pregnant uterus.2
An increase in heart rate is observed as early as from the 15th week of gestation. Pregnancy is associated with an increase in blood volume due to a marked increase in plasma volume. This increased blood volume results in increased cardiac output during pregnancy. The asynchronous increase in heart rate and stroke volume results in marked augmentation of cardiac output during pregnancy. The parasympathetic deactivation towards term may also contribute to increased heart rate and cardiac output at rest in pregnancy.3 It is observed in earlier studies that in non-pregnant women, both systolic and diastolic blood pressure increases immediately on standing and returned to basal level within 10 minutes, while in the case of pregnant women, both systolic and diastolic blood pressure decreases on standing. A reduction in the oscillation of right atrial distension from diminished pulsatility of a venous return due to the growing uterus may be responsible for lowering diastolic blood pressure in pregnancy. It was also observed that the Valsalva manoeuvres ratio in pregnancy followed a downward trend from early to late pregnancy. It is most probably due to physiologic adaptation to chronic volume overload during pregnancy.4 Pulse rate remained unchanged in both pregnant and non-pregnant woman. Heart rate response to standing expressed as postural stress test was observed to remain unaltered during early pregnancy but significant reduction in postural stress test was found during last trimester. 5 But in another study no change in heart rate responses observed in the pregnant woman. Though in the same study blood pressure changes were slightly weaker in a pregnant woman as compared to a non-pregnant woman.6 An incomplete adaptation in the cardiovascular system during early pregnancy may be the cause of this deranged cardiovascular parameter in the pregnant woman. It has been observed that the increase in blood volume during the second half of pregnancy result in improved hemodynamic stability.7
As from earlier studies, it is not clear whether there is any change in heart rate or immediate heart response to standing during pregnancy or it remains unaffected. So we planned a study with aim of evaluating of immediate heart response to standing in pregnant women and compare it with non-pregnant women.
MATERIALS AND METHODS
A case-control observational study was carried out in the Department of Physiology in collaboration with the Obstetrics and Gynecology department at Rural Medical College Loni from India. The study was carried out after the approval from Institutional Ethics Committee with Registration No. PMT/PIMS/RC/2013/226.
A total of four hundred eighty women aged from 20 to 30 years without any recent history of cardiorespiratory diseases was selected. Among the total participant, three hundred sixty were pregnant in the case group and one hundred twenty were non-pregnant in the control group. The case group was further divided into three trimesters 1st trimester, 2nd trimester, and 3rd trimester with one hundred twenty subjects in each trimester.
Inclusion Criteria:
Age group 20 to30 years.
Pregnant women visiting the hospital for a routine checkup.
Free from any systemic illness which can affect cardiovascular function.
Able to complete the tests for the cardiovascular autonomic activity
Exclusion Criteria:
H/O of any cardiovascular disorders
H/O of addiction to tobacco, mishri, alcohol etc.
H/O any type of medication which can affect cardiovascular autonomic functions.
Written consent was obtained from all the willing participants (pregnant and non-pregnant) before the start of the study. Data comprising of demographic parameters like Name, Age (Years), Height (Foot), Weight (Kg) and Family/ Medical/ Menstrual history were obtained and recorded from all pregnant and non-pregnant participant. Special emphasis was given to findings suggestive of autonomic neuropathy. The immediate heart rate response to standing (30:15 ratio) was measured by automatic “Cardiac Autonomic Neuropathy Analyzer” (CANWIN). Immediate heart rate response to standing or 30:15 ratio > 1.04 taken as normal and reduced if 30:15 ratio < 1.03.8
Statistical analysis
Statistical analyses were done by one way ANOVA between the study groups control and cases. The p-value < 0.05 was taken as significant and the p-value >0.05 was taken as non-significant.
RESULTS
Table 1 and Figure 1 Shows a comparison of anthropometric parameters results between non-pregnant and 1st, 2nd and 3rd trimesters of pregnancy. There was no significant difference in the parameters age, height and Hb in pregnant and non-pregnant women (P>0.05). But weight shows a significant difference during the 2nd and 3rd trimester when compared with non-pregnant women (P < 0.05*).
Table 2 & figure 2 shows mean and SD values of immediate heart rate response to standing in pregnant and non-pregnant women.
Table 3 shows the comparison of immediate heart response to standing in pregnant and non-pregnant women. A significant decrease in immediate heart response to standing observed in non-pregnant women and pregnant women of all three trimesters (p < 0.05).
DISCUSSION
The present case-control observational study was carried out in the Department of Physiology in collaboration with the Obstetrics and Gynecology department at Rural Medical College Loni from India. The four hundred eighty women aged from 20 to 30 years without any recent history of cardiorespiratory diseases were selected. Among the total participant, three hundred sixty were pregnant in the case group and one hundred twenty were non-pregnant in the control group. Immediate heart rate response to standing was evaluated in all the pregnant and non-pregnant women. Mean and SD of control, 1st, 2nd and 3rd trimesters of pregnant groups were 1.15 ± 0.12, 1.13 ± 0.18, 1.11 ± 0.28 respectively. In a non-pregnant woman, the immediate heart rate response to standing was 1.08 ± 0.1. Heart rate response to standing was decreased in pregnant woman and it goes on decreasing as the pregnancy advances. A significant decrease in immediate heart rate response to standing was observed among pregnant women of all trimesters as compared to non-pregnant women.
Similar results are observed by some other researchers. A case-control study by Steven L Clark et al. on ten pregnant women and ten healthy non-pregnant women found a significant decrease in immediate heart rate response to standing among pregnant and non-pregnant women. Though the sample size of the study was less as compared to the present study results observed in both studies were similar. Steven L Clark et al. concluded that there is a blunted heart rate response to immediate standing during pregnancy which results in decreased heart rate and it goes on further decreasing as the gestational age advances5. In other studies by Pyorala T et al. on sixty pregnant women during the 1st and 2nd trimester found heart rate response to immediate standing changed in both the groups and response was more sluggish with the advancement of pregnancy.9 The hemodynamic profile of the pregnant woman is supposed to be altered by changes in position, the effect of the growing fetus and enlarged uterus on vena cava and aortic blood flow in the supine position.10 The human response to orthostasis is complex. It is due to sudden pooling in the veins of the leg after standing it causes a fall in the central venous return (preload) and fall in blood pressure which ultimately result in increased heart rate.11
Thomas et al. in a study on 143 pregnant women in the 3rd trimester found a reduced difference between standing heart rate and resting heart rate.12In one other study by Nisell et al.found markedly blunted heart rate response to tilting during the last trimester of pregnancy.13. All these studies found either blunted response to heart rate or decreased heart rate response to standing during pregnancy and were in agreement with the present study. But few studies were not in agreement with the present study and doesn’t found a significant change in immediate heart rate response to standing in pregnant and non-pregnant women. No significant change in immediate heart rate response to standing between pregnant and non-pregnant women.14 Similarly one other study by Page et al. doesn’t found any significant change in heart rate between pregnant and non-pregnant women and were in non-agreement with the present study. A study by Arpita Mandal et al. on 276 healthy pregnant women from India found that serum progesterone level increase gradually throughout pregnancy and these changes in hormonal levels may also contribute to the altered autonomic functions during pregnancy.15
These differences in observations may be due to recruitment of a different group of pregnant women for study as we included subjects from all the three trimesters of pregnancy but in these studies subject from particular trimester were recruited like Ekholm et al. done study on pregnant subjects from 2nd trimester only. These changes are more significant with the advancement of pregnancy and this may be the reason for differences in the findings. The strength of the present study was subjected to all trimesters included in the study. The number of subjects in both pregnant and non-pregnant women was sufficiently large.
Limitations of the present study were the subjects mainly belongs to the rural population and the result cannot be applied to the general population. Subjects visiting for routine checkup were selected and due to proper medical supervision from early pregnancy observed result may vary when compared to subjects with no routine checkup during pregnancy.
CONCLUSION
The study showed a significant decrease in immediate heart response to standing in the normal pregnant women as compared to non-pregnant women from the rural population of India. A study of parasympathetic functions must be done to predict any pre-existing autonomic dysfunction during pregnancy.
ETHICAL APPROVAL: The study was carried out after the approval from Institutional Ethics Committee with Registration No. PMT/PIMS/RC/2013/226.
ACKNOWLEDGEMENT: The authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of the manuscript. The authors are also grateful to authors/editors. Publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. All those who have significantly contributed in this study are included as an author. All the authors sincerely pay gratitude to all the patients and healthy subjects who have given their blood for analysis and actively participated in the study.
CONFLICT OF INTEREST: NONE
SOURCE OF FUNDING: NIL
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Clark SL, Cotton DB, James MP, Lee W, Gary DVH, Thomas JB. Position change and central hemodynamic profile during normal third-trimester pregnancy and postpartum. Am J Obstet Gynecol 1991;164:883-887
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareA Comprehensive Review on Phytochemical, Nutritional, and Therapeutic Importance of Musa acuminate
English114124Nishant KumarEnglish Akash VedEnglish Ritu Rani YadavEnglish Om PrakashEnglishEnglishMusa acuminata, Banana, Musaceae, Nutritional value, Phytochemistry, PharmacologyIntroduction
Throughout evolution, the importance of botanicals for medicine and health has been enormous. Ethnobotanical literature has described the traditional usage of plant extracts, infusions, and powders for years against many diseases. For ages, plant parts have been the sole means to treat diseases and injuries in several cultures around the world, and are still in use as a traditional treatment in various countries.1 Many of these plants have been used solely based on a traditional notion and studies are now providing evidence of their efficacy. The World Health Organization WHO believes that the significant population of developing countries relies on traditional medicine for their primary health care needs. Therefore, there is an increased demand for medicinal plants in developing and developed countries. However, most of them are still obtained from wild sources without applying scientific management; hence many species are under the threat of extinction.2 Fruits and vegetables are an important component of a healthy diet. Some fruits like bananas offer great medical benefits. This is partly because bananas aid in the body's retention of calcium, nitrogen, and phosphorus, all of which work to build healthy and regenerated tissues. Musa acuminata Colla is a wild species of banana that is native to Southeast Asia. Various parts of the Musa plants have been used orally or topically as remedies in folk medicine and some studies have demonstrated this medicinal potential. It is known for many pharmacological activities and reports show that phenolic compounds present in Musa acuminata mainly contribute to this trait. All parts of the plant which include the roots, stem, pseudostems, leaves, fruits, and flowers have long been used in local and traditional medicine in America, Asia, Oceania, India, and Africa. The present review paper highlights the food and medicinal importance of different parts of the Musa acuminata plant. An integrated profile of the composition and nutritive value of the edible fruit is also provided. A comprehensive assessment of the biological activities of different plant parts is included and possible mechanisms and phytochemicals involved have also been correlated.3
Taxonomy and Classification4
Kingdom: Plantae
Clade: Tracheophytes
Clade: Tracheophytes
Clade: Angiosperms
Order: Zingiberales
Family: Musaceae
Genus: Musa
Species: M. acuminate
Synonyms
Musa acuminata is highly variable and the number of species. The following are the most commonly accepted species are Musa cavendishii Lamb, Musa Chinensis Sweet, Musa corniculata Kurz, Musa nana Lour, Musa × sapientum var. suaveolens Blanco Malag, Musa rumphiana Kurz, Musa simiarum Kurz, and Musa sinensis Sagot ex Bake, etc.5
The Musa acuminata plant exhibits considerable variation and has been split up into eight subspecies namely Musa acuminata subsp. acuminata, Musa acuminata subsp. burmannica, Musa acuminata subsp. errans, Musa acuminata subsp. halabanensis, Musa acuminata subsp. malaccensis, Musa acuminata subsp. microcarpa, Musa acuminata subsp. siamea, M. acuminate subsp. truncate, and three varieties namely Musa acuminata var. chinensis, Musa acuminata var. sumatrana, and Musa acuminata var. tomentosa.6
Origin and Distribution
Musa acuminata belongs to the Musaceae family distributed in the hot, tropical regions of Southeast Asia.7,8 Musa acuminata has a relatively wide distribution, and Malaysia is considered as the primary centre of origin of Musa acuminate.9,10 Later it spread to India and Burma11, the home of the native species of M. balbisiana. In the Indo-Burman peripheral area, natural hybridization of both Musa acuminata and M. balbisiana occurred and triploid AAA cultivars of banana arose, and therefore India is regarded as the major centre of origin for more than 300 types of banana cultivars out of the 600 types of Musa germplasm.12-18 Mention of banana in ancient Indian treatises such as Ramayana 2000 BC, Arthsastra 250 BC, and the Chilappthikaram 500 AD suggests the antiquity and long period of domestication of banana fruit in India. The genus name was adapted in the honor of Roman physician and botanist Antonius Musa 63 BC- 14 AD, and the species name acuminata is a Latin word for sharp or acuminate referring to the sharp apex of its fruits. Musa acuminata has been identified in the natural habitats of the Kaziranga forest range of Assam, Khasi hill ranges of Meghalaya, southern and middle Andamans, and in the Western Ghats of Karnataka in India.19 At present, Musa acuminata is grown in many countries worldwide, and the major producers are Brazil, China, India, Ecuador, Columbia, and Venezuela. The global distribution of Musa acuminata is shown in Figure 1.20,21
Botanical Description
The plants are perennial and stooling sparsely 1- 2 stems or freely 4 - 30 stems. The leaf sheaths and petioles are more or less glaucous or pruinose. Leaf-blades are oblong 2.0- 2.5 m long x 0.4- 0.6 m wide, truncated at the apex, and usually rounded at the base, but leaf blades rounded on one side and acute on the other side are also reported. The inflorescence is subhorizontal or vertically deflexed. Fruits are narrowed at b
ase into a pedicel of about 1 cm, and apex into a prominent acumen of 0.6- 1.5 cm length. The pericarp is about 2 mm thick with bright yellow colour at full ripeness, and the pulp is of white or cream-yellow to yellow colour. Seeds are dull black, smooth or minutely tuberculate, irregularly angulate, and measure 6- 7 mm in length and are of about 3 mm height (Figure 2).22,23
PHYTOCHEMISTRY
The phytochemical analysis of different parts of Musa acuminata such as fruit, peel, flower, leaf, pseudostem, and rhizome has shown the presence of a rich diversity of phytochemicals like saponins, terpenoids, steroids, anthocyanins, fatty acids, tannins, phenols, and alkaloids. Phytochemicals content is reported to vary with the extraction method employed, and compounds identified in various plant parts of Musa acuminata are presented in Table 1.24 Plants continue to be an important source of bioactive compounds and involve a multidisciplinary approach combining ethnobotanical, phytochemical, and biological techniques to provide new chemical compounds. The presence of bioactive compounds like apigenin glycosides, myricetin glycoside, myricetin-3-O-rutinoside, naringenin glycosides, kaempferol-3-Orutinoside, dopamine, N-acetyl serotonin, and rutin, has been reported in different species of Musa.25 The detailed structural presentations are reported in figure 3.
NUTRITIVE VALUE
Banana, tropical fruit with high calorie, provides exceptional nutrition in different forms. Banana, tropical fruit with high calorie, provides exceptional nutrition in different forms. Musa family contains starch, fructans, phenolic acid, anthocyanins, terpenoids, and sterols. In unripe plantains, starch is present over 80% of the dry weight of the pulp. The fat content of plantains and bananas are very less about 0.5% and so fats do not contribute much to the energy content.52 The total protein value of plantain is related to dry weight is more than 3.5% in ripe pulp and it is slightly less in fresh fruit. About 1.3% of sugars are present in total dry matter in unripe plantains, but this rise to around 17% in the ripe fruit. It is an excellent source of some vitamins like carotene (vitamin A), Thiamine (vitamin B1), riboflavin (vitamin B2), niacin (vitamin B3), pyridoxine (vitamin B6) and ascorbic acid (vitamin C). Pyridoxine is an important B-complex vitamin that plays a vital role in the treatment and management of neuritis and anaemia. Moreover, it helps to decrease homocysteine one of the causative factors in coronary artery disease CHD and stroke episodes level inside the body.53 Potassium, an important component of cell and body fluids, supports muscles and nerves. Banana is rich in starch and it is a rich source of potassium. Potassium benefits the muscles as it helps maintain their proper working and prevents muscle spasms. Also, recent studies are showing that potassium can help to decrease blood pressure in individuals who are potassium deficient. Potassium also reduces the risk of stroke. In addition to manganese, magnesium is essential elements for strong bone and has a cardiac active role. Manganese is used as a co-factor in the body for the enzyme, superoxide dismutase oxidation. Copper is playing an important role in the production of RBCs. Banana is rich in fructose and sucrose. It replenishes energy and revitalizes the body instantly. It is a moderate source of health-promoting flavonoid and poly-phenolic antioxidants such as lutein and zeaxanthin. It contains β- and α-carotenes in small quantities. These compounds help act as protective scavengers and neutralize oxygen-derived free radicals and reactive oxygen species ROS.54 Banana is rich in fatty acids, phytosterols, and steryl glucosides Steryl esters and free sterols such as campesterol, β-sitosterol (Figure 3c), cycloartenol (Figure 3d), and stigmasterol (Figure 3h) are the major lipophilic component found in the unripe banana peel.55 Steryl esters and free sterols are the major lipophilic component found in unripe banana peel, while free fatty acids and sterols dominate banana pulp. Banana fruits contain a major quantity of essential mineral elements and could serve as a source of minerals in human and animal daily routine diets.56,57 Detail description of the nutritional importance of Musa acuminata is described in Table 2.
PHARMACOLOGICAL ACTIVITIES
Different parts of the Musa acuminata plant have shown potential for disease prevention in traditional medicine, which may be attributed to the rich and diversified content of phytochemicals present in them. Various models were used to investigate the health-promoting properties of M. acuminata, and description of available in-vitro and in-vivo models are detailed here.
Blood cholesterol-lowering property
The antioxidants property of kepok banana peel is due to the presence of saponin, tannin, and flavonoid and responsible for the decrease in the blood total cholesterol level. The current study determines whether saponin, tannin, and flavonoid in kepok banana peels are effective against total blood cholesterol levels in obese mice. This experiment using 20 obese male mice Mus musculus L. strain Deutschland-Denken-Yoken and divided into four groups, which are normal control group, obese control group, and groups that were given an extract of Kepok Banana Peel Musa acuminata treatment with dose 8,4 mg/day and 16,8 mg/day. The treatment was given in 14 days. The total cholesterol level of each group was measured by spectrophotometer. The results obtained p=0,000, in a one-way ANOVA test. Furthermore, the Post Hoc Test generally found that there were significant differences between groups. There is an effect of giving kepok banana peel to decrease the total cholesterol level of obese mice. The effect of kapok Banana peel extract level of 8.4 mg/day remarkably decreases total blood cholesterol level compared to banana peel extract level of 16.8 mg/day. The anti-cholesterol effect of banana fibre ethanol extract proved to a significant decrease in total cholesterol in obese male mice Mus musculus L. strain Deutschland-Denken-Yoken. 62
Antioxidative properties
Banana fruits Musa acuminata Juss. are important foods, but there have been very few studies evaluating the phenolics associated with their cell walls. In the present study, + catechin, gallocatechin, and − epicatechin, as well as condensed tannins, were detected in the soluble extract of the fruit pulp; neither soluble anthocyanidins nor anthocyanins were present. In the soluble cell wall fraction, two hydroxycinnamic acid derivatives were predominant, whereas in the insoluble cell wall fraction, the anthocyanidin delphinidin, which is reported in banana cell walls for the first time, was predominant. Cell wall fractions showed remarkable antioxidant capacity, especially after acid and enzymatic hydrolysis, which was correlated with the total phenolic content released after the hydrolysis of the water-insoluble polymer, but not for the post hydrolysis water-soluble polymer. The acid hydrolysis released various monosaccharides, whereas enzymatic hydrolysis released one peak of oligosaccharides. These results indicate that banana cell walls could be a suitable source of natural antioxidants and that they could be bioaccessible in the human gut.63
Hepatoprotective and Antiulcer activity
Plant?based natural remedies remain the treatment of choice as they are deemed effective, safe, and with minimal adverse side effects. the Natural Products Discovery Laboratory at the Institute of Bio?IT Selangor, Universiti Selangor, Malaysia carried out studies on the hepatoprotective, antiulcerogenic, antioxidant, and cytotoxic activities of Musa acuminata. The results showed that under certain conditions, the methanolic extracts of unripe Musa acuminata showed equivalent activity to the commercial hepatoprotective drug silymarin and anti?ulcer drug omeprazole as demonstrated in the animal model. The extracts were not cytotoxic and exhibited low to moderate antioxidant activity. These ameliorative effects could be related to the saponins, flavonoids, and triterpenes in the peel and pulp extracts, and the tannins present in the peel extract. Further investigations are required to optimize the extraction of bioactive compounds that work synergistically to produce the ameliorative or protective effects described in our studies.64
Anticancer activity
The total phenols and flavonoids, anticancer and antioxidant activities ethanol extracts of three plants Phoenix dactylifera, Musa acuminata, and Cucurbita maxima were determined. The total phenolic contents were computed to be 342 µg/mL gallic acid equivalents in ethanol extract of banana fruit while the highest total flavonoids were in ethanol extract of molasses date 1424 µM as rutin equivalent. In vitro anticancer activity was determined using EACC and HeLa cell lines. In vitro anticancer activity against EACC revealed that the maximum inhibition was observed in ethanol extract of pumpkin seeds 100% at 100µg/ml while the maximum inhibition against the HeLa cell line was observed in ethanol extract of date seeds 90% at 100µg/ml. The antioxidant activity was determined using three different methods DPPH, ABTS scavenging activity, and reducing power. DPPH scavenging activity was found to be 85 and 84 % in ethanol extracts of date seed and banana fruit, respectively. ABTS scavenging activity was found to be 98, 98, 95, and 95 % in ethanol extracts of seeds, molasses of date, fruit, and peel of a banana, respectively. The reducing power was 873, 833, and 871 µg/mL GAE in the ethanol extracts of molasses, seeds, and fruit of date. Four different formulas were prepared from tested plants and the sensory evaluation of these formulas showed that prepared formulas were judged as highly accepted. The results showed that ethanol extracts of date parts, banana peel pumpkin seeds are promising new antioxidant and anticancer agents and prepared formulas could be used as a daily health supplement.65
Another study was performed to evaluate the radioprotective and anticancer effect of banana peels extract on male mice. Sixty male mice weighed 18- were used, the animals divided equally into six groups as follow first group act as normal, second group Tumor control implanted with Ehrlich tumour, third group, the irradiated group exposed to a single dose of 3.0 GY of gamma rays, fourth group banana peels extract 300 mg/kg/day orally for 3weeks, fifth group tumour implanted + banana peels extract 300 mg/kg/day orally for 3weeks, sixth group irradiated with dose 3.0 GY gamma+ 300 mg/kg/day for 3 weeks. At the end of the experimental mice were sacrificed by anaesthesia and the blood was collected to evaluate biochemical parameters Complete Blood Count, Carcinoembryonic antigen, Malonaldehyde, Molecular study, electrophoretic assayed. The results showed that banana peels extract ameliorate the alteration in irradiated and tumour group, and significantly decrease p≤0.05 the elevation of Carcinoembryonic antigen in tumour implanted group, significantly decrease the elevation of Malonaldehyde in tumor implanted group and irradiated group. According to protein fractions and western blotting data, it could be concluded that addition banana peels extract consider a crucial impact for Irradiation dose which is cleared through a huge increase of Polymorphism % for addition banana peels extract 20% comparing with to Irradiation treatment which didn’t reflect polymorphism. Furthermore, noticeable stimulation for P53 expression level was detected for applying banana peels extract and Irradiation as a Compound dosage.66
Inhibitory Activity
Musa species is a traditional Indian medicinal plant used for the management and treatment of many diseases. The current study was compared the anticholinesterase, anti?inflammatory, antioxidant, and antidiabetic activities of Musa acuminata Simili rajah, ABB fruits and leaves fractions followed by characterization of the phytoconstituents using HPTLC?HRMS and NMR. Leaf fractions exhibit a remarkable pharmacological activity than the fruit. Ethyl acetate fraction of the leaf contains a major concentration of total phenolic content 911.9 ± 1.7 mg GAE/g and gives significant DPPH· scavenging activity with IC50, 9.0 ± 0.4 µg/ml. It also exhibits the remarkable inhibition of acetylcholinesterase IC50, 404.4 ± 8.0 µg/ml and α?glucosidase IC50, 4.9 ± 1.6 µg/ml, but a moderate α?amylase inhibition IC50, 444.3 ± 4.0 µg/ml. The anti?inflammatory activity of n?butanol IC50, 34.1 ± 2.6 µg/ml and ethyl acetate fractions IC50, 43.1 ± 11.3 µg/ml of the leaf were higher than the positive control, quercetin IC50, 54.8 ± 17.1 µg/ml. Kaempferol?3?O?rutinoside and quercetin?3?O?rutinoside rutin were identified as the novel medicinal agent with potent antioxidant and antidiabetic activities from the ethyl acetate fraction of Musa acuminata leaf.67
Immunomodulatory activity
To explore the feasibility of Musa acuminata banana peels as a feed additive, the effects of banana peel flour BPF on the growth and immune functions of Labeo rohita were evaluated. Diets containing five different concentrations of BPF 0% basal diet, 1% B1, 3% B3, 5% B5, and 7% B7 were fed to the fish average weight: 15.3 g for 60 days. The final weight gain and specific growth rate were higher in the B5 group. The most significant improvements in immune parameters such as lysozyme, alternative complement pathway, leukocyte phagocytic, superoxide dismutase, and catalase activities were observed in the B5 group. However, the B5 group exhibited the lowest malondialdehyde activity. IgM and glutathione peroxidase activities were significantly elevated in the treatment groups, except in B1, after only 30 days of feeding. Of the examined cytokine-related genes, IL-1β, TNF-α, and HSP70 were upregulated in the head kidney and hepatopancreas, and expressions were generally higher in the B3 and B5 groups. Moreover, the B5 group challenged with Aeromonas hydrophila 60 days after feeding exhibited the highest survival rate of 70%. These results suggest that dietary BPF at 5% could promote growth performance and strengthen immunity in L. rohita.68
Wound healing activity
Banana Musa acuminata peel is a rich source of many nutrients and is considered high in carbohydrates. It has been traditionally used to treat diarrhoea, anaemia, and ulcers. Some studies have shown that banana peels possess antioxidant and anti-inflammatory properties. This study was performed to evaluate the wound healing activity of banana peels extract BPE in the rabbit. For inducing full-thickness wound in rabbits, the excisional wound model was used. The animals were randomly divided into six experimental groups. Negative control, standard and vehicle control groups, and treatment groups. All the treatment was applied topically twice daily. Healing was assessed by wound contraction and re-epithelialization rate and the tensile strength of the wound tissue sample. Histopathological studies also showed the wound healing activity of BPE. The results of this study indicated that the hydroalcoholic extract of banana peels has a strong potential for wound healing and it can be used for different types of wounds in human beings to.69
Antibacterial activity
An in vitro test was carried out to assess qualitatively the antibacterial activity of the Musa acuminata leaf methanol extract coated sample against Staphylococcus aureus ATCC 6538, a gram-positive microorganism, and Escherichia coli, a gram-negative microorganism, using nutrient agar, purchased from M/s T. Stanes & Company Limited, Coimbatore, Tamil Nadu. Nutrient agar plates were prepared by pouring 15 ml of nutrient agar medium into sterile Petri dishes. The dishes were allowed to solidify for 5 min, and 0.1% inoculum suspension was smeared uniformly and the inoculum was left to dry for 5 min. The Musa acuminata leaf methanol extract-finished fabric of 2.0 cm diameter was placed on the surface of the medium, and the plates were incubated at 37.5°C for 24 h AATCC Technical Manual, 2007. After completion of incubation, the fabric sample was taken out and the zone of inhibition formed in the fabric was measured in millimetres and the readings were recorded.70
The ethanolic 96%, acetone and petroleum ether extracts of Musa acuminata leaf showed excellent antifungal activities against two pathogenic fungi Aspergillus terreus and Penicillium solitum with up to 5.7 cm inhibition zone diameter at 20 mg/mL of the extract. 71 A formulated gel preparation containing 4% Musa acuminata leaf acetone extract was reported to show an inhibition zone diameter of 27 mm against C. albicans, which was comparable to Nystatin cream used as control.72
Antidiabetic activity
In an investigation the antihyperglycemic effect of ethanolic extract of inner peels of Musa acuminata fruit 100- 400 mg/Kg p.o. along with control 1% gum acacia, 1 mL/Kg p.o. and standard drug Glimepiride, 0.09 mg/Kg p.o. using oral glucose tolerance test in normoglycemic Wistar rats. The extract-treated group showed a dose-dependent antihyperglycemic effect, but no significant pEnglishhttp://ijcrr.com/abstract.php?article_id=3703http://ijcrr.com/article_html.php?did=3703
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareStudy on the Efficacy of Silver Nanoparticle Leaf Extract of Pluchea lanceolata
English125129Pankaj NainwalEnglish Manu PantEnglishEnglish AgNO3 nanoparticles, Pluchea lanceolata, Ultra violet, Scanning Electronic Microscopy, X-ray diffractionINTRODUCTION
Nanotechnology is a science deal in controlling substance at the molecular level. Its Incredible growth has opened up various sources of research and development field of science. It is to the lead in various areas of sciences like technology, and various courses of medical sciences. However, the application of metal nanoparticles was also found in drugs and dispensing. Gold (Au), Silver (Ag) nano-particles are mostly employed in making metal nanoparticles in various biomedical uses as well as in nano-biotechnological studies.1 There is an excellent application of nanoparticles in the production of nanoparticles in biological as well as in microbiological systems. The application of microorganism in microbiological sciences is increasing because this field is growing success day by day as well as it is very easy to form nano-particles.2 Furthermore, the synthesis of metal nanoparticles biologically, is an environment friendly in which use harsh, toxic and expensive chemicals are superseded. Pluchea lanceolata in the indigenous systems of medicine, considered to help treat inflammatory disease and is also indicated in Ayurvedic manuscripts for its therapeutic usefulness in inflammatory disease especially rheumatoid arthritis and other afflictions of joints. In folk uric use the crushed leaves were applied to the inflamed parts of the body. The vaidyas and old herbalist used Pluchea lanceolata drug in the treatment of joint pains or gout. Scientifically, the decoction of the plant has been reported to prevent the swelling of joints.2,3 The leaves are found aperients with a variety of applications like a laxative, analgesic, and antipyretic. Quercetin and iso-rhamnetin chemical's presence in the air-dried leaves of P. lanceolata has been reported so far. Anti-inflammatory potential, antioxidant properties have already been reported in a constituent neolupinol which is isolated from the flowers of this plant.3 However, no work has reported before for synthesis of Pluchea lanceolata leaves extract formation with silver oxide nanoparticles, hence an objective was made to perform this study.
Materials and Methods
Analytical grade silver nitrate (AgNO3 ≥99.9%) was purchased without any further purification. Fresh leaves of Pluchea lanceolata was obtained from the Herbal garden, Dehradun, Uttarakhand and was authenticated. The leaves were taken for washing underwater 2-3 times and then again leaves were washed with distilled water. They were then dried in shadow and after drying they have meshed with the help of a grinder then the mashed extract was taken. The extract proceeded for filtration and was filter was used for the synthesis process. 0.1 M AgNO3 solution was prepared and the filtrate was added to it. The mixture was allowed to stand till precipitation occurs. The solution was stirred for 3-4 hours gently. The colour of the solution was gradually changed from colourless to greyish black. The prior formation of silver nanoparticles was estimated by colour change (Figure 1). The solution was again taken for filtration with Whatman’s filter paper and the residue was washed 2 times with distilled water. The precipitate was collected in Petri plates. Then it was kept in shelf dryers for drying at 110-1200C for 24 hours4.
Characterizations
The detailing and description of structures of the nanoparticles were carried out at room temperature using Analytical XPERT-PRO employing a monochromatic beam of Cu Kα radiation (1.5407 A0) over 2θ range of 0?-80?. The Fourier Transform I.R. spectrum of the synthesized plant samples was recorded by employing FTIR spectrometer and the UV-Visible spectra of the synthesized nanoparticles were recorded in the range 220 nm - 920 nm covering the near UV, visible, near-infrared region using CAMAG double beam UV-Vis Spectrophotometer 5. The fluorometer was then used for recording the photoluminescence range at RT. Scanning electron microscopic analysis was carried out by Scanning electron microscope of GPJ3480 and energy dispersive x-rays analysis was done by using highly calibrated Energy Dispersive X-Ray spectrometer.
RESULTS
X-Ray Diffraction Analysis
The diffraction pattern of x-rays (Figure 2) demonstrated the Bragg's reflections at 2θ =29.7064, 32.3086, 38.2005, 46.2865, 54.9546, 57.5901 & 64.5488, which can be indexed to the (1 1 1), (2 1 2), (0 1 4), (1 1 2), (2 14), (4 1 3) and (2 2 2) planes of AgO respectively. These peak heights were found similar to the standard Silver oxide (JCPDS No: 84-1108). The assessment among all values signifies the presence of silver oxide in every phase which is present in the specimen and was identified as having a tetragonal shape with the constant a= 6.7902A?, c = 9.3659A?. lattices. Figure 3 shows Hall Williamson's plot. The average crystalline material size was found using Scherrer's formula and Hall Williamson plot6 as 28.66 nm and 24.59 nm respectively.
FTIR Analysis
This analysis is very much important for the identification of the structure of molecules as well as to seek out the possible numbers of biomolecules present in the leaves extract which was responsible for silver ion reduction and functional group of synthesizing material sample.7 However the significant peaks were identified at 1602 cm-1, 702 cm-1 and 525 cm-1 which is equivalent to C=O stretching, C-H bending and vibration occur by silver oxide in series, while besides some other signals or peaks not prominent, were also identified (Figure 4)
UV and Photoluminescence estimation
For estimation of optical characters, the synthesized crude extract's silver Nanoparticles was evaluated with the help of a UV-Visible (UV-Vis) spectrophotometer at room temperature. In fig 5, a specific signalled peak was identified at 300nm. The peak was visible with a typical absorbance under a UV spectrophotometer. The visible peak symbolizes the Surface Plasmon Resonance characteristic of silver nanoparticles. The optical band gap of leave extract silver nanoparticles was estimated by employing Tauc's equation which is expressed by (αhν) = A (hν – Eg)n. Here α signifies absorption coefficient, A is constant, hν signifies incident light energy, n is exponent whose value relies on the type of transition having values like 1/2, 2, 3/2 and 3 which is similar to allow direct, indirect, forbidden direct, indirect transition respectively. The optical band gap was identified as 3.43 eV from the truck's plot (fig.5). The silver nanoparticle-based extract of Pluchea lanceolata with silver oxide nanoparticles was studied with help of fluoro-emission spectroscopy to know its fluorescence property.8 The sample was found in an excited state at 300 nm and the emission spectra analysis were carried out within a range limit between 200-900nm, based on excitation maxima (Fig 6). The peak at 380 nm (eg = 3.3 eV) was nearly coinciding with the UV Spectra. The peaks at 520 nm and 790 nm were because of the occurrence of oxygen vacancy and surface imperfections respectively.
SEM with EDX Analysis
To study the structures of nanoparticles, a typical analysis from SEM (Scanning Electron Microscope) was used. The signals of elemental metal detection were observed by the Energy Dispersive X-Ray method for confirmation. The surface morphological detection of the silver oxide Nanoparticles was done at different magnifications ranging from 10000 to 55000 (Fig.7). The images obtained from the scanning electron microscope depicts that the density of silver nano-particles are high and also gave confirmation regarding the development of silver nanostructures.9 The aggregation of particles are observed however the surfaces between single crystals were identified and observed. The result of the Energy Dispersive X-Ray shows that there is a higher count at 3 kiloelectron volts because of the presence of silver nanoparticles (fig 8) and this is revealed by representing a typical optical absorption peak at 3 keV. It might be due to surface plasmon resonance, which also represents the occurrence of oxygen. The particles have seen rough spherical shapes.
DISCUSSION
In the present study, the method employed for the formation of silver nanoparticles on the leaves extract of Pluchea lanceolata is cost-efficient and ecofriendly. The X-ray diffraction methods were employed to identify the size and morphology of prepared extract silver nanoparticles. The green method in form of usage of eco-friendly reducing agent used in FTIR spectroscopic analysis shows the occurrence of the functional group similar to phytoconstituents present in plants.6,7,8 These phytochemical acts both capping and reductant in the synthesis process. The Silver oxide vibration by using FTIR in test samples of plant extracts showed functional groups. The optical band gap identified to be 3.42 and 3.31 from Ultraviolet and Photo luminance analysis respectively. The contrast that occurs in between was due to the stokes shift. The scanning electron microscopic analysis results from the roughly spherical structure of the nanocrystallites. Elemental compositions were analyzed by the EDAX spectrum.9
CONCLUSION
This study, also results out that if there is an increase in the concentration of silver nitrate in solution then there will be an increase in the density of nanoparticles which enhances the growth of large particles from nanoparticles. As some evidence results during the UV-Vis spectra in which there is an increase in absorbance and redshift of SPR peaks, which proves the above-said matter. The solution’s retention time also affect the silver nanoparticle’s stability and size, as particle size increase with the increase in retention time which was proved by the formation of a secondary peak in UV-Vis spectra.
ACKNOWLEDGEMENT: I would like to thanks Chancellor, Vice-Chancellor, Director Research and Director Pharmacy to provide all amenities and funds for this project.
SOURCE OF FUND: This project was approved for funding under Faculty Development Programme 2019, by Graphic Era Hill University, Dehradun, Uttarakhand.
CONFLICT OF INTEREST: None
Englishhttp://ijcrr.com/abstract.php?article_id=3704http://ijcrr.com/article_html.php?did=3704
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareHistopathological Evaluation of Hansen’s Disease in The Post Eradication Era at a Tertiary Care Hospital, South India
English130135S. G. HarishEnglish Priyadarshini DEnglish T. S. KiranEnglish D. R. ShivanandEnglishEnglishBorderline, Indeterminate, Lepromatous, Tuberculoid, Histopathology, ChronicIntroduction
Leprosy is a slowly progressive, chronic granulomatous infection caused by Mycobacterium Leprae. The disease predominantly affects the skin, the peripheral nerve bundles, upper respiratory tract mucosa and eyes. The Norwegian physician, Gerhard Armauer was the first person to identify Mycobacterium Leprae in 1873. The immune status regulates the distinctive morphological patterns of Leprosy. Ridley–Jopling Classification segregates leprosy into diverse subtypes based on histology and immune statusin1966.1 Microscopic classification of leprosy is based on histomorphological criteria like the formation of granuloma, cell type and distribution of lymphocytes, bacterial load, pathologic changes in nerves, the existence or absence of the subepidermal grenz zone, and epidermal invasion.
Tuberculoid leprosy lies at one end of the spectrum presenting with few lesions and a meagreness of the organism and the other end lies Lepromatous leprosy (LL), in which there are plenty of lesions with countless bacilli and absence of cellular immune response. In between these two lies borderline-Tuberculoid (BT) and Borderline Lepromatous (BL) leprosy. The World Health Organization classification categorizes leprosy into paucibacillary and multibacillary based on skin lesions and involvement of nerve trunk. When suspected cases of Leprosy cannot be diagnosed on clinical presentation and slit skin smears, in such cases histopathology and demonstration of acid-fast bacilli usingFite Faraco stain are of paramount importance in demonstrating Leprae bacilli.2 Great diversity has been observed while interpreting the histopathological examination because of the clinical correlation of the disease. The present study is carried out in the scenario of clinical and histopathological correlation of various patterns of Leprosy. Erythema nodosum leprosum lesions present as red and tender nodules associated with systemic manifestations.
Reduced prevalence of Leprosy in the present stage of eradication of the disease, there are only lean opportunities to study this ambiguous disease. A great level of expertise is vital in diagnosing this disease. The sequel of untreated or undertreated leprosy not only leads to permanent disability and deformity, by damaging the skin, nerves, limbs, and eyes leading to disfigurement. The disease also acts as a reservoir for infection in the community.3,4 With the community prevention programs and a united approach, there has been a gradual reduction in the disease burden but still, leprosy is the major public health problem in India. In 2016 Global leprosy strategy 2016– 2020 was launched by WHO which targets, accelerating towards a leprosy-free world. Before that from 2011–2015, the strategy was focused on early leprosy detection to reduce disabilities. This record states that the program of eliminating leprosy at the subnational level is still incomplete in many countries and will therefore continue to go after in the coming years.
Materials and methods
A prospective study was done in the Department of Pathology in our tertiary care center from January 2018 to December 2019.
Inclusion criteria
Skin biopsies with a clinical suspicion of Hansen’s disease, re-infected and relapse cases were also included in the study, for a period of 2 years from January 2018 to December 2019. Skin punch biopsies of all age groups and both genders were included in the study.
Exclusion criteria
Refusal to give informed consent, Cases released from treatment and follow up cases of previously confirmed Hansen disease were excluded from the study.
Data analysis
Pertinent clinical details such as age, sex, site, and type of lesions were noted.
Skin biopsies were fixed in 10% buffered formalin and then submitted to routine tissue processing and 3-4µ sections were taken and stained with Hematoxylin & eosin, and Fite Faraco stain on all the sections. All sections were reviewed and classified according to Ridley–Jopling classification(1966). Slit-skin smear was studied wherever available. The clinical diagnosis by the dermatologist was documented and clinical-histopathological correlation was observed.
Results
A total of 54 Hansen’s cases were reported from our tertiary care centre out of which 43skin biopsies were sent for histopathological study. The age group presented with Hansen’s disease was between 10-75 years, Majority of the patients were in the age group of 31-40 and 41-50 years (Figure 1). Males were affected in the majority of the cases than females accounting for 65% of cases and male to female ratio is 1.8:1 (Figure 2).
The most common clinical presentation were macules, papules, nodules and hypopigmented patches (Figures 3 and 4). Out of 43 cases studied histopathological and clinical correlation was obtained in 27cases, 62.7% were well correlated clinically and histopathologically.
Out of 43 cases (Figure 5) studied 32.5% cases showed features of (Figure 6) Borderline Tuberculoid (BT) type of Leprosy which was the most common histological subtype, 23.2% cases showed histology of Borderline lepromatous (BL) Leprosy,11.6% cases were borderline (BB) cases, 9.3% cases demonstrated the features of (Figure 7) Lepromatous leprosy (LL) (Figure 7), 6.9% cases displayed Tuberculoid leprosy(TT), 4.6% cases were of
(Figure 8) Histoid Leprosy (HL) and 11.6% cases were reported as Indeterminate leprosy(IL).
Fite Faraco stain showed positive in 28% cases (Figure 9), in borderline tuberculoid and all cases of lepromatous leprosy. Slit skin smears were available for 18cases and showed positive in 38.8% of cases.
Discussion
Hansen’s disease is a chronic granulomatous disease that mainly affects the skin and peripheral nerves.3 In the absence of the standard involvement of the peripheral nerves, the divergent clinical presentations of leprosy can imitate other dermatological disorders.
Histopathological features of leprosy subtypes: The Grenz zone was the prevailing feature highlighted in all the biopsies of LL.14 In our study, only 23% of the Lepromatous leprosy cases displayed the Grenz zone. It was rare in BT and completely absent in TT. It is universally recognized as a distinctive feature of nontuberculous leprosy. It is not considered as the diagnostic feature of leprosy, but aids in considering the diagnosis of leprosy and its variants.
Tuberculoid Leprosy (TT): Epithelioid cells aggregate, numerous lymphocytes at the periphery of the granuloma and a few Langhan’s giant cells, nerve with intact perineurium, and caseation in the centre. Clinically presents as one or few asymmetrical distributed hypopigmented or erythematous, anaesthetic lesions with or without nerve thickening. In the present study, clinicopathological findings were better correlated BT and LL when compared to TT similar to Manandharetal.5
Borderline Tuberculoid (BT): Diffuse epithelioid cell granuloma with a moderate number of lymphocytes and few small giant cells within the granuloma. Presence of many asymmetrically arranged hypopigmented/erythematous/anaesthetic lesions with or without thickened nerves. Our study showed the majority of cases of BT followed by BL similar to the study done by Shivamurthy Vet. al and Kumar et al.6,7
Borderline Leprosy (BB): Shows both the characteristics of TT and LL.
Borderline lepromatous (BL): Borderline Lepromatous Leprosy patients were clinically present with multiple lesions which are ill-defined, shiny and asymmetrically arranged, with or without anaesthetic patches and thickened nerves. Histomorphological features display diffuse infiltrates of macrophages, foamy macrophages and few lymphocytes were seen involving nerves and skin appendages.8
Lepromatous leprosy (LL): The prevailing histologic feature of Lepromatous leprosy is Diffuse infiltrates of histiocytes with vacuolated cytoplasm because of the globe of leprosy bacilli in the dermis. Lymphocytes may be scarce or absent.
Grenz zone is usually seen in the papillary dermis and absence of granulomas. Most patients presented with multiple- defined, shiny, symmetrical anaesthetic skin lesions with or without thickened nerves.9,10
Histoid Leprosy (HL): The multibacillary clinical type of Leprosy is Histoid leprosy (HL), which has been in the check constantly since its birth. It clinically presents as a firm, reddish dome or oval-shaped nodules or papules and shiny stretched on the overlying skin and rarely manifests as sharply demarcated plaques. The lesions are commonly seen over the lower back, face, extremities, and bony prominences. Subcutaneous histoid leprosy has to be differentiated from subcutaneous rheumatoid nodules.
In Histoid Leprosy the histiocytes are spindle-shaped and arranged in the storiform pattern mimicking spindle cell lesions described by Virendra N.Setal11our study showed similar histopathological features of Histoid Leprosy. A single case report describes Sacroidosis, atypical mycobacterial infection, and secondary syphilis as mimickers of HL.
Histoid leprosy (HL) is first defined by Wade in 1960 which a rare variant of lepromatous leprosy. Wade portrayed the histopathological view of Histoid Leprosy as bacillary rich leproma displaying spindle-shaped cells and the absence of the globe. Even though Histoid leprosy is a variant of LL it is recognized by distinct ultrastructural, immunological, clinical, and histopathological features.12
Indeterminate Leprosy (IL): Shows mild non-specific perivascular and periadnexal lymphocytic and histiocytic infiltrate in the dermis or thickened deep dermal nerve showing intraneural lymphocytic infiltration. In IL there are only minor histopathological changes that can be easily missed unless there is an adequate biopsy. In our study, the most common type of Leprosy we come across is borderline tuberculoid leprosy, succeeded by borderline lepromatous and others. Histoid leprosy and tuberculoid leprosy were the least confronted subtypes of leprosy.13,14
Few cases may show both the features of tuberculoid and lepromatous leprosy. In borderline cases, the Immunological uncertainty in these borderline cases may shift in either direction onwards the borderline spectrum. Patients who receive treatment change towards the tuberculoid pole and who do not receive treatment turn towards the lepromatous pole.
Bacillary index: Bacillary indices are maximal in lepromatous leprosy types and minimal in borderline tuberculoid types. Jopling also recognized that the bacilli are scanty or absent in borderline tuberculoid leprosy, always present in borderline leprosy, and plentiful in borderline lepromatous leprosy and lepromatous leprosy. In both clinical and histopathological evaluation, Tuberculoid leprosy shows slight variation from borderline tuberculoid leprosy often with an overlapping line of demarcation. The ample number of Leprosy cases continually shows altering immunological patterns. If a biopsy is taken in the initial stages there are more confrontations between the clinical and histopathological observation.
Indeterminate leprosy cases are ambiguous because of nonspecific histopathological changes and clinical and histopathological inter-observer discrepancy.15-17 The decisive diagnosis of IL depends on illustrating the nerve lesions and acid-fast bacilli or confirmed without any bacilli if clinical and histopathological features are reminiscent particularly in endemic areas. Immunological status is not yet known in IL which is an early and transitory stage of leprosy. Diagnosis of Leprosy clinically in the early stages is difficult which may be achievable by histomorphological examination. Histomorphological features demonstrate the exact tissue response, while the clinical features are due to underlying pathology which shows only the gross morphology of the lesions.
Significance of histopathology in determining Leprosy
In Paucibacillary Leprosy: Treatment for Leprosy kills the organisms by halting the multiplication of M. Leprae and releasing antigens into the tissues. The granulomatous inflammation disintegrates the antigens which lead to the resolution and disappearance of the granuloma. Fibro collagenous tissue is not seen during healing leading to atrophied and wrinkled lesions. Perineural and intraneural fibrosis may be seen, these sites become a nidus for bacilli causing relapse.
In multibacillary leprosy: Amid anti-leprosy treatment lepromatous lesions resolve with increased macrophages which finally converts into foam cells. Few cases show lymphoplasmacytic infiltrate in the granuloma. Invariably granuloma resolve with no residual fibrosis and scar. The Schwann cells of dermal nerves may also undergo foamy change and perineurium undergoes hyalinization. AFB (Acid-fast bacilli) in granulomas becomes fragmented and granular within two to three months of competent treatment and AFB in nerves and wall of blood vessels may survive for a longer time. Even after years of treatment few foam cells may be seen in skin biopsies. Healed lesions may show mild nonspecific chronic inflammation around the adnexa. To conclude, the present study emphasizes the importance of histopathological examination and bacillary index in the management of Leprosy. Accurate diagnosis is important as under-diagnosed cases may lead to the continuous transmission of disease. Histopathological examination remains the gold standard and continues to be a crucial diagnostic tool for accurate diagnosis and classification of leprosy.18-20
Sexual distribution: In general, leprosy is believed to be more common in males than females similar to a previous studies.5,10 It is more predominant in males due to industrialization, urbanization, and more contact opportunities and due to social customs and taboos, fewer females report to the clinic.
Clinical presentation
Loss of sensation is the most common clinical finding, nerve thickening predominant in ulnar, lateral popliteal, and radial nerve and Hypopigmented and rarely trophic ulcers.
Leprosy is healable with multidrug therapy, definitive diagnosis is required for proper management and limiting the deformities and drug resistance. Histomorphological diagnosis is also considered useful for monitoring treatment response. The preponderance of the borderline spectrum and multibacillary leprosy is due to lower socioeconomic status, poor sanitary conditions, overcrowding, and illiteracy rate in rural areas of Karnataka state.
The findings of this study might help the government authorities to develop more effective treatment strategies for rightly achieving the target of eradicating leprosy. Expanded understanding of the people to national programs makes them attend the leprosy clinic at the initial stages which commit towards the early diagnosis and treatment The bacteriological index alone does not form the basis for diagnosing various types of leprosy. Many specifications impact histopathological diagnoses like duration of the presenting lesion, biopsy depth, histopathological section quality, and Ziehl–Neelsen stain. Divergent criteria are used to select the cases, immune status of the patient, and any previous treatment taken by the patient. Clinical, histopathological, and immunological concurrence is often observed among various subtypes of leprosy. Clinical and histopathological correlation along with bacteriological index will be more precise than considering a single parameter to increase the efficiency for leprosy subtyping In our study, the clinicopathological correlation was seen in 62.7% similar to Kumar et al.7
Conclusion
Leprosy is a slowly progressive chronic infectious disease caused by a bacillus, Mycobacterium leprae which multiplies slowly and the symptoms of the disease appear after a long incubation period average of 5 years. The disease predominantly affects the skin, the peripheral nerves, upper respiratory tract mucosa, and eyes. The most commonly affected age group affected was 10 to 75 years with male predominance. The disease is classified into paucibacillary (PB) if lesions are few appearing reddish or pale, and multibacillary associated with multiple skin lesions, nodules, plaques, thickened dermis, or skin infiltration. In 2005, though the elimination of leprosy at the national level has been achieved; but still there is an incidence of this disease is reported from our region affected by this chronic debilitating disease. For eliminating Leprosy, early case detection and treatment is very important in reducing the source of infection and interrupt transmission in the community. There can be many overlapping features between different types of leprosy, both clinically and morphologically. So clinicopathological correlation along with bacteriological index will lead to more accurate typing of leprosy. Histopathology also helps in monitoring the treatment response. Leprosy is a healable disease if a proper diagnosis is made which can prevent drug resistance and deformity.
Acknowledgement
The authors are thankful to the management of the Shridevi institute of Medical sciences for their constant support and encouragement. The 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.
Sources of Funding – Nil
Authors contribution:
Design and data collection: Dr Harish S.G, Dr Shivanand D.R
Data analysis and interpretation, drafting the article: Dr Priyadarshini D, Dr Kiran T.S
Conflict of Interest - Nil
Englishhttp://ijcrr.com/abstract.php?article_id=3705http://ijcrr.com/article_html.php?did=3705
Ridley DS, Jopling WH. Classification of leprosy according to immunity. A five-group system. Int J Lepr Other Mycobact Dis 1966;34:255-273.
Parajuli S, Shah M, Sushma S. Clinico-histopathological correlation of leprosy in the western region of Nepal-A pioneer pilot study. Ind J of Clin Exp Dermatol 2016;2(3):93-97.
Prerana R, Reeta D, Prabhakar P. Histopathological Study of Leprosy Patients in a Tertiary Care Hospital in Navi Mumbai. Int J Health Sci Res 2019;9(2):6-12.
Suri SK, Iyer RR, Patel DU, Bandil S . Histopathology and Clinico-histopathological correlation in Hansen’s disease: J Res Med Dent Sci 2014;2(1):23-28.
Manandhar U, Adhikari RC, Sayami G. Clinico-histopathological correlation of skin biopsies in leprosy. J Path Nepal 2013;3:452-458.
Shiva Murthy V, Gurubasavaraj H, Shashikala PS, Kumar P. Histomorphological study of leprosy. Afr J Med Health Sci 2013;12:68-73.
Kumar A, Negi SR, Vaishnav K. A study of clinic histopathological correlation of leprosy in a tertiary care hospital in the Western district of Rajasthan. J Res Med Dent Sci 2017;2:43-48.
Narasimha PR, Sujai S. Current situation of Leprosy in India and its future implications. Ind Dermatol J 2018;9(2):83-89.
Anuja S, Rajesh KS, Goswami KC, Subash B. ClinicoHistopathological Correlation in Leprosy. J Korean Sci 2008;10(3).
Nitesh M, Nitin M. clinicohistopathological correlation within the spectrum of Hansen's disease: a multicentric study in north India. Int J Med Res Health Sci 2013;2(4):887-892.
Virendra NS, Govind S, Navjeevan S. Histoid Leprosy: Histopathological Connotations’ Relevance in Contemporary Context. Am J Dermatopathol 2009;31(3).
Mathur MC, Ghimire RB, Shrestha P, Kedia SK. Clinicohistopathological correlation in leprosy. Kathmandu Univ Med J 2011;9:248-51.
Banushree CS, Ramachandra VB, Udayashankar C: Clinicopathological correlation of Hansen’s disease: a retrospective study of skin biopsies. Ind J Path Oncol 2016;3(3):491-495.
Shubhangi TK, Sunita W, Pratibha D. Recent trend in leprosy: Histopathological study aspect in a tertiary care hospital: Ind J Basic Appl Med Res 2016;5(2):481-486.
Shivani S, Nilesh S, Jignasa B. Clinicopathological correlation in leprosy. Int J Med Sci Public Health 2019;8(6);459-464.
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Sindhushree N, Vernekar SS. A study of clinico-histopathological correlation of leprosy in a tertiary care hospital, KIMS, Hubbali, Karnataka. Int J Curr Res Biol Med 2018; 3:29-39.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareMammogram Classification with Forest Optimization using Machine Learning Algorithms
English136141Kanya Kumari LEnglish Jayaprada SEnglish Ranga Rao JEnglishIntroduction: The deadly disease in Indian women is Breast Cancer (BC). A mammogram is used for identifying the tumours in the breast in the early stages which is efficient and cost-effective.
Objective: The main objective is to predict BC in the early stages using image processing and machine learning techniques.
Methods: Our proposed methodology is 6 step process which includes preprocessing, feature extraction, feature selection, splitting the data into training and testing, classification and performance measure.
Results: The experiments are done on MIAS (Mammogram Image Analysis Society) dataset. As more noise in the images of this dataset, filters are applied to get more clarity in images. Features are extracted by Local Binary Patterns (LBP) and optimized by Forest Optimization Algorithm (FOA). These features are divided into 70% training and 30% testing data for classification. The classifiers used are K- Nearest Neighbor (KNN), Naïve Bayes (NB) and Random Forest (RF).
Conclusion: The experiments show that LBP based FOA with RF classifier achieved good accuracy in classifying the mammograms.
EnglishBreast cancer, Local Binary Patterns, Forest Optimization, Random Forest, K-Nearest Neighbor and Naïve BayesIntroduction
In recent years, most people are suffering from cancer. Not all cancer cells are dangerous. There are nearly many types of cancers. They are pancreatic cancer, cervical cancer, lung cancer, breast cancer, colorectal cancer, thyroid cancer, kidney cancer and melanoma, etc.1. Normally, the patient data is called Electronic Health Record (EHR’s). These records may be structured, unstructured or semi-structured data. If the particular format for the patient’s record is available then it is structured data. If there is no particular format for the data then it is called unstructured data. The combination of structured and unstructured data is called semi-structured data.2 Abnormal cancer cells are detected by using the number of modalities by the radiologist which is unstructured. These modalities are X-ray, CT-Scan (computed tomography), ultrasound, Thermogram imaging, PET (Positron Emission Tomography), and MRI (Magnetic Resonance Imaging).
Breast cancer (BC) is the commonest disease in Indian women. The screening for breast cancer is the digital X-ray called mammogram imaging modality which is cost-effective, efficient, and fewer side effects of radiation.3 The categories of breast cancer are from 0-5 which is given by the American college of radiology called BI-RADS (Breast Imaging- Reporting and Data System) in 1986. According to BI-RADS, category-0 is an incomplete evaluation and requires additional imaging techniques have to consider. BI-RADS category-1 is negative BC, category-2 is the benign means less probability of severity, category-3 is also benign category but 2% malignancy and category 5 is >=95% malignancy.4
Machine learning (ML) is a subset of Artificial Intelligence (AI) which gives the results based on the learning experience. There are different types of machine learning techniques known as supervised learning, unsupervised learning and semi-supervised learning. A new class label is predicted based on the labelled training data is called supervised learning whereas the class label is predicted based on the clusters (doesn’t contain labelled data) is called unsupervised learning. The combination of supervised and unsupervised learning is called semi-supervised learning. Nowadays ML is helping physiologists and radiologists in the diagnosis, prognosis, and prediction of diseases in early stages.5 For example, to predict whether the tumour is benign or malignant, ML estimates the class label as 0 or 1 for benign or malignant respectively. These techniques are not only helping the doctors in the prediction of the diseases but also involved in the correct medication to the patients.6 ML is mainly helping cancer patients to predict the disease in its early stages. The mail ML techniques used in disease prediction are Support Vector Machine (SVM), Artificial Neural Networks (ANN), Bayesian Networks (BN’s), K-Nearest Neighbor, and Decision Trees (DTs).2 The paper is organized as follows: related work is in section 2, the proposed methodology is in section 3 experimental results and discussion is in section 4.
The author’s in7 proposed a methodology to detect tumours by reducing the noise in MIAS mammograms using 2D median filters. Then the images are segmented by region growing approach. From these segmented images, features are extracted based on texture and features are selected by using the rough set. The classifier used is ANN to classify the mammograms. In8, the features are extracted for the DDSM mammogram image dataset by the root mean square slope, circularity, fractal dimension. SVM classifier has given better results than other classifiers. Polynomial classifier is used by using the features obtained from curvelet transformations and Linear Binary Patterns (LBP) to classify the DDSM images.9
Images are enhanced using chain code and a rough set. These enhanced images are segmented using vector field convolution and features are extracted by using shape, texture, and intensity.10 The classifier RF has given better results which are measured by using 5-fold cross-validation. Median filtering; harmonic filtering and logarithmic transformations are applied.11 Then features are extracted by Fourier transformations and weighted Fourier transformations. The features are selected by principal component analysis. The classifiers used are SVM and KNN in which performance is measured by 10-fold cross-validation. They investigated that SVM will give better results for classification from GLCM features and PCA as feature selection.
With aimed to classify the mammogram images into benign or malignant it was proved that genetic programming helps to select the best features from the WDBC dataset.12 Deep learning is playing an important role in the classification of mammograms.13 They have used the Convolutional Neural networks (CNN) model for feature extraction which is an improved version of AlexNet. The classifier used is SVM which gave better results.
MATERIALS AND METHODS
Our proposed methodology is a 6-step process. The steps are image acquisition, image preprocessing, feature extraction, feature selection, classification, and performance evaluation. The flow chart of the proposed methodology is represented in Figure 1.
Figure 1: The architecture of proposed methodology: The methodology is a 6 step process that includes acquiring data, preprocessing the images, feature extraction, feature selection, splitting the data into training and testing, classification and performance evaluation
The main objective of our methodology is to classify the mammogram images into either benign or malignant. To classify the mammograms first we have to acquire the image dataset. Then these images are preprocessed to get clarity in the intensities and pixel values by using preprocessing techniques. These preprocessed images are given as input to the feature extraction technique which extracts the features from the image. All the features are may not be useful for the classification. So, useful features are selected by using feature selection methods. The selected features are divided into training and testing as 75% and 25% respectively. The classifiers classify the images into either benign or malignant. The performance is measured by the confusion matrix and accuracy is also calculated to identify the good classifier.
Image Acquisition
Several imaging techniques are available to detect the tumours in mammogram images such as digital mammograms, CT-Scan (computed tomography), MRI (Magnetic Resonance Imaging), ultrasound, and PET(Positron Emission Tomography). Among these modalities, cost-effective, efficient, and less radiation is for mammograms. To our research, the mammogram image dataset is considered called MIAS (Mammogram Image Analysis Society). This dataset consists of 322 images of 1024X1024 size each and contains a combination of benign and malignant.14 Among these 322 images, 112 and 210 are normal and abnormal images respectively. The sample images from MIAS are shown in the following Figure 2.
Figure 2: Images from MIAS database: mdb033, mdb116 - sample images considered from MIAS dataset
Image preprocessing
The images are preprocessed to eliminate noise, reduce redundancy, and smoothening the edges so that efficient features are extracted. There is several preprocessing techniques are available. The image can be enhanced to get more clarity in the images. The enhancement techniques are: filtering with morphological operators, histogram equalization, noise removal using wiener filter, linear contrast adjustment, median filtering, unshaped masking, contrast-limited adaptive histogram equalization, and decorrelation stretch.15 Filtering is one of the fastest and simple techniques used for smoothening the image or enhancing or detecting edges in the images. There is several filtering techniques are available like mean/ average filter, Gaussian filter, median filter, adaptive mean filter Weiner filter, and Laplacian filter. Edges in the image are detected by using differential operator, Robert’s operator, and Sobel operator.16 Among these filters, we have applied Gaussian, Weiner, and median filters to reduce noise and smoothing images.17
Feature Extraction
After preprocessing step, features are to be extracted. Extracting the features from images is called feature extraction. Several feature extraction techniques are available. Mainly, the features are divided into two types. They are local and global features.18 Local features are concentrate on the patches of the images where are global features concentrate on the entire image. These features may be texture, structural and statistical features. Texture-based features give information about smoothness, coarseness, and regularity. So, we have used Local Binary Patterns (LBP) which is a texture-based feature extraction technique used for extracting the features. These labels each pixel in the image based on thresholding the neighbour of each pixel. The important characteristic of this is simple and efficient for grayscale images.19 LBP gives contrast information of surrounding pixels.18 If a middle pixel mp has 8 neighbouring pixels denoted by N= { n1, n2…n8 } the binary pattern(BP) can be denoted as follows:
Likewise, BP is calculated for all the pixels of an image. These LBP features are normalized and prepare as a feature vector.
Feature Selection
All the extracted features may be useful for the classifier. So the optimal features are only useful for classification. To select optimal features, heuristic algorithms are used. These algorithms are divided into two groups. They are Evolutionary Algorithms (EA) and Swarm Intelligence (SI). Example algorithms for EA are Genetic algorithms (GA), Evolutionary Programming (EP), Forest Optimization (FO), etc. Examples of SI are Particle Swarm Optimization (PSO), Ant Colony Optimization, Firefly Optimization, etc.20
In our research, we have used Forest Optimization Algorithm (FOA).21 It is an Evolutionary Optimization Algorithm used to select useful features for classification. Mainly, it works in 3- steps: 1. Local Seeding on Trees (LO) 2. Limitation of population and 3. Global Seeding (GS). Parameters like a lifetime(LI), local seeding changes(LSCH), area limit of the forest(AL), transfer learning rate(TL), global seeding changes( GSCH) are given as input. We have initialized the forest with the selected number of trees. Each tree is a 0/1 tree which is having N+1 dimensions where N is the dimensions of the feature vector and tree age is also initialized to 0. If LO operation is done then age is incremented by 1 except newly generated one.
To generate the tree children LO operation is done. This is done by a parameter called LSCH. The population of the trees is limited based on the parameters area limit (AL) and lifetime (LI). To form the candidate population (CP) some trees are removed based on age. Then the remaining trees are placed in sorted order depending on their fitness values. If the number of trees is exceeded then the trees are removed from the forest and are added to CP. A GSCH is performed on CP and is obtained by TL. Some of the bits are selected from the selected CP trees depending on GSC. The randomly chosen bits are changed from 0 to 1 and 1 to 0. In order o select the best tree from the forest, the fitness value is determined. Then make the selected best tree age as 0 and repeat this process until any one of the specific criteria reaches. The termination criteria are 1. Several iterations 2. No difference between the fitness values in the successive iterations 3. Given accuracy measure. In our methodology, we have used number iterations as the stopping criteria. In this way, the optimal features are selected.
Classification
The optimal feature vectors of the MIAS dataset is given as input to the different classifiers to predict the tumour is normal or abnormal. We have used KNN and RF classifiers.
K- Nearest Neighbor Classifier
A simple and efficient supervised learning algorithm called K-Nearest neighbour (KNN) is used to classify the mammogram into normal or abnormal. This classifier depends on the distance metric22. Several distance measures are available such as Manhattan distance, Euclidean distance, Mahalanobis distance, and Minkowski distance. Mostly used distance measure is Euclidean distance23. Based on the value of K, the classifier works. In our proposed methodology we have chosen k=4.
Naïve bayes classifier
It works on the theorem called the Bayesian theorem. It outperforms well for classification problems24. It works on the given equation(2)
The posterior probability is a sample with specific characteristics in a class. It will be calculated by multiplying prior probability and likelihood where prior probability is the probability of class appearance and likelihood is the probability of emergence of sample like characteristic in a class25.
Random Forest Classifier
It is a supervised learning machine learning algorithm used for both classification and regression. The working is based on the decision trees. Decision trees are constructed for the randomly selected samples and class labels are generated. Then voting is done for the predicted labels. The majority voted label is the final predicted class label.
Experimental results and Discussion
Our methodology is implemented using python on a personal computer which an i5 processor and 4GB RAM with Windows 10 OS. The experiments are done on the MIAS dataset. These images are preprocessed by using Gaussian, wiener, and median filters to reduce noise and smoothing the edges. These preprocessed images are given as input to the feature extraction technique called Local Binary Pattern to get a feature vector; the features are reduced by applying the Evolutionary Algorithm called Forest Optimized Algorithm (FOA). These optimized features are given as input to the classifiers KNN, NB, and random forest. The performance is measured based on the confusion matrix represented in which calculates the sensitivity26, specificity, precision, and f1-score are given in equations 3 to 6 as follows. The performance measures used for the three classifiers are represented below.
True Positives means Sick people are predicted correctly, False Positives means healthy people are wrongly predicted, True Negatives mean healthy people predicted correctly, False Negatives mean sick people predicted incorrectly. The performance measures are represented in the following table 1 and also in figures 3 where x-axis values are performance measure values in percentages and y-axis is the performance measure. The sensitivity, specificity, precision and f1-score values for LBP+FOA+KNN methodology are 94.6%, 94.8%,94.8%, and 94.4% respectively. These values for LBP+FOA+NB methodology obtained are 95.3%, 95.4%, 95.5%, and 95.8% respectively. Similarly, for LBP+FOA+RF methodology are 96.9%, 96.4%, 96.5%, and 96.1% respectively.
Figure 3: Performance measures of classifiers – Graph represents the specificity, sensitivity, precision and f1-score performance measures in %. This figure shows the performance measures of the experiments such as LBP+FOA+RF, LBP+FOA+NB and LBP+FOA+KNN
The best classifier can also be decided by another performance measure called accuracy given below in equation 7. The accuracy of each classifier is represented in table 2. The accuracies for KNN, NB, and RF obtained are 94.5%, 95.8%, and 96.2% respectively and are also represented in figure 4.
Figure 4: Accuracy of classifiers – This figure shows the accuracies obtained for the proposed methodologies such as LBP+FOA+RF, LBP+FOA+NB and LBP+FOA+KNN and observed that LBP+FOA+RF is better than the other two experiments
By observing the above performance measures, we conclude that LBP based feature extraction with FOA is giving better classification results using random forest.
Conclusion
For our study of research, we considered the MIAS mammogram image dataset. These images are having more noise and are reduced by applying filters like Gaussian, wiener, and median. By applying the filters, clarity in the image is increased. Then features are extracted by LBP and the best features are selected by FOA. These optimized features are given as input to the classifiers namely KNN, NB, and RF. These classifiers are evaluated by using the performance measures like sensitivity, specificity, precision and f1-score are 94.6%, 94.8%, 94.8%, and 94.4% for the KNN classifier. For NB classifier these measures are 95.3%, 95.4%, 95.5%, and 95.8%. For RF classifier, the measures are 96.9%, 96.4%, 96.5%, and 96.1%. Including these parameters, we have also calculated the accuracy of these classifiers and obtained them as 94.5%, 95.8%, and 96.2% for KNN, NB and RF respectively. These results analyze the mammogram images using ML algorithms and found that LBP+FOA+RF shows better results than compared to other classifiers. In future, we apply our proposed methodology to detect another type of cancers and also decided to use deep learning techniques.
ACKNOWLEDGMENT
The 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 which the literature for this article has been reviewed and discussed.
Conflict of Interest: The authors involved in the current study does not declare any competing conflict of interest
Source of Funding: No fund or sponsorship in any form was obtained from any organization for carrying out this research work.
Authors Contribution: The authors confirm contribution to the paper as follows:
1. L Kanya kumari - Design, literature search, data acquisition, manuscript preparation, manuscript editing, and manuscript review.
2. S Jayaprada- Concepts, design, literature search, manuscript preparation, manuscript editing.
3. J Ranga Rao-Literature search, manuscript preparation, manuscript editing, and manuscript review.
Englishhttp://ijcrr.com/abstract.php?article_id=3706http://ijcrr.com/article_html.php?did=37061.Cancer.net [Accessed on 19-07-2020].
2. Kanyakumari L, Jagadesh BN. A Review on Big Data Analytics in Multiple Levels of Health Informatics. Int J Sci Res 2017;73(6).
3. Fass L. Imaging and cancer: A review. Mol Oncol 2008;34:115–152.
4. Nam SY, Ko EY, Han BK, Shin JH, Ko ES, Hahn SY. Breast Imaging Reporting and Data System Category 3 Lesions Detected on Whole-Breast Screening Ultrasound. J Breast Can 2016;19(3):301–307.
5. Kouroua K, Exarchosab TP, Exarchosa KP, Karamouzisc KV, Fotiadisab DI. Machine learning applications in cancer prognosis and prediction. Comp Str Biotech J 2015;(13): 8-17.
6. Machine learning in cancer diagnostics, EBioMedicine 2019;(45): 1–2.
7. Peng W, Mayorga RV, Hussein EMA. An Automated Confirmatory System for Analysis of Mammograms. Comp Meth Progr Biomed 2015;125:134-44.
8. Li H, Meng X, Wang T, Tang Y, Yin Y. Breast masses in mammography classification with local contour features. Biomed Eng Online 2017;16(1):44.
9. Daniel O, Bruno1a T, Marcelo Z, Nascimentoab RP, Ramos VR, Leandro AB, et al. LBP operators on curvelet coefficients as an algorithm to describe texture in breast cancer tissues. Expert Systems with Applications 2016;55:329-340.
10. Dong M, Lu X, Ma Y, Guo Y, Ma Y, Wang K. An Efficient Approach for Automated Mass Segmentation and Classification in Mammograms. J Digit Imaging 2015;28(5):613-25.
11. Zhang YD, Wang SH, Liu G, Yang J. Computer-aided diagnosis of abnormal breasts in mammogram images by weighted-type fractional Fourier transform. Adv Mech Engi 2016;8(2):1-11.
12. Dhahri H, Al Maghayreh E, Mahmood A, Elkilani W, Nagi MF. Automated Breast Cancer Diagnosis Based on Machine Learning Algorithms. J Healthcare Engg 2019.
13. Zhao X, Wang X, Wang H. Classification of Benign and Malignant Breast Mass in Digital Mammograms with Convolutional Neural Networks. Proceedings of the 2nd International Symposium on Image Computing and Digital Medicine. 2018; 47–50.
14. J Suckling. The Mammographic Image Analysis Society Digital Mammogram Database. Excerpta Medica, Int Congr Ser 2015;375-378.
15. Mohan S, Ravishankar M. Modified Contrast Limited Adaptive Histogram Equalization Based on Local Contrast Enhancement for Mammogram Images. In: Das V.V., Chaba Y. (eds) Mobile Communication and Power Engineering. AIM 2012. Comm Comp Inform Sci 2012;29(6):718.
16. Punitha A, Amuthan K. Suresh J. Benign and malignant breast cancer segmentation using optimized region growing technique. Future Comp Inform J 2018;3(2):348-358.
17. B Bekta?, Emre IE, Kartal E, Gulsecen S. Classification of Mammography Images by Machine Learning Techniques. 3rd International Conference on Computer Science and Engineering (UBMK), Sarajevo, 2018;580-585.
18. Al Nahid A, Kong Y. Involvement of Machine Learning for Breast Cancer Image Classification: A Survey. Comput Mathem Meth Med 2017;21(8):325-329.
19. http://www.scholarpedia.org/article/Local_Binary_Patterns [Accessed on 30-09-2020].
20. Rao RV. Teaching-Learning-Based Optimization (TLBO) Algorithm And Its Engineering Applications. Springer International Publishing, Switzerland, 2016. DOI:10.1007/978-3-319-22732-0
21. Alaei SH, Shahraki H, Rowhanimanesh AR, Eslami S. Feature selection using genetic algorithm for breast cancer diagnosis: experiment on three different datasets. Iran J Basic Med Sci 2016;(19):476-482.
22. Kanya kumari L, Jagadesh BN. A Novel Approach for Detection of Tumors in Mammographic Images using Fourier Descriptors and KNN. Electr Engg. 2020;601:1877-1884.
23. Kourou K. Machine learning applications in cancer prognosis and prediction. Comp Str Biotech J 2015;12:8–17.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcarePredicting the Outcome of Treatment of Non-Traumatic Intracerebral Haemorrhage
English142145G. KarievEnglish A. MamadalievEnglish B. IsakovEnglish M. KhakimovEnglish A. KadirovEnglishEnglishNon-traumatic intracerebral haemorrhage, Prediction, Scale, Treatment, Outcome, Moderate neurological deficitINTRODUCTION
Non-traumatic intracerebral haemorrhage has become not only a medical but also a social and economic problem, since it ranks third among the causes of death and first among the causes of disability - up to 80% of patients who have suffered a stroke become disabled.1
Stroke affects 0.2% of the population every year. WHO registers about 20 million strokes annually. 1/3 of them die within the first year, a third become permanently disabled, and only 26% of patients return to an active social life.2 If we add two-thirds of surviving patients to the rest of the huge contingent of stroke survivors (about 1% of the population), of which half are disabled, the significance of stroke as a separate nosology leading to mortality and disability becomes enormous.3
MATERIALS AND METHODS
For preliminary prediction of the outcome of treatment based on our observations and previously proposed we have compiled and proposed scales that include the most extensive information about the patient's current state, that is, his consciousness, age, volume and depth of haemorrhage, the presence of aggravating concomitant somatic pathologies and the state of vital body functions.4-6
Parameters
15-19 points - an unfavourable outcome;
10-14 points - gross neurological deficit;
5-9 points – moderate neurological deficit;
0-4 points - a favourable outcome (minor neurological deficit).
The patient has assessed the possible outcome on both scales and, depending on the preliminary prognosis, the optimal treatment tactics were selected.
For clarity, let's give an example from a medical history:
Clinical example: Patient D., 53 years old, became acutely ill when, against the background of a rise in blood pressure at work, there were movement disorders in the right limbs and speech. Suffering from hypertension for 3-4 years. He was admitted to the Department of Neurology of the AF RSCEMP on February 20, 2018. On admission, he was in a state of moderate severity. Normal physique. Free breathing, 18 per minute. The heart rate is 80 per minute. BP 170/90 mm. Hg. Consciousness is depressed up to 11 points on the GCS. Lies with open eyes, inhibited, trying to follow instructions. Motor aphasia. Right-sided hemiparesis up to 2 points. Unilateral pathological reflexes of Babinsky and Oppenheim. No dislocation symptoms were found. MSCT of the brain revealed a mixed stroke-hematoma of the left cerebral hemisphere with a volume of 51 cm3, compression of the left lateral ventricle, displacement of the median structures to the right by 5.5 mm.
When predicting on the proposed scales, the patient scored a conditional 9 points for surgical treatment and 10 points for conservative treatment, and, accordingly, the patient was recommended to open transcortical removal of a stroke hematoma.
Within 4 hours, the patient underwent emergency surgery - resection craniotomy in the left parieto-occipital region, encephalotomy 0.5-1 cm long and removal of blood clots. During the operation, severe tissue bleeding was noted. After the operation, the patient's condition remained serious. Control MSCT of the brain, performed on the 3rd day after the operation, revealed a zone of oedema and hemorrhagic saturation of the brain in the area of ??the former hematoma with a volume of 49 cm3, displacement of the median structures to the right by 2 mm, minor haemorrhage into the lateral ventricles.
.The patient was discharged on the 12th day under the supervision of a neurologist and a cardiologist. Regression of neurological deficit was observed (right-sided hemiparesis up to 3 points), the surgical wound healed initially, the sutures were removed. At discharge, the GOSE score is 5 points. When assessing the general condition after 3 and 6 months, the patient's condition was assessed as good (6 and 7 points, respectively), which corresponded to our forecasts.
Results and discussion
To assess the results of treatment, we used the Glasgow Outcome Scale Extended (GOSE), modified by J.T. Wilson in 2000, the Glasgow Outcome Scale, which allows the quality of life of patients at various periods of follow-up, therefore, to assess the quality and adequacy of the treatment. Besides, the degree of impairment of consciousness was monitored on the Glasgow Coma Scale.
Thus, we observed a direct relationship between hospital mortality and recovery from age. In the young age group, the mortality rate in the hospital was 27.8%, in the middle - 28.8%, the elderly - 30.6%, and in the senile - 41.7%. Also, when assessing the results of treatment according to RSHIG, it was revealed that an excellent result was observed most of all in young patients (38.9%), less in middle-aged and elderly patients (28.1% and 22.2%, respectively) and the lowest rates in this aspect were revealed in elderly patients - 5.6%.
CONCLUSION
An inverse relationship was observed when assessing unsatisfactory outcomes, and the most unfavourable factor in predicting the outcome of treatment in patients in the elderly age group was the level of consciousness below the sopor, i.e. all elderly patients with a score below 9 points on the GCS on admission had a fatal outcome (62.5% - the first 7 days, 25% - the first 28 days, 12.5% ??- within 3 months). Our proposed criteria for evaluating the outcome of treatment of non-traumatic intracerebral haemorrhage make it possible to adequately predict the possible outcome of the course of the disease and choose the optimal treatment tactics.
ACKNOWLEDGEMENT
The 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.
Conflict of interest: None
Source of Funding: None
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Kuzibaev JM, Eshbobaev FY. The role of standard scales in the diagnosis and treatment of hemorrhagic strokes. Bull Emerg Med Tashkent 2009;1:35-39.
Hemphill JC, Farrant M, Neill TA. Prospective validation of the ICH Score for 12-month functional outcome. Neurology 2009;73:1088-1094.
Guzanova EV, Semenova TN, Trubilova MS, Kalinina SY. Survival of patients with non-operated non-traumatic intracerebral haemorrhage: prognostically significant factors. Med Almanac 2017;5(50):19-22.
Lee SH, Park KJ, Kang SH, Jung YG, Park JY, Park DH. Prognostic factors of clinical outcomes in patients with spontaneous thalamic haemorrhage. Medical science monitor. Int Med J Exper Clin Res 2015;21:2638-2646
Skvortsova VI, Krylov VV. Hemorrhagic stroke: a practical guide. GEOTAR-Media. 2005: 82.
Yakubov ZB, Sadykov BS. Predicting the results of treatment of intracerebral haemorrhages of non-traumatic aetiology. J Theor Clin Med Tashkent 2004;5:38-39.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareEvaluation of Incidence, Distribution and Etiopathology of Cervical Lymphadenopathy in Patna Population
English146149Mukesh KumarEnglish Ram Prasad SahEnglish Abhinav Raj GuptaEnglishEnglishCervical Lymphadenopathy, Lymph Nodes, Lymphoma, Reactive Lymphadenitis, TuberculosisINTRODUCTION
The lymphatic system is a network of tissues and organs that eliminate toxins and waste products from the body. The chief function of the lymphatic system is to transport lymph all through the body. It primarily comprises lymphatic vessels, which are connected to lymph nodes along with tonsils, adenoids, spleen and thymus.1 Lymph nodes are located at the convergence of major blood vessels, and a human body comprises around 800 nodes distributed around the neck, axilla, thorax, abdomen, and groin. Around 300 nodes are located in the neck, entrenched in the soft tissue of the neck partly or surrounded by fat.2 Lymph nodes act as a filter for lymph, phagocytose foreign materials including micro-organisms, help in proliferation and circulation of T and B cells and enlarge subsequently to local antigenic stimulation. 3
The American Academy of Otolaryngology has classified the cervical nodes into Level I- submental and submandibular; Level II- upper jugular; Level III- middle jugular; Level IV- lower jugular; Level V- posterior triangle; Level VI- anterior compartment and Level VII- superior mediastinal. Based on their location in the neck, they may be classified as circular/ horizontal and vertical. The circular chain of nodes comprises submental, submandibular, facial, preauricular, postauricular, occipital, anterior cervical, inferior hyoid, prelaryngeal, pretracheal and superficial cervical nodes. The vertical chain comprises prelaryngeal, pretracheal, paratracheal and retropharyngeal nodes.4
They are kidney-shaped, vary in size from 1-2 cm and are encapsulated by fibrous tissue, however, may be considered pathological if they increase in size, lose their kidney/ oval shape and become round in shape, with the loss of hilar fat, asymmetrical thickening of the cortex. Enlargement of the lymph node may be due to swelling of the histiocytes in the sinus, hyperplasia of lymph follicles or invasion of tumour cells.5 This condition is described as lymphadenopathy and may be caused by the invasion or propagation of either inflammatory or neoplastic cells into the lymph node. Etiological factors considered responsible for lymphadenitis include malignancies, inflammatory conditions; infections; autoimmune disorders; iatrogenic causes (phenytoin and vaccines). Based on the distribution, it may be classified as localized, generalized, and dermatopathic, based on the duration, it may be acute (2 weeks), subacute (4–6 weeks) and chronic (> 6 weeks duration).6
Cervical lymphadenopathy refers to cervical lymph nodes measuring more than 1 cm in diameter. The Head and neck region is considered a common site for lymphadenopathy. The presence of the same is indicative of underlying pathology ranging from a trifling infection (benign lymphoid hyperplasia or reactive lymphadenitis) to a metastatic malignancy. Etiology of cervical lymphadenopathy may be multifactorial including conditions like infections, malignancies, autoimmune disorders, medications, etc. Infectious conditions comprise Epstein Barr virus infection, Toxoplasmosis, Cytomegalovirus, Initial stages of HIV infection, Cat scratch disease Pharyngitis due to group A Streptococcus, Gonococcus, Tuberculosis lymphadenitis, Secondary syphilis, Hepatitis B, Rubella, Brucellosis, Typhoid fever. Autoimmune diseases comprise Lupus erythematosus, Sjogren’s syndrome, Dermatomyositis, etc. Malignant conditions include Lymphoma, Leukemia, Kaposi’s sarcoma, and Metastasis. Miscellaneous conditions comprise Gaucher’s disease, Niemann Pick disease, Fabry’s disease, Hyperthyroidism, Histiocytosis X, Hypertriglyceridemia, Angiofollicular lymph node hyperplasia, Angioimmunoblastic lymphadenopathy, Kikuchi’s lymphadenitis, Kimura’s disease, Sarcoidosis, Kawasaki disease, Silicosis/ berylliosis, etc. Medications associated with lymphadenopathy are Penicillin, Allopurinol, Phenytoin, Atenolol, Primidone, Captopril, Pyrimethamine, Carbemazipine, Quinidine, Cephalosporins, Sulfonamides, Gold, Sulindac, Hydralazine. Acute infective lymphadenopathy is usually self-resolving and can be managed with antibiotic therapy.7
During a thorough clinical examination of lymphadenopathy, the following things should be evaluated: Location: the site of the lymph node or the type involved should be examined carefully along with the number of nodes involved (generalized or localized; unilateral or bilateral); Size: Cervical lymph nodes and axillary nodes are atypical if > 1 cm, as compared to supraclavicular > 0.5cm, and inguinal nodes >1.5 cm; Consistency: a firm lymph node is indicative of an infective condition whereas a stony hard node indicates malignancy; Pain: can is a non-specific finding, however, may be a sign of inflammation or an acute reaction to an infection.8 The present study was carried out to evaluate the incidence of cervical lymphadenopathy and to describe the distribution of the various etiologies of cervical lymphadenopathy in all age groups.
MATERIALS AND METHODS
This study was carried out on 100 patients who attended the Out-Patient Department of Dentistry, Sri Krishna Medical College and Hospital, Muzaffarpur, Bihar with enlarged cervical lymph nodes; from August 2019 to February 2020.
Patients >12 years presenting to the OPD with neck swelling for more than 3 weeks were included in the study. Patients with neck swelling less than 3 weeks were excluded from the study. All the cases were confirmed histopathologically with Fine Needle Aspiration Cytology of the involved node.
All the data was recorded in an excel sheet. Patients distributed according to age, gender and carcinogenicity. Chi-square test was applied. [Ref no. 645/2019/SKMCH]
RESULTS
A total of 100 subjects presenting with a complaint of neck swelling for more than 3 weeks were included in the study. All the subjects were between the age group of 14 years to 55 years. 20 patients belonged to the age group of 10-20 years; 28 patients belonged to 21-30 years; 33 subjects belonged to 31-40 years; 17 patients belonged to 41-50 years and 02 patients belonged to 51-60 years (Table 1).
The present study comprised 65 males and 35 females (Table 2). Twenty out of 100 were diagnosed with neoplastic nodes, whereas 80 were diagnosed with non-neoplastic nodes. 57 out of these 80 non-neoplastic subjects were males, whereas 23 were females. 08 out of these 20 neoplastic subjects were males, whereas 12 were females. In the non-neoplastic variety, the majority of the patient’s had tuberculous lymphadenopathy, i.e 60 subjects; 10 had reactive lymphadenitis and 10 had non-specific lymphadenitis (Table 3). In the neoplastic variety, 06 had Hodgkin’s lymphoma, 04 had Non-Hodgkin’s lymphoma and 10 patients present with lymphadenitis associated with secondaries (Table 4).
DISCUSSION
Hundred histopathologically confirmed cases of cervical lymphadenitis were included in the study. The majority of the cases were below 50 years of age, i.e. 98 patients were between 14-50 years and only 02 patients were above 50 years. Cervical lymphadenopathy is commonly seen amongst young individuals. The incidence of lymphadenopathy decreases considerably with age.9 Majority of the subjects in the present study comprised males, being 65 with only 35 females. A study on 112 patients with cervical lymphadenopathy, out of which 79 were males and 33 were females.10 20 out of 100 were diagnosed with neoplastic nodes, whereas 80 were diagnosed with non-neoplastic nodes. Results are similar to previous study which showed that the incidence of non-neoplastic and neoplastic lesions by 90.6% and 9.4% respectively. 11
In the non-neoplastic variety, the majority of the patient’s had tuberculous lymphadenopathy, i.e 60 subjects; 10 had reactive lymphadenitis and 10 had non-specific lymphadenitis. The findings were similar to the study carried out by Jha et al. 2001 who conducted a study on 94 cases with cervical lymphadenopathy and found that tuberculosis accounted for enlargement in 60 cases.12 It has been reported that tuberculosis persists to be a ubiquitous health problem in developing countries affecting around 1.5% of the Indian population. Tuberculous adenitis is the most common cause of cervical lymphadenitis and involves upper and anterior deep cervical nodes followed by sub-mandibular and sub-mental lymph nodes.13 The condition is referred to as “scrofula” and primarily affects the cervical lymph nodes, followed by axillary and inguinal nodes. Associated systemic symptoms include unexplained weight loss, malaise, fever, cough or hemoptysis. TB lymph nodes may be multiple, matted, hard to fluctuant with draining sinuses, however, in the early stages; the consistency of the nodes may be discrete, firm, and rubbery. Jones and Campbell (1962) described stages of TB lymphadenitis as follows: enlarged, firm, mobile, discrete nodes; large rubbery nodes fixed to surrounding tissue; central softening abscess; collar stud formation and sinus tract formation.14 Only 10 subjects had reactive lymphadenitis, which may be attributed to bacterial, viral infections, dental infections and surgical procedures in the head and neck region. 10 subjects had nonspecific lymphadenitis, which is commonly seen in children and may occur secondary to bacterial infections (Staphylococcus aureus and beta-hemolytic Streptococcus); viral infections or inflammation of the draining sites or direct inflammation of the lymph nodes. These are self-resolving and do not require treatment.15
In the neoplastic variety, 06 had Hodgkin’s lymphoma, 04 had Non-Hodgkin’s lymphoma and 10 patients present with lymphadenitis associated with secondaries. Hodgkin’s lymphoma is a malignant neoplasm of cells of lymphoid tissue (B cell-derived cancer) and is the commonest of malignant lymphomas. Cervical lymph nodes are involved in the majority of cases followed by mediastinal, axillary, para-aortic and inguinal nodes. Initial symptoms may be non-specific and may include pruritus, fever, weakness, malaise, weight loss and night sweats.16
Non-Hodgkin’s Lymphoma originates from B cell precursors, mature B cells, T cell precursors, and mature T cells. It may be associated with Epstein-Barr virus (Burkitt lymphoma), Human T-cell leukaemia virus type 1, Hepatitis C virus, Helicobacter pylori; drugs like phenytoin, digoxin, TNF antagonists, immune-deficiency conditions like Wiskott-Aldrich syndrome; autoimmune disorders like Sjogren syndrome, rheumatoid arthritis, and Hashimoto thyroiditis.17
Secondary involvement of lymph nodes in the cervical region is very common and carcinoma tends to metastasize to regional nodes. Patients usually present with painless swelling, however, the presence of pain is indicative of involvement of nerves and surrounding structures. Patients usually present with symptoms like anorexia, weight loss or weakness, hoarseness of voice, etc. These nodes are initially mobile and firm later become hard and get matted together. They are usually painless and not tender.18
Conclusion
Cervical lymphadenopathy may pose a special challenge to the attending physicians. The present study reports majority of the patients with cervical lymphadenopathy belong to the non-neoplastic category, tuberculosis being the most predominant type. Sole dependence on clinical presentation may lead to a flawed diagnosis. FNAC is a promising tool to diagnose the condition and start the management accordingly. It is an easy, simple, safe, reliable and non-invasive procedure for the diagnosis of cervical lymphadenopathy. The present study may act as the foundation of awareness regarding the distribution of lymphadenitis, their mode of presentation and predilection for different strata.
Type of study: original research paper
Conflicts of interest- none
Acknowledgement- Self-financed- no funding by anyone
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Mandal A, Pan K, Maity PK, Panchadhyayee S, Sarkar G, Chakraborty S, et al. Isolated Mediastinal Lymphadenopathy – Etiological Analysis. Int J Cur Res Rev 2014;06:14-19.
Gupta R, Dewan D, Suri J. Study of incidence and cytomorphological patterns of tubercular lymphadenitis in a secondary care level hospital of Jammu Region. Indian J Pathol Oncol 2015;2:161?4.
Bazemore AW, Smucker DR. Lymphadenopathy And Malignancy. Am Fam Physician 2002;66:2103-2110.
Ramadas AA, Jose R, Varma B, Chandy Ml. Cervical Lymphadenopathy: Unwinding The Hidden Truth. Dent Res J (Isfahan) 2017;14:1:73-78.
Quadri KS, Hamdani NH, Shah P, Lone MI, Baba KM. Profile Of Lymphadenopathy In Kashmir Valley; A Cytological Study. Asian Pacific J Cancer Prevention 2012;13(1):3621-5.
Misra D, Panjwani S, Rai S, Misra A, Prabhat M, Gupta P, Talukder SK. Diagnostic Efficacy Of Color Doppler Ultrasound In Evaluation Of Cervical Lymphadenopathy. Dent Res J 2016;13:217-24.
Singh S, Arora I, Singh S, Khan DR.Cytological Diagnosis of Lymphadenopathy on FNAC - A study from rural tertiary care. J Dental Med Sci 2018;17:7:75-83
Malhotra AS, LahoriM, Nigam A, Khajuria A. Profile of lymphadenopathy: An institutional-based cytomorphological study. Int J App Basic Med Res 2017;7:100-3.
Mitra SK, Misra RK, Rai P. Cytomorphological patterns of tubercular lymphadenitis and its comparison with Ziehl-Neelsen staining and culture in eastern up. (Gorakhpur region): Cytological study of 400 cases. J Cytol 2017;34:139-43.
Mili Mk, Phookan J. A Clinico- Pathological Study Of Cervical Lymphadenopathy. Int J Dent Med Res 2015; 1:5: 24-27.
Ullah S, Shah SH, Rehman AU, Kamal A, Begum N. Tuberculous Lymphadenitis In Afghan Refugees. J Ayub Med Coll Abbottabad 2002;14:2:22-33.
Jha BC, Dass A, Nagarkar NM. Cervical Tuberculous Lymphadenopathy: Changing Clinical Pattern And Concepts In Management. Postgrad Med J 2001;77:185-187.
Chaudhary V, Ali MA, Mathur R. Tubercular Cervical Lymphadenitis: Experience Over A Four Year Period. Int J Curr Res Rev 2014;6(6):93-99.
Thakkar K, Ghaisas SM, Singh M. Lymphadenopathy: Differentiation Between Tuberculosis And Other Non-Tuberculosis Causes Like Follicular Lymphoma. Front Public Health 2016;4:31.
Pulgaonkar R, Chitra P, Moosvi Z. Benign Reactive Lymphadenopathy Associated With Submandibular Gland Enlargement During Orthodontic Treatment. J Oral Maxillofac Pathol 2017;21:181.
Küppers R, Engert A, Hansmann Ml. Hodgkin Lymphoma. J Clin Invest. 2012; 122:10: 3439-3447.
Sapkota S, Shaikh H. Non-Hodgkin Lymphoma. [Updated 2020 Sep 4]. In: Statpearls [Internet]. Treasure Island (Fl): Statpearls Publishing; 2020 Jan-
Som PM. Detection Of Metastasis In Cervical Lymph Nodes: Ct And Mr Criteria And Differential Diagnosis. Ajr Am J Roentgenol 1992;158(5): 961-9.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareRole of Perioperative Administration of 5% Dextrose in Reducing the Incidence of Postoperative Nausea and Vomiting in Laparoscopic Surgeries - A Randomized Control Trial
English150155Priya RanjanEnglish Sandip Roy BasuniaEnglish Suman ChattopadhyayEnglishEnglishDextrose, Laparoscopic surgeries, Nausea, Postoperative, VomitingINTRODUCTION
Postoperative nausea and vomiting (PONV) are one of the major concerns for patients undergoing laparoscopic surgeries.1 It may cause aspiration pneumonia, dehydration, prolonged stay in a post-anaesthesia care unit (PACU), increased hospital stay cost, wound dehiscence, water, electrolyte disturbances and acid-base imbalances.2,3 The risk of PONV is 30% in patients undergoing general surgery without prophylactic interventions, whereas the incidence rises to 80% in high-risk patients i.e. female gender, non-smoking, history of PONV, post-operative use of opioids4 and laparoscopic surgeries. The incidence of PONV dropped down to 30% with the implementation of advanced anaesthetic techniques and better anaesthetic drugs.5 Patients usually reported PONV to be more problematic than postoperative pain.6 Therefore PONV prevention is vital, economical, improving outcomes and patient satisfaction.
Both pharmacological and non-pharmacological approaches have been used for preventing PONV.7Antiemetic medications like serotonin 5 HT3 receptor antagonist, dexamethasone or droperidol are commonly used for prophylaxis of PONV. But these drugs are relatively expensive and associated with side effects such as hypotension, dry mouth, oversedation, dysphoria and arrhythmias.8
Preoperative fasting associated with hypovolemia causes gastric mucosal hypoperfusion that may be an important causative factor of PONV.9 Many studies in the past have proved that IV fluid or dextrose administration in the perioperative period is associated with decreased PONV frequency or severity probably by reducing hypovolemia9-13 and probably by reducing the postoperative catabolism and insulin resistance by preoperative administration of carbohydrate load.14-15 However, the data that indicates the use of IV dextrose solution following surgery to reduce nausea and vomiting are limited and show mixed results.16-19
Thus considering the importance of PONV prevention and conflicting and limited evidence that IV administration of 5% dextrose in the prevention of PONV, our study evaluated the role of perioperative dextrose in the prophylaxis of PONV in laparoscopic surgeries under general anaesthesia.
Material And Methods
This prospective, randomized, placebo-controlled, double-blind study was conducted in a tertiary care hospital in eastern India after getting approval from the institutional ethics committee (MMC/IEC-2-2017/2623 dt. 13/12/2017) and obtaining written informed consent from each of the patients over 18 months (February 2017 - July 2019). We enrolled a total of 60 non – diabetic, non-smoker, female patients between the age of 18- 60 years with ASA Grade-1 scheduled for elective laparoscopic surgery under general anaesthesia. We excluded patients with a history of PONV and motion sickness, any cardiac, renal or hepatic dysfunction, diabetes mellitus, pregnant patients, allergy to study fluid, operative time more than 2 hours, inability to insert venous cannulae into dorsum of both hands and sustained perioperative hypotension.
On the preceding day of operation a final pre-anaesthetic check-up was done and patients were instructed to rate the intensity of nausea and vomiting by verbal descriptive scale (VDS).20 All patients were advised to fast for at least 6 hours for solid food and 2 hours for clear liquid before surgery.
A total of 74 patients were assessed for eligibility. However, 8 patients were excluded and 6 patients declined to participate in the trial. The remaining 60 patients were randomized and allocated to two equal groups i.e. Group D and Group N respectively of 30 patients each. All the patients were followed up throughout the study period. There was no loss to follow-up or at the stage of analysis (Figure 1).
All 60 patients were randomized into 2 groups: the intervention group (Group – D) received 5% Dextrose and the control or comparator group (Group – N) received 0.9% Normal Saline solution. Randomization was performed by opening a closed envelope inside the preoperative holding area containing the computer-generated random assignment number ranging from 1 to 60. The anaesthesia providers, surgeons, perioperative nurses, PACU nurses and patients were blinded to group assignment throughout. One of the anaesthesia providers gave the study solution and another anaesthesia provider collected the data. Any anaesthesia personnel concerned with the study fluid preparation were not included in the data collection.
On arrival of the patient to the operating room, two 18 G IV cannula was inserted at the dorsum of each hand and 5 leads ECG, NIBP & pulse oximeter monitoring were attached and baseline hemodynamic parameters were recorded. Capillary blood glucose level (CBG) was recorded before induction, 15 mins after stopping of study fluid infusing and after 12 hours of induction by using Dr TrustTM USA Gold standard 9001 machines. No prophylactic anti-emetics were given as premedication, to decrease the possibility that treatment effects of study fluid administration could be masked.
All the patients were pre-oxygenated with face-mask @10 litres/min for 3 minutes, and pre-medicated with glycopyrrolate 10 mcg/kg, midazolam 30 mcg/kg. Ringer’s Lactate solution was started @ 3 ml/kg/hr in one hand and 100ml of paracetamol infusion on other hand was given at the beginning of surgery. Both the groups received Ringer Lactate intravenously as intraoperative maintenance fluids at 3 mL/Kg/hr in one dorsum. On the dorsum of the other hand, either the intervention drug (5% Dextrose) or comparator/control drug (0.9% Normal Saline) were infused by an infusion pump at a fixed rate such that Group N (30 patients) received 0.9% normal saline and the patients of group D (30 patients) received 5% dextrose @ 125 ml/hour for 2 hours (250 ml) beginning with the start of surgical closure. Both the study fluid (dextrose) and placebo fluid (normal saline) were delivered in opaque bags labelled with the randomization number of a particular patient with the help of an infusion pump (DP2070- Perfusor CompactTM), thus blinding them to patients and doctors alike inside OT.
All patients have followed a uniform standard technique for GA using IV thiopentone sodium 5 mg/kg for induction, IV fentanyl 2 mcg/kg to attenuate stress response and analgesia, IV atracurium 0.5 mg/kg to facilitate intubation and maintenance. Anaesthesia was maintained with isoflurane 0.5 to1.0 % in a mixture of oxygen and nitrous oxide (33%:66%). Neostigmine 50 mcg/kg and glycopyrrolate 10 mcg/kg IV were used to reverse residual muscle relaxation. No narcotic was given after surgery and in the post-anaesthesia care unit (PACU). However to maintain postoperative analgesia one dose of diclofenac 1.5 mg/kg IV and if still there was pain 2 doses of paracetamol 1% 100ml infusion (maximum 4 doses) was given. A decrease in mean arterial pressure (MAP) by more than 20% from baseline value or systolic blood (SBP) pressure less than 90 mm Hg were treated with 100 mcg phenylephrine IV bolus. Any patient receiving more than 3 doses of phenylephrine were excluded from the study.
PONV scores were assessed at 0,30,60,120 min in the PACU and 6,12 and 24 hours postoperatively in the ward by verbal descriptive scale (VDS)20 which consist of score 0= no PONV: no complaint of nausea and vomiting, score 1 = mild PONV: complains of nausea but refuse antiemetic treatment, score 2 = moderate PONV: the patient has nausea and allow treatment with antiemetic and score 3 = severe PONV: the patient has nausea with episodes of emesis (retching or vomiting) requiring treatment. Rescue antiemetic treatment (Ondansetron 4mg IV) was given when VDS scores were 3 or more, only after excluding other cause of PONV such as hypotension, hypoxia (SpO2 ≤ 90%), etc. All patients received supplemental oxygen (5L/min) using a well fitted facemask for 4 hours and Ringer’s lactate (2ml/kg/hr) postoperatively for 24 hours. Study was completed after 24 hours of completion of surgery. Statistical analysis
The minimum study sample size was estimated at 42 based on a two-sample proportions test (Pearson's chi-squared test) based on data on proportions of patients having PONV in a relevant previous study1 and taking the alpha value of 0.05 and power of 0.2 as adequate for the current study. For enhancing the validity of the study and to compensate for any loss of patients during the study period the total sample size was enhanced to a total of 60 divided into two groups for purpose of the study. For statistical analysis including sample size calculation SPSS (version 24.0; SPSS Inc., Chicago, IL, USA) software was used. Data for a test statistic that either exactly follows or closely approximates a t-distribution under the null hypothesis is given. Unpaired proportions were compared by Chi-square test or Fischer’s exact test, as appropriate. If the calculated p-value is below the threshold chosen for statistical significance (≤ 0.05) then the initial null hypothesis is rejected in favour of the alternative hypothesis.
Results
Overall 74 patients referred to our hospital during the study period. Out of which, 8 patients did not meet the inclusion criteria and 6 patients declined to participate in the study. So data were analysed with 60 patients who completed the study. Demographic and clinical characteristics of patients age, height, weight and BMI and duration of surgery are comparable in both groups (p>0.05) (Table 1). In terms of intra-operative haemodynamic characteristics of participants like HR, SBP, DBP, MAP were also comparable between two groups (p > 0.05).
Out of 60 patients, 19 (63.3%) patients in group-N and 11 (36.7%) patients in group-D had a VDS score ≥of 3 at arrival in PACU within 30 mins and rescue antiemetic was given. In this study we found, the incidence of PONV was significant only on admission to PACU (p = 0.0388) in Group N. At other times till 24 hours post-op. the incidences of PONV were comparable between the two groups (p>0.05) (Table 2 and Figure 1).
Overall 27(45%) patients had an incidence of PONV. In group-D 8 (36.4%) patients and group-N 19 (63.3%) patients needed rescue antiemetic 24 hrs after surgery. The incidence of PONV was reduced by 26.9 % in group D which is significantly less (p-value = 0.0029) (Table 3, Figure 2).
Perioperative difference of CBG before induction, 15 mins after stopping of study fluids and after 12 hrs of induction in group N and group D were comparable (p>0.05) and were within normal range throughout the perioperative period (Table 4). No adverse effects were observed in any patient during the study period.
Discussion
Laparoscopic surgeries are associated with a higher incidence of PONV.21 It may be due to stimulation of the mechanoreceptor of the gastrointestinal tract because of carbon dioxide pneumoperitoneum, which leads to the release of serotonin and other neurotransmitters.
Different antiemetic medications were tried in the past for preventing PONV with a variable success rate but with lots of side effects. The data regarding the effect of perioperative fluid therapy and glucose administration on PONV is also controversial and somewhat scarce.18-20 In the present study, we observed the effectiveness of perioperative IV dextrose administration for the prevention of PONV after laparoscopic surgeries. The principal findings of this study were that cumulative incidence of PONV and overall rescue antiemetic requirement was significantly less in patients of Group-D (P= 0.0029) with comparable perioperative blood glucose level with the control group.
Perioperative dextrose for prophylaxis of PONV because of its high osmotic pressure might reduce muscle contraction of the gastrointestinal tract,13,20 inhibition of vagal cholinergic pathways by the reduction in gastric acid secretion. Hyperglycemia also leads to an increase in plasma cholecystokinin level which decreases pain and anxiety by modulating brain function with a decrease in postoperative pain as well as nausea and vomiting.23-25 Another hypothesis of reduction of incidence of PONV in this study was caloric supplementation in the form of dextrose which leads to a reduction in postoperative catabolism and insulin resistence.22
Our study was similar to the study by Saleh et al. in which 10% dextrose was administered after laparoscopic surgery and found a lower incidence of nausea and rescue antiemetic consumption.21-23 Atashkhoei et al. in their study administered 5% dextrose intraoperatively in patients undergoing diagnostic gynecologic laparoscopy and found that there is the decrease in incidence and severity of PONV as well as frequency and reduced total dose of rescue antiemetic.24,27 In the study, Firouzian et al. concluded that administration of IV dextrose in patients undergoing laparoscopic cholecystectomy, before induction of anaesthesia leads to significant decreased incidence and severity of PONV and antiemetic medication requirement in comparison to the control group.19,25 Consistent with our study Mishra et al. concluded that perioperative administration of 5% dextrose in patients undergoing laparoscopic cholecystectomies at 100ml/hr can reduce the incidence of PONV by 38% and decrease the consumption of rescue antiemetics.1,26 Our study is also supported by Dabu-Bondoc S et al. where postanaesthesia IV dextrose administration resulted in a reduction in rescue antiemetic medication requirements and PACU length of stay.13,27 In contrast to our data, Rao V et al. had found that the incidence of antiemetic requirements was similar.28 Patel P et al. had found that there were no significant intergroup differences in time of onset of PONV, duration of PONV, or the number of antiemetic doses or drug classes given to control PONV.29 McCaul et al. had found that administration of dextrose containing IV fluids was not effective in preventing PONV when compared to dextrose free IV fluid administered after gynaecological laparoscopy.30 Yokoyama et al. had found that compared to placebos, perioperative intravenous dextrose administration may decrease postoperative nausea but not vomiting. 31
In our study, data suggested that during perioperative blood glucose levels was slightly higher in group-D as compared to group-N, though blood glucose levels are within the normal range (Table 4). Similar findings are shown in the previous studies.19,26 This is also supported by a study done by Patel et al in which, the patients who received the intravenous glucose during the emergence of anaesthesia had greater blood sugar level than the placebo group after study but within normal range.29
The present study showed that ondansetron requirement as ‘rescue antiemetic’ was significantly higher in Group N compared to Group D. 5% dextrose is considered cost-effective in terms of single preoperative administration versus multiple post-operative administration of antiemetics. We used. thiopentone sodium as an induction agent instead of propofol which has an additional antiemetic effect, confounding actual results.32 Our study has several limitations. As our study group was limited to ASA I, non-smokers, undergoing laparoscopic surgeries. The effect of our study may not be the same in patients undergoing surgeries of different duration and type. We have not included diabetic patients in our study, which demands further research. We did not evaluate postoperative pain as a risk factor for PONV. The sample size could have been larger. Lastly, total IV fluid received were calculated in fixed volume rather than dosages per Kg body weight for study purpose.30,31
CONCLUSION
Perioperative administration of 5% dextrose is a safe and effective method of reducing the incidence of PONV and consumption of antiemetics in adult non-smoking female patients undergoing laparoscopic surgery under general anaesthesia.
Acknowledgements: The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed
No financial support
No conflict of interest
Englishhttp://ijcrr.com/abstract.php?article_id=3709http://ijcrr.com/article_html.php?did=3709
Mishra A, Pandey RK, Sharma A, Darlong V, Punj J, Goswami D, et al. Is perioperative administration of 5% dextrose effective in reducing the incidence of PONV in laparoscopic cholecystectomy? A randomized control trial. J Clin Anesth 2017;40:7–10.
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Magner JJ, McCaul C, Carton E, Gardiner J, Buggy D. Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecological laparoscopy: comparison of 30 and 10 mL kg (-1). Br J Anaesth 2004;93(3):381–5.
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Firouzian A, Kiasari AZ, Godazandeh G, Baradari AG, Alipour A, Taheri A, et al. The effect of intravenous dextrose administration for prevention of postoperative nausea and vomiting after laparoscopic cholecystectomy: A double-blind, randomised controlled trial. Indian J Anaesth 2017; 61(10): 803-10.
Boogaerts JG, Vanacker E, Seidel L, Albert A, Bardiau FM. Assessment of postoperative nausea using a visual analogue scale. Acta Anaesthesiol Scand 2000 Apr;44(4):470–4.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareDetection of Heart Problem Using Internet of Things Application
English156161Sesha Vidhya SEnglish Shanthi KGEnglish Manikandan AEnglish Senthil Kumar KEnglishEnglishWHO (World Health Organization), ECG (Electro Cardio Gram), IoT (Internet of Things), WBAN (Wireless Body Area Network), GSM (Global System for Mobile Communications), (SMS) Short Message Service.INTRODUCTION
The World Health Organisation survey says that the heart disease is the common cause of population death in the world. The heart’s main function is to pump blood into the circulatory system of human beings; if one of its ventricles fails to work, the heart gets attacked, and in due course, leads to death if not resuscitated on time. Most of the time, a heart attack results in abrupt death before the patients get any consideration from a medical Professional. For instance, in the republic of China, they used to practice a traditional health care system. This means that the concerned patients will make a call to the healthcare service centres themselves. In case of sudden heart attack, the unconscious patient may not be able to call the service, and hence the unwanted death situation will occur. With the help of IoT technology, the heart attack problem is overawed.
The patients now switch the system from inactive to a pervasive one and trigger the health care services to be aware of his/her situation. Hence, this calls for a remote patient monitoring system.1 The IoT plays an essential role in our day to day routine activities. It provides the means through which many machines and devices are monitored and controlled remotely without human intervention.2 The IoT technology tremendously increases the data value, performance, efficiency, accuracy, speed of the system operation and output results. The advancement in the IoT technology coupled with the sensors has brought tremendous development in the health care system. Sensors along with an integrated IoT health care system has provided the possibilities of monitoring and control of patient’s data from anywhere in the world. There is the need to have medical personnel close to the patient for direct monitoring and control for better monitoring of the patient.3 For the past few years flourishing attention is incorporated in the field of Biomedical communication for the advancement of a one-to-one care system to perceive greatly a hominoid dynamic body part action. Wireless body area network (WBAN) is used for measuring an Electrocardiogram (ECG) signal and transmitting it to a smartphone via WiFi for data analysis.4
However, having medical personnel to take care of the patient at all times is impossible due to their scarcity and tight schedules. Therefore, remote patient monitoring and control is the best proposal to take appropriate medical care of the patient. This kind of approach provides physical parameters that are required by the medical personnel, and the data is transmitted remotely via the internet. Hence, the dedicated approach for monitoring heart activity and controlling its parameters is essential.
LITERATURE REVIEW
In recent years wireless body area network and the Internet of things have strongly emerged in the medical field for the health care of the patient. It collects the patient's data regarding the heartbeat rate and pulse rate. The collected data is continuously monitored and will be sent to a Doctor.
Vaishnave et al, proposed the measurement of the human heartbeat and body temperature using Arduino UNO and sends the information to clients end utilizing microcontroller with sensible cost.5 Patel et al., presented detection of Heart attack and heart rate monitoring using IoT.6 It consists of an android WIFI module, a heartbeat sensor and a pulse sensor. The heart rate readings have been sensed by the pulse sensor and the result is displayed on the LCD (Liquid Crystal Display) screen. They have used a set-pointer through the system which helps in determining whether a person is healthy or not, by checking their heartbeat and comparing it with the set point. If the setpoint is beyond the limit the system will send an alert message. But there is a chance to display the false result due to varying limits in set-pointer.
Gurjar et al. proposed Heart attack recognition by heartbeat identifying using IoT.7 The components used in this work is ATMEGA 328, heartbeat sensor, temperature sensor, and pressure sensor. The transmitter circuit includes AVR (Alf and Vegard's RISC (Reduced-instruction-set Computing)) family microcontroller interfaced to the LCD screen to display, the receiver circuit includes an LED device and Buzzer sound which is used to alert a person. The main drawback of this method is, it alerts the patient only. Later the patient has to go and consult a Doctor.
Ajitha et al. depicted IoT based heart attack finding and alert system.8 The tools used in this work are an AVR controller, wireless module, Analog sensor, ECG leads. This project uses an alert and LCD that are capable of monitoring the heart rate. But there is no message alert to the Doctor. Barai et al. dealt with the comparison of non-invasive heart rate monitoring system using GSM module and RF module. Internet of things IoT based heart attack and heart rate measurement using Arduino is promising for remote monitoring of heart rate, yet it does not offer any real-time monitoring system.9
Gupta et al. proposed a smart Health Care Kit based on IoT.10 Their system collects data such as Heart rate, blood pressure and ECG signal of the patient and sends alerts to the doctor so that he has full knowledge of the patient’s health from time to time. But their system lacks in collecting diabetic conditions of the patient and, therefore, would be incapable to detect heart attack caused by diabetes or obesity. Mamidi et al. proposed an IOT based heart attack detection and heart rate monitoring. The components used are RFID or near field communication technology. At first, they record the default values of pulse rate, systolic pressure so that the application records the user’s activity and check the collected data with the default values whether it is near to it or not. The system which they proposed has the quality of detecting heart attacks with the help of monitoring heart rate and blood pressure based on IoT. But in this method, there is a possibility of hacking the data.
Mallick et al. presented a heart rate monitoring system using fingertip through Arduino and processing software.11 This technology uses NodeMCU (Lua based firmware for the ESP8266) and fingertip sensor. It is based on the principle of Photo Plethysmography (PPG) which is a non-invasive method of measuring the variation in blood volume in tissue using a light source and detector. The heart rate counting and monitoring are performed by the processing unit. But the fingerprint sensor does not take into consideration when a person’s finger changes in sizes or form/pattern over time. Raihan et al., portrayed Smartphone-based ischemic heart disease risk prediction using clinical data and data mining approach.12 The tools used in this are chi. square, ACS, IHD, Data mining. The main aim of this work is to make a simple approach to detect the risk of IHD and to avoid sudden death. The main drawback is that there is no alerting system to alert the patient.
Prittopaul et al. approached the cyber-physical system for the detection of heart attack using wireless monitoring and actuation system.13 This involves a Cyber-Physical System (CPS) which contains a small wearable device to transmit the ECG signal to the patient’s mobile phone. In case of any emergency or irregularities in the heartbeat, it makes an alert. But, this model only detects heart failure that occurs due to variation in heart rate as the system is completely based on the data gathered by ECG signals and neglects the heart failure that is caused due to smoking, obesity, alcohol intake, physical inactivity etc.
Pawar et al. proposed a system for heart rate monitoring using Arduino Uno and an IR based sensor.14 It is used to monitor the physical parameter like heartbeat and then it sends the data that is measured, to a doctor through a short message service. The system also consists of an IR base heartbeat sensor, GSM module and an Arduino UNO. But IR sensors can’t measure an accurate value for heart rate. Das et al presented a Microcontroller based low-cost heart rate counter.15 The Microcontrollers have been used to measure heart rate using an Infrared (IR) sensor but IR sensors can’t measure an accurate value for heart rate and are not versatile too.
Ashrafuzzaman, et al. depicted Heart attack detection using a smartphone.16 The technology is used in this paper are data mining, fuzzy logic. It detects the heart attack by placing the index finger on a mobile camera to determine the peak value of blood pressure. The main idea of the proposed system is to find out the average distance between adjacent peaks for heart rate calculation. Issac et al. presented a real-time heart monitoring system using an android application.17 The technology used in this paper are CUEDETA (A Real-Time Heart Monitoring System Using Android Smartphone) and also contains a location tracking ECG sensor. This paper is used to monitor the ECG signals of the patient and to send alerts to his/her contacts. The alert message has been used to find the exact position of the patient through google map. But there is a chance to detect false alerts due to arranged mode.
Srinivas et al. described an analysis of coronary heart disease and prediction of a heart attack in coal mining regions using a data mining technique.18 This paper involves various algorithms for the prediction of a heart attack. The technologies used in this paper are, Decision Tree, Neural Network, Multilayer Perceptron (MLP), Bayesian model and SVM with an accuracy of 82.5%, 89.7%, 82% and 82.5% respectively. According to their result, Multilayer Perceptron acquires the highest accuracy of 89.7% as compared to other algorithms since the syndrome is a collection of symptoms, and it is a concept which is developed employing mapping symptoms to Traditional Chinese Medicine (TCM) expert’s brain. As the syndrome is recognized by the human brain, multilayer perceptron is considered a good model. According to their research, it may implement false alarm rate because of time series modelling and more continuous data should be used instead of categorical data to study patient’s morbidity condition concerning clinical care.
Landaeta, et al, portrayed the detection of heart rate from plantar bioimpedance measurements.19 They have proposed a technique for measuring heart rate and it also relies on electrical impedance variations which are detected by a plantar interface with both feet, such as those in some bathroom weighing scales for the analysis of body composition. The Heart-related impedance variations that arise in the legs come from arterial blood circulation and are below 500 m Omega. But usage of feet makes it uncomfortable for many patients.
PROPOSED WORK
We proposed a system, which consists of an ECG sensor that uses electrodes connected to the ECG board via standard electrode cables to measure an ECG signal from the patient. The measurements have been sent to the ESP32 controller, where they are processed and sent to the IoT Cloud Platform. Then, the data has been broadcast to the user’s phone via WIFI. To publish the data to the IoT Cloud, we need some IoT platform. So Ubidots is one such platform that offers a platform for developers that allows them to catch the sensor data and turn it into a piece of useful information. The Ubidots platform is used to send data to the cloud from any Internet-enabled device which will turn the sensor data into information that matters for business decisions, machine-to-machine interactions, educational research, and thereby increase the economization of global resources. It serves as an easy and affordable means to integrate the power of the IoT into your business/research. Its platform for application enablement will support interactive, real-time data visualization (i.e. widgets), and also an IoT app builder that provides developers to extend the platform with their HTML code for individualization. Ubidots empower the data from device to visualization.
Figure 1 describes the working principle of the proposed work. The ESP32controller is connected to the AD8232ECG sensor. Remaining all of the components and the electrodes, are placed in an assembly box. The switched-mode power supply (SMPS) of 12v is given to the voltage regulator as it will provide only the required voltage to the ESP32 controller. The ESP32 controller will operate at a voltage of 3.3v. The electrodes are placed on the chest of the patient and hence the heart beats are obtained which will be of analog form. So, for achieving efficient transmission of data, it is converted into digital form using AD8232 ECG sensor. Then the digital data obtained is given to the ESP32 controllerwhich acts on the signal, based on the instructions that are coded in embedded C language. Then the signals are interfaced with the Ubidots, an IOT platform to view the ECG signal. By analysing the ECG waveform, it detects the heart problem, if any. If the heartbeat rate is beyond a certain limit (abnormal condition), then the Ubidots platform sends an SMS message to the Doctor, stating that the patient condition is abnormal. At the same time, the Buzzer and LED also make an alert to notify the condition of the patient of their caretaker.
ECG Sensor
The ECG sensor used is a low-cost board, used to measure the electrical activity of the heart. This electrical activity of the heart is viewed as ECG or Electrocardiogram and output as an analogue reading. ECG signal what we obtained is noisy, therefore used AD8232 an Op-amp to obtain a clear signal from the PR, QT and ST intervals easily. The AD8232 acts as signal conditioning for ECG and it is also used to measure other bio-potential measurement signals. It is designed to amplify the bio-potential signal in the presence of noise.
ESP- 32 Developing Kit
The AD8232 Op-amp consists of nine connection pins and wires. The other connectors include LO+, LO-, OUTPUT, 3.3V, GND are the essential pins used for operating the Op-amp with an Arduino. Also, three lead electrodes on this board are provided, RA (Right Arm), LA (Left Arm), and RL (Right Leg). The electrodes are placed at the particular location of the body to obtain an ECG signal because only at the particular location, the required frequency of the heart is obtained.
Figure 2 represents the interfacing AD8232 ECG Sensor with ESP32-WROOM-32 developing kit. The AD8232 is power supplied with 3.3V from the ESP32 module. The output pin of AD8232 will be an analogue signal. This pin is then connected to the VP pin of ESP32-WROOM-32. Similarly, LO and LO+ ofAD8232 are also connected to the pin D3 and D2, respectively on ESP32-WROOM-32.
SYSTEM DESIGN AND IMPLEMENTATION
This paper presents the design and implementation of a human heartbeat rate monitoring using a heart pulse sensor and IoT-based technology. This sensor senses the human heartbeat and is recorded. The read data are processed by the ESP32 controller and transmitted to the WiFi module for uploading to the internet server platform (Ubidots) for further analytics and visualization. When the data was captured the same is processed and stored in real-time with a date and time stamp. The proposed work consists of the ECG sensor unit, the power supply unit and the user interface unit as the input units. The WiFi Module unit serves as the output unit. The ESP32 controller unit monitors and controls the signals. The system is programmed using embedded C programming language.
The ECG sensor will sense the heartbeat. The sensed data from the sensor is transmitted to the analogue to a digital converter (ADC) for conversion to a digital signal. The obtained digital signal is then transmitted to the ESP32 controller. The ESP32 controller acts on the signal based on the instructions which are coded in embedded C language. Furthermore, the data are sent in real-time to the WiFi module and transmitted to the webserver (Ubidots)for further analytics and visualization. The analyzed data are updated synchronously in real-time to display the status of the human heartbeat rate. It is also associated with a Buzzer and an LED, which will be active when the heart condition goes abnormal. An SMS alert will also be sent to the Doctors.
Android Application
The Android application is made to handle data from the sensor. The application has two modes: one that displays ECG voltage readings and another that shows the SMS alert to the Doctor. As the application is launched, it performs a scan for devices and allows the user to select the ECG sensor. The application then receives and interprets data from the sensor and displays it on the screen as a plot. It involves the implementation of an IoT based ECG Monitoring with AD8232 ECG Sensor and ESP32 developing kit using an online IoT platform called Ubidots. The ECG sensor AD8232 has been interfaced with ESP32, then it generates an ECG signal by connecting ECG electrode in the chest of the patient.The ECG signal from a patient heart has been viewed continuously by the Doctor using their smart phone. Using parameters of Ubidots, the ECG graph will be sent to cloud. The experimental results that are obtained from the implemented prototype were found to be accurate. Because the system is up to sense the data and then through the internet it transmits the data that has been sensed. Since the last few decades, heart diseases are becoming a greater issue and many people lost their lives because of such health problems. Hence, the heart disease cannot be taken lightly. By analyzing and continuously monitoring the ECG signal at the initial stage, heart disease would be prevented (Figure 3).
The Short Message Service (SMS) allows text messages to be sent and received from mobile phones. An alert message stating that ‘the patient condition is abnormal’ will also be sent to all the Doctors available, in case of any emergency of abnormal conditions made. This is accomplished by GSM (Global System for Mobile communications) mechanism.
Conclusion and Future Work
We proposed an IoT based heartbeat monitoring with AD8232 ECG Sensor and ESP32 developing kit. Since the last few decades, heart diseases are becoming a greater issue and many people lost their lives because of such health problems. Hence, heart disease cannot be taken lightly. By analyzing and continuously monitoring the ECG signal at the initial stage, heart disease would be prevented. The ECG signal obtained is discussed and reviewed. The IoT based computational frameworks for heart monitoring play a crucial role in early diagnosis, prediction and cardiac disease management. This experimental work explores an IoT connected low power wireless sensor interface implementation for long term monitoring of cardiac parameters. The regular use of the device is very helpful for preliminary detection of heart diseases and to reduce severe damage and mortality rate due to cardiovascular diseases. Similar to this user-friendly ECG monitoring system, additional health monitoring systems such as temperature measurement, Blood Pressure, Diabetes, etc., can be developed using IoT that will greatly help to decrease existing health problems to a certain amount.
Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Conflict of Interest: NIL
Source of Funding: NIL
Englishhttp://ijcrr.com/abstract.php?article_id=3710http://ijcrr.com/article_html.php?did=3710
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareA Clinicopathological Study and Diagnosis of Helicobacter Pylori by Special Stains in Gastric Biopsies–Is it Noteworthy?
English162167Sonti SulochanaEnglish Vithya Priya KEnglish Muhamed Yusup AEnglishEnglish Activity, Gastric biopsies, H. pylori, Inflammation, StainsINTRODUCTION
Helicobacter pylori are gram-negative, microaerophilic, spiral organism which inhabits the gastric mucosa. H.pylori-related diseases are the most prevalent in the world especially in the subcontinent of India.1Itis an important etiological factor of numerous benign, premalignant and malignant lesions like peptic ulcer, chronic gastritis, intestinal metaplasia, gastric carcinoma, and Mucosa-associated lymphoid tissue lymphoma[MALT].2 It was first discovered by Warren and Marshall in 1983. The occurrence of H.pylori infection is more common in developing countries when compared with developed countries and the incidence increases with age.3 But most of the cases are seen in adults mainly due to lifestyle changes and associated co-morbid conditions.
The diagnosis of H. pylori in gastric mucosal biopsies is important because of its pathogenicity. For an accurate diagnosis of H.pylori, multiple biopsies are required from different sites such as two corpora and two antral specimens.4,5 Nowadays various methods are available to detect H. pylori in gastric specimens.6 To date, several studies have found that histopathological examination remains the best technique for H. pylori identification.7The culture method is highly specific for H. pylori detection, but it is a strenuous and time-consuming method. PCR is extremely sensitive and very specific when compared with any other prevailing diagnostic methods. It also plays a role in detecting mutations seen with antimicrobial resistance, typing of organisms, and testing of virulence of organisms.8
Antibody test detects the presence of IgG antibodies specific to H.pylori in whole blood, serum, and urine, usually seen around twenty-one days of infection which persist for a long time even after eradication.9 Urea Breath test identifies the organism through H.pylori urease activity. After consuming urea labeled either with radioactive isotope 14C or nonradioactive isotope 13C, in the presence of organisms, there will be the production of labeled carbon dioxide which is measured in expired breath.10 The sensitivity and specificity of H&E slides increased with all levels of observers.11 When the magnifying field is large and the bacterial count is high, routine H&E staining is adequate to establish the presence of the organism. But if the density of the micro-organisms is low and when atrophic mucosal changes are present, special stains are required. IHC staining is also highly sensitive and reliable and advantageous in patients partially treated for H. pylori gastritis, which can result in atypical (including coccoid)forms, which may mimic bacteria or cell debris on H&E preparations The major advantages of IHC stain is less screening time and high specificity. The morphological changes in gastritis are activity, chronic inflammation, atrophy, intestinal metaplasia, and H. Pylori density are graded as mild (G1), Moderate (G2), and severe (G3) by the Updated Sydney System.
Activity is defined as the additional presence of neutrophils. It is an indicator of acute inflammation and H.pylori infection. In H.pylori-positive cases, "pit abscesses" are formed by neutrophilic infiltration in the epithelium, lamina propria, and in the foveolar lumen. The severity of the infection and the level of mucosal damage usually correspond to the density of neutrophils in the epithelium. The presence of neutrophils in post-treatment biopsies is highly suspicious of H. pylori infection. So in this condition, the use of immunostains or special stains for detecting H. pylori is important.
Chronic gastritis is marked by the uniform infiltration of superficial and/or deep lamina propria by lymphocytes, monocytes, eosinophils, plasma cells, and mast cells. It is graded as mild, moderate, and severe. Even after complete eradication of H. pylori, chronic inflammatory cells take several years to disappear or become normal in gastric mucosa. Atrophy refers to the loss of gastric mucosal glands which leads to mucosal thinning or the presence of intestinal metaplasia in the antral epithelium. Metaplastic change in gastric antral and/or fundic mucosa is caused by intestinal goblet cells, absorptive cells, and Paneth cells.
This study aimed to compare the efficacy of each special stain. Only a limited number of researches have examined the sensitivity and specificity of various staining techniques.12No studies have compared the special stains in h.pylori negative cases, to our knowledge only we have done this study.
MATERIALS AND METHODS
A Case Series Analysis of 50 gastric biopsies (positive and negative cases of H.pylori by H& E stain) was studied in the Department of pathology, saveetha medical college and hospital, March 2019-August 2019. Endoscopic biopsies were taken from the antrum, body, and other sites were included in the study, and gastrectomy specimens were excluded. The clinical details of the cases were accessed from biopsy requisition forms. The tissues were fixed in 10% formalin, processed and the sections were stained with hematoxylin and eosin(H&E) and five special stains.
Methods of Special stains
Modified Giemsa staining
To prepare the stock solution of Giemsa, 4 grams of stain powder was dissolved in 250 ml glycerol at 60°C with regular shaking. Add 250 ml of methanol was added, shook the mixture, and allow to stand for 7 days. The working Giemsa stain was prepared by adding 4ml of Giemsa stock solution to 96 ml of Acetate buffered distilled water(pH6.8). Sections are rinsed in buffered distilled water - a pH of 6.8. The working Giemsa stain is added to the specimen and left undisturbed for the whole night. Then rinsed in distilled water. Then rinsed in 0.5% aqueous acetic acid till the section becomes pink. Dehydrated with alcohol, cleared and mounted.
Toluidine blue staining
The toluidine blue solution contains toluidine blue in pH 6.8 phosphate buffer, add Sorenson's phosphate buffer, pH 6.8 - 50 ml, and 1% aqueous toluidine blue -1 ml. Stained with buffered toluidine blue for 20 minutes, washed with distilled water. Dehydrated and mounted.
Warthin-starry silver staining
The Warthin-starry silver staining solution contains acetate buffer, pH 3.6, sodium acetate 4.1 g, acetic acid 6.25 ml, distilled water 500 ml,1% silver nitrate in pH 3.6 acetate pH. Sections are immersed in a slightly acidified aqueous solution of silver nitrate and kept for 30 to 60 minutes. Immersed in a freshly made handmade reducing solution containing hydroquinone, gelatine, and a low concentration of silver nitrate. Rinsed in tap water for several minutes at 55–60°C, then in buffer at room temperature. Dehydrate, clear, and mount.
Acridine orange staining
The reagents used in acridine orange staining are acridine orange (CAS 10127-02-3)-0.1 g, 0.2 M,acetate buffer (pH 4.0) -1000.0 ml. The slide is fixed with absolute methanol for two minutes or with heat. Acridine Orange stain is flooded in the slide and kept undisturbed for two minutes. Rinsed with water and allowed to dry. Examined under 40X magnification using a fluorescent microscope.
Cresyl violet staining
Cresyl violet staining solution contains cresyl violet (acetate) -0.1 g, distilled water -75 ml and the working solution contains cresyl violet solution- 6 ml ,acetate buffer solution pH 3.6- 50 ml.Filter with 0.1% cresyl violet acetate onto a slide or into a Coplin jar for 5 minutes. Rinsed in distilled water. Blotted, dehydrated rapidly in alcohol, cleared, and mounted.
All cases were evaluated microscopically under the oil immersion objective(1000X, except acridine orange) for the presence of H.pylori. The H.pylori appeared as pink in H&E stain, Dark blue against a pink- pale blue background in modified Giemsa stain, dark blue against a variably blue background in toluidine blue stain, black against the golden yellow background in Warthin-starry silver stain, bright orange against a green-fluorescing or dark background in Acridine Orange stain and finally blue-violet in shades of blue-violet background in Cresyl violet staining (Figure 1)
All the data obtained were entered into a master sheet in Microsoft Excel. The findings were compared and sensitivity, specificity was calculated. The study was approved by the institutional ethics committee, SMC/IEC/2019/07/003
RESULTS
Out of 50 cases of gastric biopsies, 25 cases were H. pylori positive and 25 cases of H.pylori negative case controls in H&E staining were included in the study. The males (56%)are affected more than females (44), 2:1 ratio, the incidence is high in the age group ranging from 21 to 60 years.
Clinical diagnosis/symptoms
The most common clinical presentation is gastritis, dyspepsia, and acid peptic disease. The rare clinical presentation is gastric outlet obstruction, GERD, gastric ulcer, and gastric carcinoma (Table 1). To date, Histopathology and culture were the gold standards for the diagnosis of H.pylori, but the culture was not utilized nowadays because it takes a long time and also the availability of more advanced invasive and non-invasive procedures. H.pylori can be detected routinely by H&E stain, but when the density was low; its identification can be highly supplemented by special stains. In all positive and negative cases, five special stains were done. All the special stains showed a statistically equivocal result in H.pylori positive cases and less than 50% positivity in H.pylori negative cases in H&E staining (Table 2).
Microscopic findings
Activity, inflammation, atrophy, and H.pylori density were categorized by the updated Sydney system. In this study, out of 50 cases, mild activity in 22 (44%)cases, moderate activity in 26 cases (52%), and severe activity in 2 cases (4%). The intestinal metaplasia was seen in 7 cases (14%), chronic inflammation(lymph plasma cells and lymphoid follicles) in 12 cases (24%), and mixed inflammation (neutrophils, lymph plasma cells, and eosinophils) in 38 cases(76%). Depending upon the activity, the positivity of H.pylori in mild activity was 21, 18, 15, 12, and 5 cases and in moderate activity18, 21, 17, 20 and 10 cases were in acridine orange, cresyl violet, modified Giemsa, toluidine blue, and warthin starry stain respectively. In the H&E stain, 8 and 14 cases were positive for mild and moderate activity. In all stains positivity was increased in moderate activity (Figure 2) So the sensitivity was more in acridine orange followed by cresyl violet, Giemsa, toluidine blue, and low sensitivity, and more specificity was seen in warthin-starry stain (Tables 2,3). In our study, we compared all special stains with H&E stain(in positive, negative cases) depending upon the staining quality for interpretation of H.pylori, cost, and staining time. The most reliable stains were acridine orange, cresyl violet, Giemsa stain, and toluidine blue. The most time-consuming, complex, and expensive stain was the Warthin-starry stain (Table 4).
DISCUSSION
Helicobacter pylorus is a gram-negative, spiral organism that colonizes the gastric mucosa. H.pylori revives in the acidic medium of the stomach and burrows into the mucus layer, because of its helical shape. The common site of biopsy for the detection of H. pylori is the antrum because the colonization of bacilli is more severe than in the body. In our study, 47(94%) cases were obtained from the antrum and 3 (6%) cases were from lesser curvature.
The most common age of occurrence is between 21 and 41 years. Comparison of the male and female distribution of helicobacter pylori infection with other studies showed (Table 5). All studies showed males were commonly affected, except Adisa et al., and studies showed females were more affected than males.
Histopathology and culture were the gold standards for the diagnosis of h.pylori, but the culture was not doing nowadays because it takes more time to get results and also the availability of various invasive and non-invasive procedures. This study aimed to compare the efficacy, cost-effectiveness, and time of each special stain in both positive and negative cases diagnosed by H&E staining. The number of bacteria in the specimen determines the sensitivity of the test. The outcome of every test result depends on the hands of experienced has good sensitivity and specificity.13 In the present study, the sensitivity of acridine orange showed 96% accuracy which is the same as Haqqani MT, Langdale-Brown, et al and Gowsik K.13,14 They conducted two different studies in 1998 and have mentioned that Acridine Orange is not specific but 100% accurate and a study by Rotimi et al in 2000 also suggested the same.15 It is an easy and simple procedure to perform, but most of the labs do not have a fluorescence microscope. Kaur et al. in their study observed Toluidine Blue stain was cheap and easily applicable and consumed in only 4 minutes.16 The sensitivity and specificity were less when compared with MG, but in the present study, it was almost equivocal where sensitivity was 80% and specificity was 64% in TB and 84% and 60% in MG.
Previous studies et al found that H&E stain was cost-effective to use as they are routinely performed for the evaluation of gastric biopsies.16In our laboratory, we are also routinely used hematoxylin stain for H. Pylori detection in the majority of cases. However, in a small number of cases, an immune-histochemical stain can be particularly useful in severe active gastritis in which no H.pyloricould be detected on hematoxylin stains, to avoid the false-negative results, and for the follow-up, biopsies to confirm the absence of H. pylori.17 Wilkins in her study, said that increase in staining time of hematoxylin can give good results, but the sensitivity is low due to the lack of contrast between the bacteria and surrounding tissues, and specificity is also low due to the non-specific staining of the non-HP bacteria.16
A study done by Fiaz Ahmad al alshowed, 68% were positive in Giemsa and 76% were positive in Cresyl fast violet. Cresyl fast violet is a good stain for the diagnosis of H. pylori gastritis.18 In our study, the sensitivity of cresyl violet was 92% and 84% in Giemsa. Sulakshana et al. showed that the sensitivity of Warthin - Starry stain was the same as that of Giemsa, but Ashton et al have shown that the sensitivity is higher than that of Giemsa and the disadvantage of this stain is complex, not reproducible, and difficult to interpret because of nonspecific staining of mucus, and water bath contaminants.19,20 In our study, the sensitivity was low(52%) and high specificity (84%) when compared with all special stains. It was true, the same problem happened in our study. It was very expensive, complex, and suitable when the bacterial load is more and less reliable because of more granular and fibrillary artifacts.
However, hematoxylin and Eosin stains can be used as a standard procedure for initial screening. Even though IHC is a gold standard, the special stains are more useful in the diagnosis of H.pylori when it was not detected by H&E. These special stains were especially useful in small setup laboratories due to lack of facilities for Immunohistochemistry (IHC) and easy to perform, less expensive.
CONCLUSION
The routinely used H& E stain is cost-effective, easy to use. Positive and negative cases ofH.pylori were detected by Haematoxylin and Eosin, and compared with Giemsa, Cresyl violet, Toluidine blue, Acridine orange, and Warthin-Starry special stains. The most reliable stains are Cresyl violet, Acridine orange, Modified Giemsa, and Toluidine blue in terms of positivity, cost-effectiveness, time-consumption and can be used for definitive identification of Helicobacter Pylori. The sensitivity of five special stains was good(>90%) in all positive cases and > 50% positivity in negative cases, except Warthin- Starry stain has high specificity and low sensitivity in our study. So, we conclude that H.pylori can be identified easily with a careful examination by using any stain. In our study, the highly sensitive stain was cresyl violet. So we propose, Cresyl violet can be used for routine histological diagnosis of Helicobacter pylori in adjunct with H&E. Use of Acridine orange was limited, it required immunofluorescence microscope attachment,
Author Contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.
Conflict of interest: None.
Acknowledgement: We all thank our technicians who helped in this project.
Englishhttp://ijcrr.com/abstract.php?article_id=3711http://ijcrr.com/article_html.php?did=37111. Ramakrishna BS. Helicobacter pylori infection in India: the case against eradication. Indian J Gastroenterol 2006; 25(1):25-8.
2. Garg B, Sandhu V, Sood N, Sood A, Malhotra V. Histopathological analysis of chronic gastritis and correlation of pathological features with each other and with endoscopic findings. Pol J Pathol 2012; 63(3):172-8.
3. World gastroenterology organization global guideline: Helicobacter pylori in developing countries. J Diagn Dis 2011;12(5):319-26.
4. Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis.The updated Sydney System.International Workshop on the Histopathology of Gastritis, Houston 1994. Am J Surg Pathol 1996:20(10):1161-81.
5. Odze RD, Goldblum JR. Surgical pathology of the GI tract, liver, biliary tract, and pancreas. In: Richard H. Lash , Gregory Y,Lauwers Robert D,Odze , Robert M. Genta, editors. Inflammatory Disorders of the Stomach.2nd ed. Elsevier Health Sciences; 2009. p.269-320.
6. Chey WD, Wong BC. American College of Gastroenterology guideline on the management of Helicobacter pylori infection. Am J Gastroenterol 2007;102(8):1808-25.
7. el-Zimaity HM. Accurate diagnosis of Helicobacter pylori with biopsy. Gastroenterol Clin North Am 2000;29(4):863-9.
8. Lawson AJ, Elviss NC, Owen RJ. Real-time PCR detection and frequency of 16S rDNA mutations associated with resistance and reduced susceptibility to tetracycline in Helicobacter pylori from England and Wales. J Antimicrob Chemother 2005; 56(2):282-6.
9. Ho B, Marshall BJ. Accurate diagnosis of Helicobacter pylori: serologic testing. Gastroenterol Clin North Am 2000;29(4):853-62.
10. Gisbert JP, Pajares JM. Review article: 13C?urea breath test in the diagnosis of Helicobacter pylori infection – a critical review. Aliment Pharmacol Ther 2004;20(10):1001-17.
11.Wang XI, Zhang S, Abreo F, Thomas J. The role of routine immunohistochemistry for Helicobacter pylori in a gastric biopsy. Ann diagn Pathol 2010;14(4):256-9.
12. Wabinga HR. Comparison of immunohistochemical and modified Giemsastain for demonstration of Helicobacter pylori infection in an African population. African Health Sci 2002;2(2):52-5.
13. Haqqani MT, Langdale-Brown B. Campylobacter pylori--acridine orange stain and ultraviolet fluorescence. Histopathology 1988;12(4):456-457.
14. KanimozhiGowsik, Archana V. Comparison of various histochemical staining methods for identification of Helicobacter pylori. Trop J Path Microb 2019;5(9): 692-695.
15. Yakoob J, Jafri W, Abid S, Jafri N, Abbas Z, Hamid S, et al. Role of rapid urease test and histopathology in the diagnosis of Helicobacter pylori infection in a developing country. BMC Gastroenterol 2005; 5:38.
16. Kaur G, Madhavan M, Basri AH, Sain AH, Hussain MS, Yatiban MK, Naing NN. Rapid diagnosis ofHelicobacter pylori infection in gastric imprint smears. Southeast Asian J Trop Med Public Health 2004;35(3):676-680.
17. Mégraud F, Lehours P. Helicobacter pylori Detection and Antimicrobial Susceptibility Testing. Clin Microbiol Rev 2007;20:280-322.
18. Ahmad F, Jaffar R, Khan I. Helicobacter pylori detection in chronic gastritis: a comparison of staining methods. J Ayub Med Coll Abbottabad 2011; 23(2):112-4.
19. Sulakshana MS, Siddiq M. Ahmed and Raghupathi A R. A histopathological study of the association of Helicobacter pylori with gastric Malignancies. Int J Curr Aca Rev 2015;3(3):10-28.
20. Ashton M, Diss T C, Isaacson P G.Detection of H.pylori in gastric biopsy and resection specimens. J Clin Pathol 1996;49:107-111.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareAttitude of MBBS Students Towards Cadaveric Dissection and their Views on Anatomy as a Subject for Career Option in Uttar Pradesh
English168173Umesh ChoudharyEnglish Priyanka BhartiEnglish Amit Kumar NayakEnglishIntroduction: Anatomy is one of the important subjects taught to the MBBS first-year students. Cadaveric dissection plays an important role in the deeper understanding of three- dimensional relationship of different anatomical structures, appreciating anatomical variations which are key to practice health and medicine. First-year medical students when encountering human cadavers for the first time faces lots of emotional and mixed feelings. The exposure has both physical and psychological impact on students. Objective: This study aimed to explore the knowledge and attitude of medical students regarding cadaveric dissection and anatomy as a career option. Methods: The study was conducted at Mayo institute of medical sciences, Barabanki. A total of 300 students of MBBS batch 2016 - 2017 and 2017- 2018 participated in this study. It is a questionnaire-based study done to evaluate student’s behaviour, experiences and emotions regarding cadaver dissection and also to access their views on anatomy as a career option. Results: The emotional and physical stress encountered initially was decreased gradually after 3 months of dissection. It was found that students were not much interested in pursuing Anatomy as a career option due to a lack of opportunities. Conclusion: This study concludes that anatomical dissection remains an essential part of medical education and it should not be replaced by any other modern learning methods. The emotional shock experienced by the students can be greatly reduced if they are properly counselled before the dissection class. Research and job opportunities should be encouraged in the subject to develop interest among the young medical graduates for pursuing anatomy as a career.
EnglishAnatomy, Cadaver, Dissection, Experience, First year, Medical StudentsINTRODUCTION
Anatomy, the study of the structure of the human body, is the first most basic and one of the most important subjects studied by medical and paramedical students when they first began their medical career.1Anatomical knowledge remains a cornerstone of medicine and related professions, despite the reduction in importance, time committed to, and status of anatomical education in modern curricula.2 Cadaveric dissection has been a regular feature in anatomy teaching since the epoch. Andreas Vesalius (1514-1564) was the first medical student to dissect the cadaver and also continued with it even as a professor.3 Dissection has been labelled as the "royal road"4 and the cadaver as the "first patient".5 Cadaver dissection has also been called the "sharp-end" of medical education.6 Surgeons advocate experience with dissection not only for learning anatomical detail but also to familiarize students with variations in anatomy. Students from their childhood are trained to emphasise scoring good marks rather than applying the knowledge practically, they enter the medical course holding the same perception. But the professional educational environment is very much different from the traditional school and junior college environment. Medical school's learning orientation has a solid scientific basis with its practical implementation on the patient in the long run.7 Anatomy is the first subject which students admitted to medical course come across. Medical students experience a lot of emotional and physical stress when they encounter a human cadaver for the first time. Working with a cadaver constitutes potential stress which includes both positive and negative experiences in this subject.8 some authors consider that cadavers may present several disadvantages. Their colour, texture, and smell are not like real life, and cadavers cannot be palpated, auscultated, or usefully asked to change position. Their use may present health hazards and ethical/legal difficulties.9
Another major concern in Anatomy is the shortage of teachers in medical colleges at the global level. The number of medically qualified teachers in preclinical subjects is continuously decreasing.10 Postgraduate seats in medical colleges are left vacant in preclinical subjects. Therefore, it is an urgent need to enhance awareness amongst students regarding available job opportunities and research possibilities in the subject of anatomy.
The present study aims to assess student's attitude towards dissection by recording their attitude thrice. First when they entered the dissection hall for the first time, second after three months of dissecting experience and third once they pass out their MBBS first year. This study also aims to evaluate the opinion of medical students regarding anatomy as a subject for a career option.
MATERIALS AND METHODS
The study was conducted at Mayo institute of medical sciences, Barabanki. It is a questionnaire-based study. A total of 300 students of MBBS batch 2016 - 2017 and 2017- 2018 was involved in this study. The objectives of the study were explained to the students. All the 150 students of MBBS batch 2016- 2017 were given 3 sets of questionnaires.
First - on the first day of their dissection hall experience
Second- after three months of dissecting experience
Third - after passing the first-year MBBS
The same process was repeated with the remaining 150 students of MBBS batch 2017- 2018. For each question, the students had to choose any one response - yes, no or neutral.
RESULTS
Out of the total of 300 students who participated in the study, 160 were male and 140 female (Figure 1). The age group of students who participated in this study ranges between 19- 25 years. On the first day of the dissection hall experience, 98% of the students were excited, 50% of them had not seen a dead body before. About 82.66% of the students were mentally prepared for dissecting a human cadaver. The majority of them suffered from various physical symptoms, of which eye irritation was the most commonly experienced by 70.33%, these symptoms decreased gradually with time. 85.33% wanted to give the first incision while 39% of them hesitated to start dissection as they had a thought that the cadaver which they are going to dissect was once living (Table 1).
After three months of dissection, 63% felt elated. 23. 66% of students had recurrent thoughts of the dead body even being away from the college, while 13% even dreamt of dead bodies. About 34% had the recurrent smell of formalin even at their dining table. 40% wished to take a bath after coming from the dissection hall. The majority of students felt that dissection logically enhances the skill of thinking. 96% of them had respect for cadaver and regard it with sanctity. 79% think that teachers and anatomy staff plays an important role in reducing their fear and stress and creating a comfortable environment in the dissection hall (Table 2).
The majority of students after passing first-year MBBS felt anatomy dissection as an important part of a medical degree and participating in cadaver dissection provides more opportunities to develop professional skills, therefore they consider themselves benefited from the knowledge of anatomy later in clinical terms. 50% of them accepted that anatomy is not difficult to understand and retain while 51.33% of them felt that one year time allotted to teach anatomy is not sufficient. 96% do not want cadaver dissection to be replaced by any other modern learning methods such as plastic models, computer-assisted training etc in the near future.96.66% think that every good clinician needs to have a sound knowledge of anatomy besides the clinical specialties.50.33% of students would like to take up anatomy as a career if better research facilities and job opportunities are made available while 41% would like to be an anatomist if modified integrated curriculum with other clinical specialities is introduced. Only 43% of the students participating in the study would recommend anatomy as a career to their peers (Table 3).
DISCUSSION
In the present study, dissection was considered important for gross anatomy learning particularly the three-dimensional aspect of human anatomy. It enhanced the student’s skill of logical thinking which helped them in better understating other medical subjects. This is in concordance with the previous studies.11-24
Furthermore, the majority of the students agreed that actual hands-on training on cadaver dissection gave better results than the demonstration of the protected specimen and it should not be replaced by any other learning methods. This finding is consistent with the findings from previous studies.25 It is at variance with the observations made by some other authors.26-29
It was found that the physical and emotional symptoms suffered by the students decreased gradually. This finding is similar to the previous observations made.30-32 It has been reported that sometimes the urge and strong interest in medicine career motivates students and lowers the level of mental stress while increasing their preparedness.17 We observed that most of the students were excited after visiting the dissection hall on the first day. This is in agreement with the previous studies done.34-36 It is also suggested that the majority of the students were upset at the beginning of the dissection.29 In the present study most of the students felt elated after dissection, which is similar to the previous finding done by Cahill KC et al. on Irish medical students.37 Most of the students considered that cadavers were once living humans and had sympathy and respect for them. This finding is in concordance with studies done.19,22,34 There is a need to emphasize the sanctity of the cadaver as a human specimen, to inculcate into students carefulness and empathy, which is important in the subsequent medical practice.
It is very despondent to notice that very few students are interested to pursue anatomy as a career option similar to the previous findings.32,38 This issue needs immediate intervention measures to be taken to develop career interest in this subject by increasing research and job opportunities. Financial consideration is a major criterion for career selection and preclinical subjects as a career option are associated with low financial returns, which may be one of the major reasons for low interest in anatomy as a career. This is also agreed in the previous studies done.39-43
CONCLUSION
Anatomical dissection is still valued as one of the most effective and indispensable teaching tool for human anatomy, which help students in every walk of their medical career. However, to make the dissection hall experience more pleasant, there is a need to address the students physical, mental and emotional problems repeatedly through proper counselling. Furthermore, interest in anatomy as a career option can be increased by better remuneration, increased research opportunities and career guidance. Research opportunities can be increased by linking clinical embryology and andrology labs, cytogenetic labs, radiological labs and neurobiology labs to the department of anatomy.
ACKNOWLEDGEMENT
We are grateful to all the students of batch 2016- 2017 and 2017- 2018 of Mayo Institute of Medical Sciences, Barabanki, Uttar Pradesh for their punctual assistance in responding to the questionnaire. The 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.
CONFLICT OF INTEREST – NIL
SOURCE OF FUNDING – NIL
AUTHOR’S CONTRIBUTION –
UC: Designed the analysis and collected the data.
PB: Contributed to data analysis and interpretation of the result.
AKN: Wrote the paper.
Englishhttp://ijcrr.com/abstract.php?article_id=3712http://ijcrr.com/article_html.php?did=3712
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Cahill DR, Leonard RJ, The role of computers and dissection in teaching anatomy: A comment (Editorial). Clin Anat 1997;10:140-141.
Parker LM. What’s wrong with the dead body? Use of the human cadaver in medical education. Med J Aust 2002;176(2):74-76.
Johnson JH. Importance of dissection in learning anatomy: Personal versus peer teaching. Clin Anat 2002:15:38-44.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareEvaluation and Comparison of Drug Advertisements Published in Medical Journals Using WHO Criteria for Ethical Medicinal Drug Promotion and OPPI Criteria for Drug Advertisements
English174178Dabhade SAEnglish Dabhade SSEnglishBackground: Advertisements in medical journals is also an important and effective way that is used by pharmaceutical companies to promote their drugs and to reach clinicians. In drug advertisements, misleading and wrong information is seen and sometimes such literature is of poor scientific and educational utility. However, despite the availability of guidelines and self-regulatory codes worldwide, pharmaceutical advertisement in a medical journal are being of poor.
Objective: To evaluate drug promotion advertisement in Indian and Non-Indian medical journals.
Methods: 30 drug advertisements each published in Indian and non-Indian scientific medical journals were selected randomly Drug promotional advertisements that promote allopathy medicines. Each drug advertisements were evaluated for - Compliance with WHO ethical criteria for medicinal drug promotion. Each drug advertisement was also evaluated for - compliance with the OPPI code. The percentage was calculated for compliance to WHO criteria, OPPI code and claims made. An unpaired t-test was used. P< 0.05 was considered significant for comparison.
Results: Adjuvants were mentioned in 56.66% of Indian journals and 86.67% non-Indian journals advertisements. Side effects, warnings, contraindications precautions were significantly more mentioned in non-Indian journal advertisements.
Conclusion: Pharmaceutical companies are involved in establishing a commercial relationship with the treating physicians wherein the educational aspect of scientific information about drugs is compromised. Pharmaceutical companies did not meet all the WHO criteria and OPPI code for ethical drug promotion. Strict compliance to these criteria is necessary for rational drug therapy and the benefit of the patient. Hence critical appraisal of all forms of drug promotion including journal advertisement by the physicians is very crucial. This study recommends that code for drug promotion should be supported by government legislation and strict regulatory implementation.
EnglishCompliance of drug advertisement, Medical journal, OPPI code, Pharmaceutical industries, Drug advertisements, WHO ethical criteria for medicinal drug promotionIntroduction
According to the World Health Organization (WHO), drug promotion is every informational and persuasive activity of the pharmaceutical companies, which can induce prescription, supply, purchase, and use of medicinal drugs.1 Pharmaceutical industries promote their drugs in many ways, such as direct email advertisements or drug information sheet by medical representatives. Gift articles and free drug samples, sponsorship of scientific and educational activities, seminars, conferences and tours are also provided by pharmaceutical industries. For the doctors, the literature promoting the drugs given by medical representative becomes an important source of information about drugs. It mainly targets physicians.2 Gahalaut et al. said that it may also modulate the prescribing behaviour of physicians without their knowledge.3 Advertisements in medical journals is also an important and effective way which is used by the pharmaceutical companies to promote their drugs and to reach clinicians. Journal advertisements attract physician’s attention because they have appealing graphs and pictures.4 Hence it is necessary that drug advertisements including advertisements in medical journals should provide scientific information. For a better understanding and utilization of drugs in patients, the doctors must observe the research findings and draw conclusions. In drug advertisements, misleading and wrong information is seen and sometimes such literature is of poor scientific and educational utility. This may lead to irrational prescribing. It may also lead to unnecessary adverse effects. Influencing physicians through promotional activities without necessarily benefitting the patients contribute to increased health care costs.5
For drug promotional advertisements, two guidelines are used, one of which is ‘ethical criteria for medicinal drug promotion by WHO. The main objective of ethical criteria for medicinal drug promotion is to support and encourage the improvement of health care through the rational use of medicinal drugs1. Another code is the code of pharmaceutical marketing practices by the International Federation of Pharmaceutical Manufacturers Association (IFPMA).6 In India drug promotional advertisements are not regulated by the governmental agency. In India, promotional activities by pharmaceutical companies are governed by the Organization of Pharmaceutical Producers of India (OPPI). It is a self-regulatory code of pharmaceutical marketing practices.7 OPPI has adopted a self-regulatory code of pharmaceutical marketing suggested by IFPMA.
However, despite the availability of guidelines and self-regulatory codes worldwide, pharmaceutical advertisement in a medical journal is being of poor quality.8In India few studies about the evaluation of drug promotional advertisements published in scientific medical journals have been reported. Drug promotional advertisements found to be not adherent to WHO criteria for medicinal drug promotion.9 Comparison of drug advertisements in medical journals by using WHO criteria and OPPI code of pharmaceutical marketing practices is lacking in India. Hence this study has planned to evaluate and compare the ethical standards of drug advertisements in scientific medical journals using WHO criteria and the OPPI code of pharmaceutical marketing practices. In the present study we aimed to evaluate drug promotion advertisement in Indian and Non-Indian medical journals. Our evaluated and compare the compliance of drug advertisements to WHO criteria for medicinal drug promotion in Indian and non-Indian medical journals, the compliance of drug advertisements to Organization of Pharmaceutical Producers of India (OPPI) code in Indian and non-Indian medical journals and the claims made in drug advertisements in Indian and non-Indian medical journals.
MATERIALS AND METHDOS
This is an observational and crosses?sectional study conducted in tertiary care hospital, Pune. Thirty drug advertisements each published in Indian and non-Indian scientific medical journals were selected randomly out of 50 literature each using a random number generator.
Inclusion criteria:
Drug promotional advertisements that promote allopathy medicines,
Drug promotional advertisements that contain at least one therapeutic claim was included for the analysis in this study.
Exclusion Criteria:
Those advertisements promoting medicinal equipment’s (e.g., insulin pump, etc.) and devices and orthopaedic prosthesis, product monographs,
Ayurvedic and Siddha medicines, reminder advertisements were all excluded from this study.
Each drug advertisements were evaluated for - Compliance to WHO criteria for medicinal drug promotion which includes 1) INN of the active substance (i.e., generic name) 2) Brand name and content (per dose) 3) Name of other ingredients 4) Approved use 5) Regimen 6) Side effects 7) Warnings 8) Contraindications 9) Precautions 10) Interactions 11) Name and address of manufacturer 12) references.
Each drug advertisement was also evaluated for - compliance to OPPI code which includes
Brand name.
The name and address of the drug industry.
The active ingredients, using approved generic names.
Date of production of the advertisement.
Approved indication or indications for use, together with the dosage and method of use; and a statement of the contraindications, precautions, and side effects.
One mark is given for the presence of criteria/claim in journal advertisement and zero marks is given for the absence of criteria/claim, the percentage was calculated for compliance to WHO criteria, OPPI code and claims made. An unpaired t-test was used. P< 0.05 was considered significant for comparison. The percentage of claims made in Indian and non-Indian medical journals were calculated.
Results
Table 1 and Figure 1 showed that 93.33% of Indian journals and 100% non-Indian journals had mentioned generic name in the advertisements. Both the journal gave the brand name in 100% advertisements. Adjuvants were mentioned in 56.66% of Indian journals and 86.67% non-Indian journals advertisements. Mentioning adjuvants were significantly more in non-Indian journals. Approved use of drug in of the advertised drug was mentioned in 90% Indian journal and 93.33% non-Indian journals advertisements respectively.
Regimens of the advertised drug were mentioned in 76.66% Indian journal and 93.33% non-Indian journals advertisements. Side effects of the advertised drug were mentioned in 86.67% Indian journal and 98% non-Indian journals advertisements. Warnings were mentioned in 46.67% of Indian journal and 80% non-Indian journal advertisements. Mentioning of warnings were significantly more in non-Indian journals. Contraindications were mentioned in 60% of Indian journal and 76.67% non-Indian journal advertisements. Precautions were mentioned in 66% of Indian journal and 90% non-Indian journal advertisements. Drug interactions were mentioned in 40% of Indian journal and 76.67% non-Indian journals advertisements. Mentioning of drug interactions were significantly more in non-Indian journals. The name and address of the manufacturer were mentioned in 90% of Indian journal and 93.33% non-Indian journals advertisements. References were mentioned in 53.33% of Indian journal and 83.33% non-Indian journals advertisements. The mentioning of references were significantly more in non-Indian journals.
Table 2 and Figure 2 showed that 100% Indian and non-Indian journals were mentioned.
The name of the product (normally the brand name) in the advertisements 90% of Indian and 98%non-Indian journals were mentioned the name and address of the pharmaceutical company or its agent responsible for marketing the product. 93.33% Indian and 98%non-Indian journals were mentioned the active ingredients, using approved names where they exist. 30% Indian and 83.33%non-Indian journals were mentioned the date of production of the advertisement. date of production of the advertisement was significantly lower in Indian journals. Approved indication or indications for use together with the dosage and method of use; and a statement of the contraindications, precautions, and side-effects were mentioned by 73.33% Indian journal and 98% non-Indian journal advertisements. This was significantly more mentioned in non-Indian journal advertisements.
Table 3 showed the claims made in the journal advertisements. Efficacy was mentioned in 89.33% of Indian journal and 83.12% non-Indian journal advertisements. Safety was mentioned in 32.78% non-Indian journal and 35.67% of Indian journal advertisements. The cost was mentioned in 9.32% non-Indian journal and 12.89% of Indian journal advertisements. PK properties were mentioned in 9.44 % of non- Indian journal and 6.99% Indian journal advertisements. Pharmaceutical properties were mentioned in 9.81 % of non- Indian journal and 5.56% of Indian journal advertisements.
Discussion
Marketing d0rugs through drug advertisements is one of the strategies adopted by pharmaceutical companies. Pharmaceutical companies are involved in establishing a commercial relationship with the treating physicians wherein the educational aspect about scientific information about drugs is compromised.10 It has been observed in this study that pharmaceutical companies did not meet all the WHO criteria and OPPI code for ethical drug promotion. In this study, generic name, brand name and address of manufacturer were seen in >90% of drug advertisements in both Indian and non-Indian journals. Less than 60% of drug advertisements in Indian journals are compliant with WHO criteria like the name of adjuvant, warnings, interactions, references. Whereas more than 80% of drug advertisements in non-Indian journals were compliant with to above WHO criteria. These findings are statistically significant and are similar to Jadhav et al.11 and Ganashree et al.12
It has been observed that the majority of drug advertisements in Indian and non -Indian medical journals are compliant with dosage schedule and therapeutic indications. But drug advertisements in Indian medical journals are less compliant to mentioning adverse drug reactions, precautions, contraindications, and interactions. Strict compliance to these criteria is necessary for rational drug therapy and the benefit of the patient. Hence critical appraisal of all forms of drug promotion including journal advertisement by the physicians is very crucial. In this study, it is observed that Indian journals are significantly less compliant to OPPI criteria as compared to non-Indian journals in mentioning of approved indications, dosage, method of use, contraindications, precautions, and side-effects are considered. Indian medical journals are significantly less compliant in mentioning the date of production of that advertisement as required by the OPPI criteria.
Indian journals are significantly less compliant with the OPPI code, while Non-Indian journals are significantly more compliant with the IFPMA code.13 This study endorses this finding. It needs to be noted that the OPPI code is derived from the IFPMA code hence we can say that Indian journals are less compliant with the IFPMA code. This means that Indian journals are significantly less compliant to voluntary code proposed by associations of pharmaceutical industries (OPPI, IFPMA). In this study, claims made in the advertisements in medical journals were evaluated and compared. It is found that efficacy claims are present in 89.23% and 83.12% in Indian and non-Indian medical journals respectively. Safety claims are present in 30.67% and 32.78% in Indian and non-Indian medical journals respectively. Cost and convenience claims are more in non-Indian journals as compared to Indian journals, though it is not significant. These finding are similar to Mali et al.10 where efficacy claims were made in 92% of drug advertisements and safety claims in 37.8% of drug advertisements.
In this study, pharmacokinetic claims and pharmaceutical claims (e.g. sustained-release preparation, dispersible tablets etc) were seen in 5.44% and 5.61% of advertisements respectively in Indian and non-Indian journals. Mali et al. mention 16.4% claims on pharmacokinetic properties and 29.6%. claims on pharmaceutical properties in drug advertisements. Thus, from the above findings, it is seen that pharmaceutical companies highlight the positive aspects of their products while omitted the negative aspects.
Conclusion
Drug advertisements in medical journals are an important source of providing information about drugs to doctors. Drug advertisements in Indian journals are not adequately compliant with the WHO and OPPI code. For further improvement in the quality of drug advertisements in Indian journals, this study recommends that code for the drug promotion should be supported by government legislation and strict regulatory implementation. Medical practitioners and medical students need to be educated to critically evaluate the drug promotional activities and increase their ability to recognize misleading promotional advertisements. Doctors should be encouraged to report any violation of the ethical code of drug promotion to the regulatory authorities.
Acknowledgement: Authors would like to acknowledge librarian Dr.D.Y.Patil medical college, Pimpri, Pune for making the medical journals available.
Authors’ Contribution: The first author has given the idea of the topic and written the article. The second author has done the data collection and statistical part.
Conflict of Interest: None
Source of Funding: None
Englishhttp://ijcrr.com/abstract.php?article_id=3713http://ijcrr.com/article_html.php?did=3713
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareFrom Hazardous Practices to Hot Experiences of Young Adult’s Exposure Towards Sexually Explicit materials: Analysis of Case Studies
English179182Samiksha JainEnglish Neelam PandeyEnglish Waheeda KhanEnglishEnglish Sexually explicit material, Hazardous practices, Experiences, Exposure, Young adults, Case studieshttp://ijcrr.com/abstract.php?article_id=3940http://ijcrr.com/article_html.php?did=3940Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareTo Study the Comparative Effect of Nebivolol and Metoprolol on Fasting and Post-meal Blood Glucose Level in Patients of Type II Diabetes Mellitus with Essential Hypertension
English183187Bhagat AHEnglish Magare ASEnglishIntroduction: Diabetes mellitus (DM) is a metabolic disorder characterised by excessively high blood sugar levels and elevated oxidative stress, resulting in lipid, protein, and carbohydrate metabolism problems. Diabetes mellitus increases the risk of coronary artery disease, stroke, and other vascular problems considerably. Aim: Nebivolol has enhanced tolerability profile with respect to adverse effects usually allied with nonselective β-blockers so, the study’s goal is to assess the comparative effects of nebivolol and metoprolol on metabolic parameters in type II diabetes mellitus with essential hypertension patients. Methodology: The subjects enrolled for this study are selected from the Out Patient Department of Medicine, MGM medical College, Aurangabad according to the inclusion and exclusion criteria. Written informed consent is obtained from each patient. Various biochemical parameters are assessed for comparative study of nebivolol and metoprolol drugs in patients. 3 month randomized open label study design is selected and 40 patients are divided into 2 groups, administered nebivolol and metoprolol in each group. Parameters like fasting blood glucose level, postprandial blood glucose level (BGL), HbA1c level, systolic and diastolic blood pressure are assessed using student paired and unpaired t-test. Result: Fasting blood glucose level, postprandial BGL, HbA1c and systolic blood pressure except diastolic blood pressure are found to be reduced significant in nebivolol treated group than compared to metoprolol group patients. Nebivolol doesn’t show side effect of fatigue. Conclusion: This comparative study concluded that Nebivolol more efficacious than metoprolol in terms of reducing BGL, HbA1c and blood pressure along with lesser side effects in type II diabetic and hypertension patients.
EnglishNebivolol, Metoprolol, Fasting blood glucose level, Postprandial blood glucose level, HbA1c, Blood pressurehttp://ijcrr.com/abstract.php?article_id=4513http://ijcrr.com/article_html.php?did=4513Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241139EnglishN2021May7HealthcareTo Assess Effectiveness of Topical Application of Pure Honey on Radiation-Induced Mucositis in Cancer Patients Undergoing Radiotherapy
English188196B. Geetha PraveenaEnglish P. Naga JyothiEnglishIntroduction: Mucositis is an inflammatory illness that affects the mouth’s mucous membranes.It could be the result of an infection or an indication of something more serious. Oncology nurses play a crucial role in improving patient outcomes related to oral mucositis. Honey has long been used to prevent and cure oral mucositis. Aim: The aim of the study to assess the effectiveness of topical application of pure honey on radiation-induced mucositis in cancer patients undergoing radiotherapy. Material and Methods: The style adopted for the study is true experimental design with two group pre-tests with the experimental analysis approach was wont to judge the effectiveness of topical applications of pure honey on radiation-evoked mucositis patients. This study was conducted in GSL Cancer hospital Rajahmundry. The sample size consisted of sixty patients suffering type oral mucositis patients who are admitted in GSL cancer hospital at Rajahmundry. Sample random sampling technique was used for the choice of sample. knowledge was collected by mistreatment WHO mucositis assessment scales & one observation checklist to assess the grade of radiation-induced mucositis in patients. Modified WHO oral mucositis assessment scale. Data were analysed using descriptive and inferential statistics. Result: The results of this study showed that, oral mucositis score of experimental and control groups mean were 9.73 and1.7 respectively. The standard deviation was 0.927 and 14.55 respectively. Hence calculated t’ value 2.66 is greater than tabulated ‘t’ value 2, ‘p’ value is 0.0101 shows that there was significant oral mucositis scores between post test scores in both experimental and control groups. Applications of pure honey was effective. Conclusion: The findings of the study concluded that, the application of pure honey was effective on radiation-induced mucositis in cancer patients undergoing radiotherapy and the level of mucositis is decreasing.
EnglishAssess, Effectiveness, Pure honey, Topical application, Radiation induce mucositis, Radiotherapyhttp://ijcrr.com/abstract.php?article_id=4514http://ijcrr.com/article_html.php?did=4514