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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareTeledentistry: An Update
English0101Dr. Little MahendraEnglishEnglishhttp://ijcrr.com/abstract.php?article_id=3714http://ijcrr.com/article_html.php?did=3714Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareInsights into Biomedical 3D Printing
English0203Prachi KhamkarEnglishEnglishhttp://ijcrr.com/abstract.php?article_id=3715http://ijcrr.com/article_html.php?did=3715Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareOccupational Hazards and Health Status of Welders: A Letter to the Editor
English0404Debasish Kar MahapatraEnglishEnglishhttp://ijcrr.com/abstract.php?article_id=3716http://ijcrr.com/article_html.php?did=3716Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareEffect of Extracorporeal Shockwave Therapy, Pulsed Electromagnetic Field Therapy and Drug Therapy on Chronic Pelvic Pain Syndrome: A Prospective Randomized Study
English0510Mostafa Ahmed AbdelhameedEnglish Adel Abdelhamid NossierEnglish Haidy Nady AshmEnglish Ahmed Mohamed Zaky AnwarEnglishBackground: chronic pelvic pain syndrome is one of the most common diseases in urology, the disease involving discomfort in the perineal area, pelvis, pubic area with ejaculatory and voiding problems. Objective: The main objective of the current study to evaluate the therapeutic effect of Extracorporeal Shockwave Therapy (ESWT), Pulsed Electromagnetic Field Therapy (PEMF) and Drug therapy in treating chronic pelvic pain syndrome. Methods: Seventy-five male patients with chronic prostatitis assigned into three main groups twenty-five for each Group A received Extracorporeal Shockwave Therapy (ESWT) for one month, group B received pulsed electromagnetic therapy for one month and Group C received drug therapy for one month, the treatment plan was pretreatment evaluation by both measures NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) and ultrasonography which were used to evaluate the patients, all were assessed before and after treatment. Results: There was a significant decrease between pre and post values of (shockwave, Pulsed Electromagnetic Field Therapy (PEMF) and Drug Therapy group on the NIH scale and in the US Examination. Conclusion: ESWT is effective in treating non-inflammatory chronic pelvic pain syndrome in men as manifested by a decrease in prostate volume and NIH-CPSI also PEMF and drug therapy are effective in the treatment of chronic prostatitis/chronic pelvic pain syndrome (CP/CPP) but the ESWT is more effective.
EnglishChronic prostatitis/chronic pelvic pain syndrome, Extracorporeal Shockwave Therapy, Pulsed Electromagnetic Field therapy, NIH-Chronic Prostatitis Symptom IndexINTRODUCTION
Prostatitis is one of the most common urological problems and results in > 2 million doctor visits in the U.S. every year.1 Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is defined as the presence of chronic pelvic pain without documented infection or any other clear local pathology that explain pain for more than 3 months.2 The National Institutes of Health (NIH) defines CP/CPPS as type III prostatitis which is prevalent in men before the age of 50.3 The NIH-Chronic Prostatitis Symptom Index (NIH-CPSI) is the standard used tool for assessment of symptoms severity in patients with CP/CPPS and includes, pain, urinary symptoms and quality of life QOL impact.4
Extracorporeal shock wave therapy (ESWT) was introduced in the past for kidney stones destruction and in the management of musculoskeletal disorders; nowadays, it has been vastly utilized in pain and wound management.5 ESWT must be considered as a promising new therapy for CPPS, in particular as it is easy to apply and causes no side effects.6
Magnetic stimulation provides a new treatment option for CP/CPPS patients who do not respond to pharmacotherapy.7 Drug therapy whether single or in combination is a commonly prescribed treatment for CP / CPPS 8. There is a lack of ideal treatment of CP/CPPS probably because of the uncertainty of aetiology and the best evidence-based management of CP/CPPS strongly suggests a multimodal therapeutic approach addressing the individual clinical phenotypic profile.9 So, the purpose of this study was to evaluate the therapeutic effect of ESWT, PEMF and Drug therapy in treating chronic pelvic pain syndrome.
MATERIALS AND METHODS
Seventy-five patients with CP/CPPS according to NIH classification 3 were enrolled in this study from 20 of October 2017 to 15 June 2019 and were randomly distributed into three equal groups using the closed envelop method
Group A: Included 25 patients with CP/CPPS who received ESWT for one month.
Group B: Included 25 patients with CP/CPPS who received PEMF for one month.
Group C: included 25 patients with CP/CPPS who received drug therapy for one month.
Procedure
The technique of Extracorporeal shock wave therapy (ESWT)
The patients in (Group A) treated by Shockwave device shock master 500 Gymna. Patients were reclined in an adjustable plinth, and their testicles were pushed forward gently during the procedure. Shock waves were applied directly to the perineal area over the maximum site of pain. Ultrasound gel was used as a coupling agent and the applicator of ESWT was held perpendicular to the treatment surface throughout the treatment. During the initial impulses, patients were instructed to adjust the applicator to feel the shock waves targeting the localized region of pain.
Patients were treated by ESWT once a week for 4 weeks. Energy density was adjusted to 3000 impulses each time, with 0.25 mJouls/mm2 and 3Hertz of frequency were delivered, although 0.05 mJouls/mm2 was added in each week (0.3 mJouls/mm2 in week two, 0.35 mJouls/mm2 in week three, and 0.4mJouls/mm2 in week four).10 The treatment impulses were 12000 extracorporeal shock wave impulses in 4 sessions over four weeks (3000 extracorporeal shock wave impulses every session) Frequency: 3 Hz was used for all the treatments. The position of the shock wave transducer was changed after every 500 pulses, to adjust the duration of the session to 5-15 minutes depending on patient tolerability.
The technique of Pulsed Electromagnetic Field Therapy (PEMF)
The patients in (group B) were treated by PEMF electromagnetic device; ASA, magneto therapy pmt qs Italy. The active treatment regime was empirical and consisted of 2 sessions weekly for 4 weeks (total 8 sessions). The frequency was set low at 10 Hz for the first 15-minute period and was increased to 50 Hz for the second 15-minute period.11 During the half-hour period of the session, the patient would keep the supine position.
Drug therapy
The patients in (group C) were treated with a combination of drug therapy in the form of (Tamsulosin 0.4 mg one capsule at bedtime for one month, diclofenac potassium 50 mg/ tablet twice daily after meals for one month and baclofen as a muscle relaxant 10mg twice daily for one month.12
Outcome measures
NIH-CPSI
Patients were monitored by NIH-CPSI before the start of therapy and one month after completion of the therapy, we used the Arabic version which previously republished by Elnashaar et al.13
Prostatic volume
Abdominal ultrasound was used in the current study to evaluate prostate volume before and after treatment and to assess if there is a relation between the volume of the prostate and treatment of CP/CPPS. Imaging of the prostate was performed in sagittal and axial views; volume should be measured with the machine settings using the length width and height. Abdominal ultrasound is an effective modality to evaluate prostatic enlargement 14. Ultrasound diagnostic system CMS180 CONEC with Sony video graphic printer up-895MD was used to determine prostatic volume in a cubic centimetre.
Statistical analysis
Descriptive statistics including the mean, standard deviation of post-treatment data (pain, Urinary symptom, quality of life, total score and Prostatic Volume) as compared to pre one. 3 x 2 mixed design Multivariate Analysis of Variance (MANOVA) was used to compare the therapeutic effect of ESWT, PEMF and Drug therapy on pain, Urinary symptom, quality of life, total score and Prostatic Volume in participants with chronic pelvic pain syndrome. The study included two independent variables. The first independent variable (between-subject factor) was the tested group with three levels: experimental group (A), experimental group (B), and control group (C). The second independent variable (within-subject factor) was the testing time with two levels: pre-testing and post-testing. The four dependent variables were pain, Urinary symptom, quality of life, total score and Prostatic Volume. All statistical measures were performed using SPSS version 23 for Windows. The level of significance for all statistical tests was set at p0.05) between the three groups regarding to demographic characteristics as shown in Table 1.
3× 2 mixed design MANOVA
Multivariate tests for outcome measures indicate a statistically significant effects for group (F= 13.645, p= 0.001, Partial η2= 0.505), time (F= 262.81, p= 0.001, Partial η2= 0.951, and group-by-time interaction (F= 22.671, p= 0.001, Partial η2= 0.629). Within-group analysis revealed a statistically significant reduction (p < 0.05) for pain, Urinary symptom, quality of life, total score and Prostatic Volume) in the three studied groups. Comparing the results among the three tested groups, it was revealed that there was a significant improvement (p < 0.05) in the post-testing mean values of pain, Urinary symptom, quality of life, total score and Prostatic Volume in the experimental group (A) and group (C) compared with the group (B). There was no significant difference in the post-testing mean values of all measured variables except ultrasound between the two experimental groups (A) and (A) as shown in Table (2).
Undesirable side effects
There were no side effects for the ESWT, PEMF groups but there were some side effects related to drug therapy in the form of dizziness, headache, postural hypotension and anejaculation.
DISCUSSION
Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a common yet poorly understood condition, with severe impact on QOL of diagnosed patients, especially on sexual function. 15 Various lines of treatments for CP/CPPS are available including ESWT,16 PEMF 17 and drug therapy 18 whether in single or multimodal therapy. The current study is the first study to compare the efficacy of ESWT, PEMF and drug therapy on CP/CPPS in a prospective method.
The use of ESWT to treat CP/CPPS has been reported previously.10,16 There are different mechanisms through which ESWT reduces pain. Mechanical effects include; stimulation, promotion of revascularization and enhancement of the healing process.19,20 Another chemical effect is explained by the release of endorphins locally and it's probable that "gate control phenomena" enter into the explanation for healing.19,20
Zimmermann et al. reported a significant statistical improvement in pain and QOL in the ESWT group. Urinary symptoms improved, but voiding symptoms were temporarily improved with no statistical significance.16 Similar results were obtained by Zeng et al.21 after a 12-week follow-up. Moayednia et al. reported that after a short-term follow-up, they found that ESWT was a safe and effective therapy for CPPS.22 Vahdatpur et al. showed an improvement in NIH-CPSI score including; pain, QOL, urinary score, but a slight deterioration of all variables occurred during the 12 weeks follow-up.22 On the contrary, Al Edwan et al.23 reported the long-term efficacy and safety of ESWT on CPP/CP, They showed significant statistical improvement in pain level, CPPS-related complaints, micturition and QOL with the maintenance of the effect without any significant side effects over the 12 months follow up with ESWT. In our study there was a highly significant decrease between pre and post values of shockwave group in NIH scale with a percentage of improvement for a total score of NIH-CPSI was 47.95%, this compares favourably with previous studies.
Yang et al. reported that Both electromagnetic stimulation and biofeedback applied to the pelvic floor muscle are effective for pain reduction, increased QoL, and improvement of lower urinary tract symptoms in male. Electromagnetic stimulation showed significant improvement in all items of the NIH-CPSI score except in urinary and quality of life score was a slight improvement after the treatment.24 Kim et al. conceded that extracorporeal Magnetic Stimulation offers a new treatment option for patients with CP/CPPS who do not respond to pharmacotherapy. Patients who received electromagnetic stimulation showed significant improvement in all items of the NIH-CPSI score except in urinary symptoms and QoL score.25 There was a signi?cantly improved pain and lower urinary tract symptoms in CP/CPPS patients who did not respond to medical treatments and more than 70% of patients were satis?ed with electromagnetic stimulation. These data suggest that electromagnetic stimulation could be considered as a safe and effective treatment option for CP/CPPS patients who do not respond to pharmacotherapy. Paick et al. concluded that magnetic therapy offers a new approach for pelvic floor stimulation that improves CP/CPPS.26 A longer follow-up is required to determine how long the benefits of treatment will last and whether retreatment will be necessary. In addition, the next step in future research will be to determine possible mechanisms of action of magnetic therapy and to identify factors influencing the outcomes.26
In our study there was a significant decrease between pre and post values of the PEMF group in the NIH scale (pain, urinary symptoms and improve quality of life) with a percentage of improvement for a total score of NIH-CPSI was 30.22%. Drug therapy for CP/CPPS is variable and includes, α-blocker, antibiotics, anti-inflammatory drugs and muscle relaxants. These could be used in single or multimodal therapy.27 In a double-blind study by nickel et al .including 272 patients with CP/CPPS. Alfuzosin 10mg/d and placebo showed a significant decrease in the NIH score in both groups.28 Tu?cu stated that Doxazosin 4mg/d has a significant effect in the treatment of chronic prostatitis, with a significant decrease in the NIH score in the Doxazosin group over placebo.29 Kim et al. concluded that based on most studies to date, although the mechanisms of improvement conferred by alpha-blockers have not been verified, both alpha-blocker monotherapy and antibiotic combination therapy showed considerable improvement in CP/CPPS patients (by NIH-CPSI scores).29 However, the current treatment strategies, including antibiotics, alpha-blockers, anti-inflammatory agents, and other medical agents, are not effective for all patients with CPPS.30 In our study there was a significant decrease between pre and post values of the Drug Therapy group in NIH-CPSI scale (pain, urinary symptoms and improve quality of life) with a percentage of improvement for a total score of NIH-CPSI was 36.93%. In the current study, we used unpaired tests to compare different groups including ESWT, PEMF and drug therapy. ESWT Showed the most significant effect between the other groups in the NIH-CPSI score.
They noted the feasibility of the prostate transabdominal dynamic contrast-enhanced ultrasound imaging, taking advantage of the lower ultrasound frequencies suitable for contrast-specific imaging. Time-intensity curves in 10 patients were successfully extracted and analyzed. Given the high incidence of prostate pathology, especially prostate cancer, and the evolving role of dynamic contrast-enhanced ultrasound imaging in its localization, the use of a transabdominal prostate approach may be a clinically useful option for patients to be selected for biopsy, active monitoring and treatment monitoring and follow-upm.31 Our current study is the first one at which we used abdominal ultrasonography to evaluate CP/CPPS and its symptoms through the prostate volume, we suggest that the tool of evaluation needs more research and studies to prove its quality to evaluate CP/CPPS. The current study has some limitations, including small number of cases, short follow-up time, use of abdominal us instead of transrectal us. In addition, many points supporting the study including prospective nature, it was a single centre study and it was the first study to compare ESWT, PEMF and Drug therapy.
CONCLUSION
ESWT is effective in treating non-inflammatory chronic pelvic pain syndrome in men as manifested by a decrease in prostate volume and NIH-CPSI. This study demonstrated that using the ESWT is beneficial in decreasing prostate volume, decreasing the NIH-CPSI and improving quality of life in patients with non-inflammatory chronic pelvic pain syndrome also PEMF and Drug therapy each of them has the efficacy to improve CPP/CP but lesser than the efficacy of ESWT.
Conflict of Interest: None
Source of Funding: None
Authors Contribution
Adel Abdelhamid Nossier (preparation of the research project, interpretation of data, preparation of the manuscript and development literature)
Mostafa Ahmed Abdelhameed (preparation of the research project, data collection, statistical analysis, interpretation of data, preparation of the manuscript, development literature and obtaining funds).
Ahmed Mohamed Zaky Anwar (preparation of the research project, preparation of the manuscript and development literature)
Haidy Nady Ashm (preparation of the research project, data collection, statistical analysis, interpretation of data and preparation of the manuscript)
Englishhttp://ijcrr.com/abstract.php?article_id=3717http://ijcrr.com/article_html.php?did=37171. Zimmermann R, Cumpanas A, Hoeltl L, Janetschek G, Stenzl A, et al. Extracorporeal shock-wave therapy for treating chronic pelvic pain syndrome. Br J Urol Int 2008;102(8):976–980.
2. Fall M, Baranowski AP, Elneil S, Engeler D. EAU guidelines on chronic pelvic pain. Europ Urol 2010;57(1):35-48.
3. Schaeffer AJ, Datta NS, Fowler JE. Overview summary statement. Diagnosis and management of chronic prostatitis/ chronic pelvic pain syndrome (CP/CPPS). Urology 2002;60(6):1-4.
4. Wagenlehner FM, Van Till JO, Magri V, Perletti G. National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) symptom evaluation in multinational cohorts of patients with chronic prostatitis/chronic pelvic pain syndrome. Eur Urol 2013;63(5):953-9.
5. Aboelnour NH, Ewais NF and Hamada HA. Focused versus radial extracorporeal shock wave therapy in post burn hypertrophic scar: A single blinded randomized controlled trial. Fizjoterapia Polska 2019;19(4): 150-155.
6. Kim YW, Shin JC, Yoon JG, Kim YK, et al. Usefulness of radial extracorporeal shock wave therapy for the spasticity of the subscapularis in patients with stroke: a pilot study. Chinese Med J 2013;126(24):4638-43.
7. Kim TH, Han DH, Cho WJ, Lee HS, et al. The efficacy of extracorporeal magnetic stimulation for treatment of chronic prostatitis/chronic pelvic pain syndrome patients who do not respond to pharmacotherapy. Urology 2013;82(4):894-8.
8. Khan A, Murphy AB. Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome. World J Pharmacol 2015;4(1):1-6.
9. Magistro G, Wagenlehner FM, Grabe M, Weidner W, et al. Contemporary management of chronic prostatitis/chronic pelvic pain syndrome. Eur Urol 2016;69(2):286-97.
10- Zhang ZX, Zhang D, Yu XT, Ma YW. Efficacy of radial extracorporeal shock wave therapy for chronic pelvic pain syndrome: A nonrandomized controlled trial. Am J Men's Health 2019;13(1):1557988318814663.
11. Rowe E, Smith C, Laverick L, Elkabir J. A prospective, randomized, placebo controlled, double-blind study of pelvic electromagnetic therapy for the treatment of chronic pelvic pain syndrome with 1 year of followup. J Urol 2005;173(6):2044-7.
12. Rayegani SM, Raeissadat SA, Taheri MS, Babaee M, et al. Does intra articular platelet rich plasma injection improve function, pain and quality of life in patients with osteoarthritis of the knee? A randomized clinical trial. Orthop Rev 2014;6(3).
13. El-Nashaar A, Fathy A, Zeedan A, Al-Ahwany A, et al. Validity and reliability of the arabic version of the National Institutes of Health Chronic Prostatitis Symptom Index. Urol Int 2006;77(3):227-31.
14. Manzoor T, Shahid K, Ibrahim M, Waris N. Role of abdominal ultrasound in evaluating patients with urinary retention due to benign prostatic hyperplasia. Biomedica 2016;32(2):101.
15. Zhao Z, Xuan X, Zhang J, He J. A prospective study on association of prostatic calcifications with sexual dysfunction in men with chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS). J Sexual Med 2014;11(10):2528-36.
16. Zimmermann R, Cumpanas A, Miclea F, Janetschek G. Extracorporeal shock wave therapy for the treatment of chronic pelvic pain syndrome in males: a randomised, double-blind, placebo-controlled study. Eur Urol 2009;56(3):418-24.
17. Kessler TM, Z'Brun S, Haeni K, Burkhard FC. Combined sono-electromagnetic therapy for treatment of refractory chronic pelvic pain syndrome: A new therapeutic possibility? Eur Urol Suppl 2008;7(3):159.
18. Nickel JC, Touma N. α-Blockers for the treatment of chronic prostatitis/chronic pelvic pain syndrome: an update on current clinical evidence. Rev Urol 2012;14(3-4):56.
19. Yan X, Yang G, Cheng L, Chen M, et al. Effect of extracorporeal shock wave therapy on diabetic chronic wound healing and its histological features. Chinese J Rep. Reconstr surgery. 2012;26(8):961.
20. Tassery F, Allaire T. Radial shock wave therapy for the treatment of lower limbs. FIBA Assist Mag 2003;3:57-8.
21. Zeng XY, Liang C, Ye ZQ. Extracorporeal shock wave treatment for non-inflammatory chronic pelvic pain syndrome: a prospective, randomized and sham-controlled study. Chinese Med J 2012;125(1):114-8.
22. Moayednia A, Haghdani S, Khosrawi S, Yousefi E, et al. Long-term effect of extracorporeal shock wave therapy on the treatment of chronic pelvic pain syndrome due to non bacterial prostatitis. J Res Med Sci 2014;19(4):293.
23. Al Edwan GM, Muheilan MM, Atta ON. Long term efficacy of extracorporeal shock wave therapy [ESWT] for treatment of refractory chronic abacterial prostatitis. Ann Med Sur 2017;14:12-7.
24. Yang MH, Huang YH, Lai YF, Zeng SW, et al. Comparing electromagnetic stimulation with electrostimulation plus biofeedback in treating male refractory chronic pelvic pain syndrome. Urol Sci 2017;28(3):156-61.
25. Kim W, Lee JS, Lee G, Cho W, et al. The efficacy of electromagnetic stimulation for treatment of chronic prostatitis/chronic pelvic pain syndrome patients who do not respond to pharmacotherapy. J Urol 2011;185(4S):e572-3.
26. Paick JS, Lee SC, Ku JH. More effects of extracorporeal magnetic innervation and terazosin therapy than terazosin therapy alone for non-inflammatory chronic pelvic pain syndrome: a pilot study. Prostate Can Prost Dis 2006;9(3):261-5.
27. Khan A, Murphy AB. Updates on therapies for chronic prostatitis/chronic pelvic pain syndrome. World J Pharmacol 2015;4(1):1-6.
28. Nickel JC, Downey JA, Nickel KR, Clark JM. Prostatitis?like symptoms: one year later. BJU Int 2002;90(7):678-81.
29. Tu?cu V, Ta?ç? A?, Fazl?o?lu A, Gürbüz G. A placebo-controlled comparison of the efficiency of triple-and monotherapy in category III B chronic pelvic pain syndrome (CPPS). Eur Urol 2007;51(4):1113-8.
30. Thakkinstian A, Attia J, Anothaisintawee T, Nickel JC. α?blockers, antibiotics and anti?inflammatories have a role in the management of chronic prostatitis/chronic pelvic pain syndrome. BJU Int 2012;110(7):1014-22.
31. Mischi M, Demi L, Smeenge M, Kuenen MP. Transabdominal contrast-enhanced ultrasound imaging of the prostate. Ultrason Med Bio 2015;41(4):1112-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareOcular Camouflage Adoption for an Anophthalmic Anthrophobic Patient
English1115Vini RajeevEnglish Ajay JainEnglish Rajeev ArunachalamEnglish Sridevi UgrappaEnglishEnglishAnophthalmic socket, Artificial eye, Custom eye prosthesis, Enucleation, Ocular prosthesis, Scleral shellINTRODUCTION
An anophthalmic socket is most undesirable and might affect the psychosocial aspects of the affected individual. Such individuals face emotional and behavioural changes and their quality of life will be affected if they remain with their compromised facial integrity. An ideal ocular prosthesis that imitates a natural eye can make an individual improve their social relationships and can bring back a stress-free environment thereby advancing the quality of life. The relic of an ocular prosthesis dates back to as early as 2800 years ago and the sixteenth century made a dramatic change with the introduction of ocular prosthesis made of metals like copper, bronze, and gold in the contracted anophthalmic socket. The fabrication of ‘Hypoblepharae’ by Ambrose Pare in the sixteenth century changed the future and quality of life of those suffering from loss of an eye. The attempts of the pioneer in ocular prosthesis started with gold and silver, but he later improved the design using glass and porcelain, which set a zenith in the field of maxillofacial prosthodontics.1 Glassprosthesis, was the popular material from the 17th century until the introduction of synthetic materials in the twentieth century. Currently, ocular prostheses can be fabricated using cryolite glass and acrylic resin. The silicone material also plays a major role in the rehabilitation of orbital prosthesis to cover the deformations in the periorbital facial region.2 Most recently, the prominence of computer-aided design and computer-aided manufacturing and rapid prototyping has activated the era of high-speed prosthodontics thereby promoting the fabrication of 3D printed customized prostheses.
Ocular defects can be congenital or acquired. Acquired ocular defect ensue by three types of surgery (a) Evisceration, the removal of the internal content of ocular bulb keeping the bulb in the orbit (b) Enucleation, the removal of whole ocular bulb keeping the adjacent structures in the orbit; and (c) Exenteration, the removal of the whole content, eyelid, and posterior coverage of epidermal tissue with a graft. These defects should be considered for rehabilitation to improve the esthetic appearance and functional requirements that include preventing eyelid deformation, maintaining adequate width of the orbital fissure, protecting the cavity and orienting the lacrimal flux thereby avoiding its accumulation.2
Modugno et al. in their research among 8018 ocular prosthesis wearers, found that 63% were males and 37% were females, with a mean age of 29 years. The main cause of ocular prosthesis application was a traumatic event (54%). Based on the above study, there was no significant difference in gender on other most common causes for ocular rehabilitation which
includes end-stage ocular diseases, tumours, and congenital malformations.3 Based on another research conducted in the southern zone of India on 118 individuals over 5 years, 66% of the male population had ocular defects. Trauma (46%) and pathogenic (44%) causes were the main reasons over nonspecific (8%) and congenital (2%) reasons.4 Goiato et al. stated that ocular prosthesis causes a positive influence on the patients’ socio-psychological status.5
CASE REPORT
A 20-year-old female patient reported to the Faculty of Dentistry, AIMST University for the rehabilitation of her anophthalmic socket. Her medical history revealed enucleation of the left eye due to retinoblastoma at the age of 3 years. The patient used a conformer immediately after surgery and discontinued its use within two weeks due to discomfort. The patient started wearing a stock ocular prosthesis only seven years after the surgery which has led to the reduction in the space of the palpebral fissure. The lack of space resulted in poor retention of the prosthesis thereby causing frequent displacement of the prosthesis. Overall, the patient was dissatisfied with the esthetics and the fit of the prosthesis. This case report aims to display the fabrication processes of an ocular prosthesis which improved the confidence and attitude of a twenty-year-old university student.
Patient evaluation
The patient has changed her prefabricated ocular prosthesis multiple times and the current prosthesis was being used for 1 year. Examination of the socket revealed no signs of inflammation. The patient’s stock eye did not correspond with the pupil position of the right eye (Figure 1). Preoperative evaluation of the socket was performed and the patient was explained about the possible limitations of the treatment.
Observations during clinical examination:
Evaluation of the muscular control of the palpebra was performed and was observed as minimal compared to the right eye. The movement was better during opening and closing compared to lateral movements.
The palpebral fissure dimension was reduced. Internal anatomy of the socket in a resting position and during full excursive movements of the eye musculature revealed a lack of depth for the eye bed increasing the challenge of placement of the prosthesis. The surgical scar tissue at the outer canthus of the left eye made the area very shallow compromising in retention of the prosthesis. The anatomy near the medial canthus was the only favourable area for retention of the prosthesis.
Mobility of the posterior wall of the defect during the movement of the intact eye was absently necessitating the use of spectacles to mask the discrepancy during lateral movement
Impression
The ophthalmic socket was recorded using light body addition silicone impression material (Aquasil Ultra LV, Dentsply). A modified impression technique adapted from the concepts of Allen and Webster was used for this patient.6 The patient’s previous custom made acrylic conformer was modified with wax and duplicated using acrylic resin to use as an impression tray. The conformer was perforated to a 5 mm diameter hole at the approximate location of the pupil. Multiple minute perforations were made over the remaining surface. An acrylic hollow cylinder of 5mm diameter and 5mm length was fabricated and attached to the tray (Figure 2a). The tray was inserted into the socket and the mixing tip for addition silicone was inserted into the cylinder and the impression material was dispensed through it till it filled the socket and excess material flown out through the additional holes. The patient was seated erect gazing at a spot in front until the impression procedure was completed to ensure the recording of the approximate position of the eye and the muscles (Figure 2b).
Fabrication of working cast
After the setting of the impression material, the tray was removed from the socket. A two-piece Type IV Die stone cast was poured using a plastic dish and the lower part of the impression was immersed initially. Once the die stone was set, the separating medium was applied to the surface. Index notches were prepared on all four sides for reorientation and the second layer was then poured (Figure 2c).
Fabrication and try-in of the sclera wax pattern
Molten modelling wax was poured into the aligned two-piece cast. The wax pattern was contoured and carved to fit into the anophthalmic socket. Try-in of the wax pattern was done to check for the retention and support, size, unobstructed eye movement, and eyelid competency while closing.
Positioning of Iris on the scleral pattern
The custom iris disc with the stalk was fabricated using a metal mould and clear acrylic. The patient was instructed to fix the gaze to an object kept 3 feet in front and at eye level. Digital vernier calliper measured 11.11 mm as the diameter of the right iris. The fabricated iris disc was trimmed 0.5 mm less than the right iris to accommodate the limbus at the final stage of iris painting. The position of the iris of the natural eye about the outer canthus, inner canthus and facial midline was transferred to the left side for the positioning of the left iris. The position of the iris about upper and lower lids was also measured and transferred to the affected side using the calliper (Figure 3).
Iris disc painting and attaching of iris lens
Iris painting was performed using oil paints (Camel Artists’Oil Colour). The iris painting was done in five steps to simulate the pupil, the limbus, the collarette, the stroma and the individual striations. The black base colour was given to the iris according to the hue of the natural iris. The pupil was painted first in the centre of the iris disk. Additional colour like flake white, titanium blue, yellow ochre and burnt sienna was used to create the remaining features within the iris. Very fine striations were produced on the disc using a camel hairbrush. The paints mixed with oil were more intense than the colour of the natural iris to avoid fading after processing. The colour was compared with the natural iris by applying a droplet of water to the centre of the disc. The water allows the iris characterization to be viewed as it will appear within the iris-corneal assembly. Once the colour matching was perfect, the prefabricated iris button was attached to the corneal disc using Monopoly syrup and one drop of cyanoacrylate. The stalk of the iris disc was trimmed off and the assembly was attached to the wax pattern for further verification.
Acrylisation and characterization of sclera
Final try in of wax pattern with the iris-lens assembly was performed. The esthetics and function were compared to the right eye. The patient was advised to perform the eye movements in all direction (Figure 4a-f). On confirmation of the effectiveness of the wax pattern, it was flasked and packing was performed using A2 shade heat cure acrylic resin for obtaining the sclera. A short curing cycle was carried out. After acrylisation, 1 mm of the scleral acrylic was reduced to aid for further characterization.
Oil paints of cobalt blue, yellow ochre and burnt sienna were used for colouring. Red cotton fibres resembling nerves were attached using monopoly syrup for enhancing the natural appearance of the prosthesis in comparison with the right eye. The characterization on the outer layer was secured by acrylising the remaining 1mm space with clear heat cure acrylic(Figure 5). The final trimming and polishing were done and the prosthesis was inserted (Figure 6a-b).
Post insertion instructions
The patient was demonstrated on the method of insertion and removal and was advised to remove it every night. The patient was advised to clean the prosthesis once every month using a mild soap solution without alcohol content to clean it. Use of eye lubricant solution was also advised to avoid drying of the eye bed and clearing of discharges inside the socket. The patient was asked to return to the operatory for further trimming and polishing if she experiences any pain while using the prosthesis.
DISCUSSION
Anthropophobia, a major concern for individuals with surgical ocular defects can be treated with an ocular prosthesis, an artificial replacement of the bulb of the eye. A multidisciplinary approach involving ophthalmologist, oral and maxillofacial surgeon, plastic surgeon, and maxillofacial prosthodontist is essential to impart successful rehabilitation and maintenance care to restore the patient's quality of life.
Various techniques in the fabrication of ocular prosthesis have been discussed in the literature. Ocularists and prosthodontist always attempt newer impression and processing techniques required in the fabrication of eye prosthesis.7-10 As a result, prefabricated and custom made ocular prosthesis are in demand. Implant-supported ocular prosthesis is also in call nowadays. Even though ocular implant enhances the coordinated movement of the affected eye to an extent, due to the associated economic factors; many individuals have to decline the option. This situation favours the benefit of custom made ocular prosthesis which superior in esthetic and functional outcome in comparison with prefabricated prosthesis.
The expertise of an operator in providing a better quality of life for a patient with the enucleated eye can be enhanced by empirically fitting a prefabricated eye, modifying a stock eye by making an impression of the ocular defect or by providing a custom made eye prosthesis to fill the socket. Based on the studies by Beumer et al., the ocular prosthesis should remain in contact with the tissue bed thereby distributing the pressure within the socket evenly.11 Use of a prefabricated prosthesis can compromise on this requirement and hence should be avoided to the maximum. The socket constantly produces mucus and secretions and the prosthesis to an extent should be able to self-cleanse these secretions. The unfitted areas of the prefabricated prosthesis can act as stagnation zones thereby irritating the mucosa and emerge as a potential source of infection.11,12 Considering the condition of the socket, poor fit of the existing stock eye and potential side effects of the prefabricated prosthesis, a custom ocular prosthesis was suggested for this patient.
The brilliance of an eye prosthetist is revealed in the characterization of the iris. This determines the esthetic acceptance of prosthesis by the patient and the society. Various techniques can be adapted for iris colouring, selection and positioning.13Various techniques in iris characterization has been discussed in the literature.14,15 Prefabricated iris discs can be selected and modified, painting of custom made iris discs can be done or even digital imaging and printing of iris can also be done. In this case, painting of the iris has been performed using oil paints.
Based on the studies conducted by Fernandes, all paints underwent exhibited ageing whereas; oil paint had the highest resistance to accelerated aging.16 Hence, oil paints were used for the characterization in this case. The monopoly syrup attributed to better handling and fixing of colours. Red cotton fibres concluded the final characteristic feature of the sclera.
Post insertion care plays a major role in maintaining a flawless prosthesis. The prosthesis should be cleaned whenever there is clogging of precipitate inside the socket. This ensures the removal of discharges and enabled the conjunctiva to increase lubrication. This can be done every month or a period not exceeding six months. Constant removal was contraindicated as it can cause mechanical irritation due to the friction produced during removal. Cleaning of fingers is recommended to avoid the incorporation of external dust and bacterial load on to the prosthesis. The prosthesis should be stored in water or contact lens solution after removal. In general, the prosthesis should be kept in a socket as long as it is comfortable.17 Use of spectacles will protect the natural eye and the artificial eye from external irritants.
CONCLUSION
The custom ocular prosthesis in this case was alluring and ensured maximum functionality within the anatomic limitations of the anophthalmic socket. It could exhibit various eye movements and could retain the shape of the defective socket to an extent by preventing ptosis. It could simulate the palpebral opening almost similar to the natural eye. The gaze and the colour mimicked her right eye and this artistic and innovative approach has boosted her confidence and was socio-psychologically uplifted.
Acknowledgement: Authors acknowledge Ms See Gaik Lan for her contribution to the laboratory procedures involved and also AIMST University, Faculty of Dentistry for providing the facilities.
Source of Funding: Self-Funded
Conflict of Interest: NIL
Authors’ Contribution: Dr. Vini Rajeev - Clinical procedures and manuscript preparation
Dr. Ajay Jain - Clinical Procedures
Dr. Rajeev Arunachalam – Manuscript editing
Dr. Sridevi Ugrappa – Manuscript editing
Figurelegends
Fig.1a – Preoperative view
Fig. 2a- custom impression tray
Fig. 2b – Ocular impression
Fig. 2c – two pieces split cast for wax pattern fabrication
Fig. 3 – Evaluating the iris position
Fig. 4a-4f – Evaluating the ocular movement with a wax pattern
Fig. 5 – Final acrylisation of the prosthesis
Fig. 6a – Anophthalmic socket
Fig. 6b – Post operative view
Englishhttp://ijcrr.com/abstract.php?article_id=3718http://ijcrr.com/article_html.php?did=3718
Martin O, Clodius L. The history of the artificial eye. Ann Plast Surg 1979;3(2):168-71.
Goiato MC, de Caxias FP, Santos DM. Quality of life living with ocular prosthesis. Expert Rev Ophthalm 2018;13(4):187-189.
Modugno A, Mantelli F, Sposato S, Moretti C, Lambiase A, Bonini S. Ocular prostheses in the last century: a retrospective analysis of 8018 patients. Eye (Lond) 2013;27(7):865–870.
Raj N, Singh M, Raj V, Anwar M, Kumar L. Prevalence of ocular defects among patients visiting in an institutionalized hospital setting: A cross-sectional study. Natl J Maxillofac Surg 2016;7(1):67–70.
Goiato MC, dos Santos DM, Bannwart LC, et al. Psychosocial impact on anophthalmic patients wearing an ocular prosthesis. Int J Oral Maxillofac Surg 2013;42(1):113–119.
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Laney WR, Gardner AF. Maxillofacial prosthetics. PSG Publishing Company, Littleton, Massachusetts; 1979.
Ow R, Amrith S. Ocular prosthetics: Use of a tissue conditioner material to modify a stock ocular prosthesis. J Prosthet Dent 1997;78:218-22.
Beumer J, Curtis TA, Firtell DN. Maxillofacial rehabilitation: Prosthodontic and surgical consideration. CV Mosby Co, St. Louis; 1979.
Pathak C, Pawah S, Singh G, et al. Prosthetic rehabilitation of completely blind subject with bilateral customised ocular prosthesis: a case report. J Clin Diagn Res 2017;11(1):ZD06–ZD08.
Taicher S, Steinberg HM, Tubiana I, et al. Modified stock eye ocular prosthesis. J Prosthet Dent 1985;54(1):95-98.
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Gupta L, Aparna IN, Dhanasekar B, Prabhu N, Malla N, Agarwal P. Three?Dimensional Orientation of Iris in an Ocular Prosthesis Using a Customized Scale. J Prosthod 2014;23(3):252-255.
Fernandes AU, Goiato MC, Batista MA, Santos DM. Colour alteration of the paint used for iris painting in ocular prostheses. Braz Oral Res 2009;23:386-92.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareVaginal Vault Prolapse after Total Hysterectomy in Obese Women
English1620Dilshod A. ShomirovEnglish Rustem B. Yusupbaev*English Mehriban DauletovaEnglishntroduction: Total hysterectomy is one of the most common surgical interventions in gynaecology, the frequency of which varies from 30% to 60%, according to various authors. Moreover, the number of performed extirpation of the uterus has been steadily growing every year. The most common indications for uterine extirpation are uterine fibroids, abnormal uterine bleeding that cannot be treated conservatively, as well as cervical and endometrial cancer. Objective: Developing effective methods of surgical prevention and correction of vaginal vault prolapse in obese women undergoing a total hysterectomy Methods: This article describes an individual approach to the prevention of vaginal vault prolapse after total hysterectomy in obese women. The article discusses the features of total hysterectomy in 121 patients with obesity. The author compares 2 surgical tactics for the prevention of apical prolapse after a total hysterectomy. Results: Long-term results were studied from 2 months to 2 years; the majority of women who operated on the improved technology were satisfied with the results of operations. Everyone noted an improvement in the quality of life related to health. Conclusion: The proposed parameters of the method allow achieving the set technical result: reducing the risk of early and late postoperative development in hospitals of any level.
EnglishTotal hysterectomy, Obesity, Uterine fibroids, ProlapseINTRODUCTION
Genital prolapse is a multi-factorial disease, which necessitates the reasonable choice of a standardized treatment method, on the one hand, and an individual method of surgical correction, on the other hand, for each patient. Vaginal vault prolapse after total hysterectomy is a condition in which the vaginal vault, the bladder, and the anterior wall of the rectum form hernial bulging into the vaginal canal, extending beyond vaginal opening at the later stages of the postoperative period.1,7 This condition is not only a medical but also a serious socio-economic and psychological problem that significantly reduces the quality of life of a woman. The significant proportion of vaginal vault prolapse among gynaecological nosology in departments of operative gynaecology, even in highly specialized hospitals, is 19.9-49.6%.2,7,9
Only a comprehensive approach will improve the results of surgical treatment of patients with genital prolapse, reduce the frequency of relapses of this disease and the risk of immediate and long-term adverse results of surgery.6,7 The problem is compounded by the fact that almost 2/3 of women with this complication are obese women, who have several technical difficulties during the total hysterectomy due to the pronounced fat layer.2 However, the tendency towards obesity among women has been increasing recently. For example, in the United States, the frequency of hysterectomies among laparotomic (abdominal) gynaecological operations is 36%, in Russia from 32.5% to 38.3%, in Sweden 38%, in the UK-25%.3,4
Vaginal vault prolapse, as a rule, is accompanied by various unpleasant symptoms that cause a woman to experience severe discomfort. Often this process is accompanied by severe pain, urine retention or, conversely, urinary incontinence, frequent urination, problems with defecation.3,8,5 With complete vaginal prolapse after hysterectomy, the mucous membrane of its walls is subject to severe injuries, which leads to the development of infectious diseases, abscess, and even tissue death.5, 9, 12 Existing methods of surgery do not always radically eliminate the pathology, which makes it necessary to develop new methods of surgery.
In the present study we aimed to develop effective methods of surgical prevention and correction of vaginal vault prolapse in obese women who have undergone total hysterectomy.
MATERIALS AND METHODS:
The study group consisted of 141 women with uterine fibroids more than 12 weeks and obesity that underwent total hysterectomy with abdominal access. At the first stage, there was a comprehensive clinical and laboratory examination of all patients who were admitted for planned surgical treatment for uterine fibroids and with obesity in the Republican specialized scientific-practical medical centre of obstetrics and gynaecology.
Indications for the operation were determined by a diagnosis made based on a comprehensive clinical laboratory examination. In this study the following research methods were used: clinical (interview, examination, gynaecological status), laboratory (examination of general blood and hematocrit before surgery and during the second day after the surgery) and special (examination of the blood clotting sequence). The cultures of the cervical canal, vagina, and urethra were examined.
Patients in the hospital underwent additional examinations, which included ultrasound (trans-vaginal and abdominal access), Doppler study, computed tomography (CT scan), magnetic resonance imaging (MRI), etc.
RESULTS
Taking into account the method of surgical intervention, all the patients were divided into 2 groups. The main group of 87 women who underwent total hysterectomy operations with laparotomic access using advanced technology attaching the ligamentous apparatus to the vaginal vault, in which the top of the vagina was left open during the operation. The control group consisted of 54 patients who underwent total hysterectomies with laparotomic access using the traditional method. All operations were performed for the purpose of surgical treatment of uterine fibroids more than 12 weeks.
The subjects of both groups were comparable in terms of socio-biological characteristics and severity of the disease. The study groups included patients with obesity and uterine fibroids more than 12 weeks requiring surgical treatment, aged 45 to 52 years, with an average age of 49.4±1.78 years. The decision on the scope of surgical treatment was made individually in each case.
87 operations were performed (the main group) - total hysterectomy with laparotomic access using advanced technology. The essence of the method is to apply a direct clamp simultaneously with the capture of the Sacro-uterine ligaments, cardinal ligaments and vascular bundle at an angle of 45 degrees concerning the conductive axis of the uterus body, which makes it possible to combine the stages of surgery, thereby shortening its duration, reducing the volume of blood loss. Subsequent fixation of Sacro-uterine, cardinal, circular ligaments with the sidewalls of the vagina on each side and simultaneous application of a twisted suture on the front and back walls of vaginal vault is performed with a single thread. Moreover, the beginning of the suture begins with ligation of the vascular bundle on one side, followed by the capture of the cardinal, Sacro-uterine ligaments and the transition to the back wall of the vaginal vault (the beginning of the needle injection into the vaginal vault begins from inside to outside, i.e. from the vaginal mucosa). The opposite side is sewn in reverse order. After ligation of the vascular bundle, it is necessary to fix the circular ligament with the transition to the anterior wall of the vaginal vault (performed by a similar technique). It is necessary to finish the suture by fixing the circular ligament on the opposite side.
Thus, the proposed improved technique of total hysterectomy operation with abdominal access prevents vaginal vault prolapse in obese women. Because when suture is fixed, the size of the Douglass space decreases due to its stretching and lifting, which prevents the further formation of enterocele in obese women. This method preserves the physiological horizontal axis of the vagina in relation to the levators (levatoris ani externa), due to this, sexual function is not disturbed.
The duration of total hysterectomy surgery using advanced technology varied from 45 to 75 minutes, with an average of 52.5+1.5 minutes.
With the traditional method of abdominal total hysterectomy, the duration of the operation varied from 90 to 110 minutes, 98.6 ±5.6 minutes, (pEnglishhttp://ijcrr.com/abstract.php?article_id=3719http://ijcrr.com/article_html.php?did=37191. Korshunov MY. Effectiveness of vaginal hysterectomy with the high suspension of the vaginal dome to the Sacro-uterine ligaments in the treatment of pelvic organ prolapse in women: scientific publication. Russian Bull Obstetri Gynec 2015;13(2):61-65.
2. Navruzov BS. Diagnostics of rectocele in pelvic organ prolapse in women: scientific publication. Bull Ass Phys Uzbekis 2014; 1:45-47.
3. Gasparov AS, Dubinskaya ED, Babicheva IA, Lapteva NV. Role of connective tissue dysplasia in obstetric and gynaecological practice. Kazan Med J 2014;95(6):897-904.
4. Dovlatov ZA, Dovlatov ZA. Mesh implants in the treatment of pelvic organ prolapse in women: complications and ways to prevent them. Mod Probl Sci Edu 2015;5:351.
5. Plekhanov AN, Strezelecki VV. minimally Invasive approaches in the surgical treatment of patients with uterine fibroids larger sizes. Moscow Surg J 2008;2(2):11-17.
6. Puchkov KV, Ivanov VV, Bakov VS, Usachev IA. Optimization of the technique of surgical treatment of pelvic prolapse. minimally Invasive technologies in surgery: materials Mezhregion. scientific-practical conf. Makhachkala 2005;12:159-160.
7. Fedorov AA. Influence of hysterectomy on the anatomical and functional state of the urinary system. Abstract. Diss. for the Degree of Doctor of Science 2005;5:8-16.
8. Shalaev ON, Radzinsky VE, Plaksina ND, Salimova LY. Fixation of the vagina to the Sacro-spinous ligament as prevention of recurrent genital prolapse. Bulletin of the Peoples' Friendship University of Russia, Moscow. 2017;7:17-18.
9. Ghetti C. Pelvic organ descent and symptoms of pelvic floor disorders. Am J Obstet Gynecol 2018;7:53-57.
10. Gasparov AS, Babicheva IA, Dubinskaya ED, Lapteva NV, Dorfman MF. Surgical treatment of pelvic organ prolapse. Kazan Med J 2014;95(3):341-347.
11. Mgeliashvili MV, Buyanova SN, Marchenko TB, Rizhinashvili ID. Experience in the use of synthetic prostheses for the treatment of severe forms of genital prolapse in elderly women. Almanac of Clin Med 2015;37:118-122.
12. Moroz NV. Ultrasound in the assessment of the pelvic floor. Obstet Gynec 2015;14(2):31-37.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareA Rare Case of Extra Hepatic Portal Hypertension as a Consequence of Chronic Pancreatitis
English2123Chamoli AnkitEnglish Singh NavtejEnglish TarunEnglishBackground: Chronic pancreatitis is a rare cause of portal hypertension. As hepatic pathology mostly contributes to the same. Extrahepatic portal hypertension followed by pancreatitis is a rare condition with most patients being asymptomatic. Objective: This paper aims to present clinical presentation, diagnosis and management of extrahepatic portal hypertension because of chronic pancreatitis. Case Study: A 40-year-old male presented with chief complaints of pain epigastrium and nausea from past 3-4 days which was sudden in onset, progressive in nature, severe in intensity radiating to the back, aggravating on taking food, relieved on leaning forwards and associated with nausea. Results: Clinical features, radiological and other investigations suggested rare diagnosis. Conclusion: Extrahepatic portal hypertension is an important cause of the upper gastrointestinal bleed. Pancreatic aetiology should be considered and most of the times it asymptomatic.
English Chronic pancreatitis, Extrahepatic portal hypertension, Gastric varices, SplenomegalyIntroduction
Extrahepatic portal hypertension is a rare cause of gastrointestinal bleeding which is characterized by splenomegaly, isolated gastric varices and normal liver condition.1 Sixty percent of the cases of extrahepatic portal hypertension are caused by pancreatitis specifically chronic pancreatitis accompanied by splenic venous thrombosis.2 Isolated gastric varices occur as a result of thrombosis or obstruction of the splenic vein leading to back pressure changes in the left portal system. The primary pathology manually arises in the pancreas, common etiologies being pancreatitis and pancreatic neoplasm.3 However not all patients with extrahepatic portal hypertension would experience bleeding complications. Agrawal et al reported that 22 percent of patients having chronic pancreatitis had imaging evidence of splenic vein thrombosis, only 15% of those had gastrointestinal bleeding.4 More evidence suggests watchful waiting as acceptable course of management in asymptomatic individuals.5
Case presentation
A 40-year-old male presented with chief complaints of pain epigastrium and nausea from the past 3-4 days which was sudden in onset, progressive in nature, severe in intensity radiating to the back, aggravating on taking food, relieved on leaning forwards and associated with nausea. The patient was known case of diabetes mellitus for six months. The patient had a history of a similar episode eight months ago. Routine investigations were done along with serum amylase levels. The patient was a chronic alcoholic and smoker and quit alcohol after the first episode. There was no history of fever, loose stools or vomiting. On general examination, the patient’s vitals were stable and he was afebrile. On Per abdomen, findings revealed tenderness in the epigastric region with guarding present. Rest of the examination was normal with no signs of peritonitis or ascites. Air entry was bilaterally equal with chest X-Ray showing no signs of pleural effusion. The patient was kept nil per oral, put on intravenous proton pump inhibitors, fluids and analgesics. The blood sugar level monitoring was done intensively and managed accordingly. All routine investigations were within the normal limits including LFT and serum amylase levels. Lipid profile and serum calcium levels were also normal. A contrast-enhanced CT scan of the abdomen was suggestive of chronic pancreatitis with portal hypertension with perigastric varices. USG abdomen was done to rule out liver cirrhosis and cholelithiasis. On ultrasonography, echotexture and size of liver were normal with no evidence of gall bladder and common bile duct stones.
USG colour doppler of the splenic vein was done with no evidence of splenic vein thrombosis. Hence, the diagnosis of extrahepatic portal hypertension as a complication of chronic pancreatitis was made. Upper gastrointestinal endoscopy was done for variceal status, which revealed no oesophagal varices and no actively bleeding perigastric varices. The patient was started on non-selective beta-blockers. The patient was managed conservatively. The patient improved symptomatically with no complications to date and he is on regular follow up.
Results
The investigations were as follows- Hb = 12.7gm/dl, TLC = 9000/ml, Platelet count= 2 lacs/ml, serum amylase = 47 U/l, serum creatinine = 1.0 g/dl, SGPT = 45U/l, SGOT= 30U/l, serum calcium= 9.2, lipid profile was within normal limits. Arterial blood gas analysis revealed pH= 7.41, HCO3¯ =25mEq/lt, pCO2 = 39mm of Hg, pO2 = 90mm of Hg.
Discussion
Extrahepatic portal hypertension (EPH) is defined as hypertension of the extrahepatic component of the portal venous system which does not result due to liver cirrhosis.6 Initially, this entity had been thought to be restricted solely to the splenic vein, so that in the past it has been referred to as segmental, left-sided, regional, localized, splenoportal, sinistral, compartmental, or lienal hypertension.7
It represents a lesser common complication of chronic pancreatitis and involves either the individual superior mesenteric or splenic venous branch or may involve the whole splenomesentericoportal axis. The latter possibility appears less likely as in most cases of extrahepatic portal hypertension complicating pancreatitis the splenic vein alone is involved because of its proximity to the pancreas.8 As this condition was observed with increasing frequency, it became apparent that every part of the splenomesentericoportal venous axis may be involved.9 The most probable cause seems to be the progressive fibrosis characteristic of chronic pancreatitis, leading to progressive constriction of the splenomesentericoportal axis that passes through the pancreatic substance.10 The pathology of EPH is characterized by two major forms; a complete occlusion of branches of the venous splanchnic system (occlusive form) 11 or a subtotal obstruction of one or more of these branches (non-occlusive form).12
Greenwald and Wash in 1939 were the first to present a case of left-sided portal hypertension occurring due to splenic vein obstruction (thrombosis or from outside pressure).13 Due to the occlusion of the splenic vein, the blood from the spleen having no other outflow tract flows into the vasa brevia and other collaterals of splenic and pancreatic circulation. Gastric or oesophagal varices may then develop from the resulting increased left-sided splanchnic pressures. Extrahepatic portal hypertension is a rare clinical syndrome characterized by splenomegaly, isolated gastric varices that may bleed, and normal liver condition.14 Pancreatic disease is the most common aetiology. Extrahepatic portal hypertension may complicate chronic pancreatitis as a result of splenic vein thrombosis/obstruction.15 Gastrointestinal bleeding with normal liver function and unexplained splenomegaly should raise suspicion for extrahepatic portal hypertension.15
Splenectomy is the preferred treatment modality for symptomatic extrahepatic portal hypertension. In symptomatic patients of chronic pancreatitis undergoing operative treatments, concomitant splenectomy should be strongly considered if extrahepatic portal hypertension and gastroesophageal varices are also present.16 However, just the presence of extrahepatic portal hypertension does not warrant intervention. Expectant management is justifiable in asymptomatic patients with pancreatitis.17 In most cases, the varices are formed in the fundus of the stomach, while sometimes severe gastrointestinal bleeding may occur due to rupture of oesophagal varices. Extrahepatic portal hypertension is commonly an incidental finding seen in diagnostic imaging for other conditions due to its asymptomatic presentation.18
Conclusion
Extrahepatic portal hypertension is an important cause of life-threatening upper gastrointestinal bleeding. Primary pancreatic pathology should be considered in patients with isolated gastric varices, splenomegaly with the normal status of the liver. Most of the cases are asymptomatic. Splenectomy is the appropriate management option when it is associated with major upper gastrointestinal bleeding. Extrahepatic portal hypertension occurs when a pathological process causes occlusion of the splenic vein. Extrahepatic portal hypertension followed by chronic pancreatitis is a rare condition, which is usually asymptomatic.
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
Englishhttp://ijcrr.com/abstract.php?article_id=3720http://ijcrr.com/article_html.php?did=3720
Khanna R, Sarin SK. Idiopathic portal hypertension and extrahepatic portal venous obstruction. Hepatol Int 2018; 12, 148–167.
Li ZY, Li B, Wu YL, Xie QP. Acute pancreatitis associated left-sided portal hypertension with severe gastrointestinal bleeding treated by transcatheter splenic artery embolization: a case report and literature review. J Zhejiang Univ Sci B 2013;14(6):549-554.
Thompson RJ, Taylor MA, McKie LD, Diamond T. Sinistral portal hypertension. Ulster Med J 2006 Sep;75(3):175-7.
Agarwal AK, Raj Kumar K, Agarwal S, Singh S. Significance of splenic vein thrombosis in chronic pancreatitis. Am J Surg 2008;196(2):149-54.
Heider TR, Azeem S, Galanko JA, Behrns KE. The natural history of pancreatitis-induced splenic vein thrombosis. Ann Surg 2004;239(6):876-82.
Longstreth GF, Newcomer AD, Green PA. Extrahepatic portal hypertension caused by chronic pancreatitis. Ann Intern Med 1971;75:903–908.
Malka D, Hammel P, Levy P, Sauvnet A, Ruszniewski P, et al. Splenic complications in chronic pancreatitis: prevalence and risk factors in a medical-surgical series of 500 patients. Br J Surg 1998;85:1645–1649.
Madsen MS, Petersen TH, Sommer H. Segmental portal hypertension. Ann Surg 1986; 204: 72-7.
Ribet M, Quandalle P, L’HermineC,Wurtz A, Latreille JP. Superior mesenteric venous hypertension in chronic pancreatitis. Chirur. 1971; 97: 273–282.
Izbicki JR, Yekebas EF, Strate T, Eisenberger CF, Hosch SB, et al. Extrahepatic portal hypertension in chronic pancreatitis: an old problem revisited. Ann Surg 2002;236(1):82-89.
Warshaw AL, Jin GL, Ottinger LW. Recognition and clinical implications of mesenteric and portal vein obstruction in chronic pancreatitis. Arch Surg 1987;122: 410–415.
Bloechle C, Busch C, Tesch C, Nicolas V, Binmoeller KF, et al. Prospective randomized study of drainage and resection on non-occlusive segmental portal hypertension in chronic pancreatitis. Br J Surg 1997;84:477–482.
Greenwald HM, Wasch MG. The roentgenology demonstration of oesophagal varices as a diagnostic aid in chronic obstruction of the splenic vein. J Pediatr 1939;14:57-65.
Madsen MS, Petersen TH, Sommer H. Segmental portal hypertension. Ann Surg 1986; 204:72–77.
Sakorafas GH, Sarr MG, Farley DR, Farnell MB. The significance of sinistral portal hypertension complicating chronic pancreatitis. Am J Surg 2000;179(2):129-133.
Köklü S, Coban S, Yüksel O, Arhan M. Left-sided portal hypertension. Dig Dis Sci. 2007;52(5):1141-1149.
Singhal D, Kakodkar R, Soin AS, Gupta S, Nundy S. Sinistral portal hypertension. A case report. Bri J Surg 2006;7(6):670-673.
Bradley EL. The natural history of splenic vein thrombosis due to chronic pancreatitis: indications for surgery. Int J Pancreatol 1986;2(2):87–92.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareComparative Study of Endodontic Practices among Dentists in India: A Nation-wide Cross-sectional Survey
English2428Swadheena PatroEnglish Ankita MohantyEnglish Diplina BarmanEnglish Avinash JEnglishIntroduction: Endodontic in the field of dentistry is a constantly evolving specialty; hence it recommends the need to update the clinical practice with more advanced techniques and materials. Objective: To investigate the attitude of the dentists towards modern endodontic treatment options and to study the association of the no. of patients treated and the type of tooth treated with the preferred method of working length determination, method of magnification, instrumentation and the drug regimen followed by them. Methods: A questionnaire-based cross-sectional, descriptive survey was conducted among the dentists who are enrolled under the Masters of Dental Surgery (MDS) (postgraduates) curriculum or have completed MDS and are into speciality or general partitioning in different dental colleges of India from November 2020 to March 2020. A total of 1601 dentists enrolled in the study. A self-fabricated questionnaire was prepared and validated. It was made into Google Form format and the link was emailed and shared among the eligible participants. There were twenty self-explanatory closed-ended questions themed on “Root Canal Treatment practices”. Results: The study findings depict that most of the dentists treated multi-rooted tooth and it was seen that the MDS other branch practitioners treated more than ten patients every week followed by Endodontists. It was seen most of the dentists preferred the combination method of working length determination and the technique of instrumentation. A strong correlation between the number and type of tooth treated with the preference of drug prescribed was observed. Conclusion: The study findings reveal that there is still a lack of adaptation of various modern endodontic practices, which recommends the need to incorporate training of the postgraduate students about the advanced methods of endodontic practice
EnglishEndodontists, Survey, Endodontic practices, Dentists, Nationwide survey, QuestionnaireINTRODUCTION
Endodontic in the field of dentistry is a constantly evolving speciality. Modern endodontic treatment protocols are persistently under the scanner as it encompasses different types of armamentarium, techniques, and materials which are promoted every day. However, adapting to the latest techniques does not always translate into a success rate of treatment. Thereby, a better comprehension of the current trends enclosing operating microscopes, nickel-titanium rotary devices, ultra-sonic endodontic tips and techniques of working length determination, prescription of certain drug regimens, and many more holds prime importance, as they affect the daily endodontic practice.
Not only the above factors but also the number of patients encountered by practising dental health care professionals paramount to the reason behind why certain techniques or methods of instrumentation are taken up by these professionals. This enables one to have a clear understanding of the suggested failure rates in endodontic treatment which escalate up to 78.8% as stated by Iqbal et al.1
A Questionnaire survey serves as a prevalent method to study the drastic change in scenarios about all the above-mentioned factors.2 The following web-based survey not only throws light on the materials and methodology but also the importance of dentist to population ratio and the increasing tendency of patient referrals to specialist dentists. This survey will help in spotting the lacunae in the current protocols and reveal the ratio of dentists who do not comply with the already established guidelines. The purpose of the current study is to investigate the attitude of the dentists towards modern endodontic treatment options and to study the association of the no. of patients treated and the type of tooth treated with the preferred method of working length determination, method of magnification, instrumentation and the drug regimen followed by them.
MATERIALS AND METHODS
A questionnaire-based cross-sectional, descriptive survey was conducted among the dentists who are enrolled under the Masters of Dental Surgery (MDS) (postgraduates) curriculum or have completed MDS and are into speciality or general partitioning in different dental colleges of India from November 2020 to March 2020.
Sample Population
The total study population was divided into four groups: Endodontist, MDS-other branch, Dentists enrolled in MDS – Endodontia, and also MDS other branch students. A total of 2100 Dentist were approached for the survey through email conversation; finally, 1601 dentists enrolled for the study. A total of 76.23% was the response rate. The dentists who practised root canal treatment regularly either in the clinic or in the college and willingly participated in the survey were included.
Sampling
Proportionate multistage cluster random sampling methodology was adopted. The country was fractionated into five different zones: Central zone, Northern zone, Southern zone, Eastern zone, and Western zone. Uneven dispensation of the dental colleges in the divided zones indicated a proportionate random sampling technique. The southern zone had the highest density of dentists while the eastern zone had the least. The list of colleges imparting MDS courses was made and the colleges were randomly selected using the lottery method. The list of the practitioners satisfying the inclusion criteria was attained from the state dental council and the postgraduates who fulfilled the criteria were enlisted from the Heads of the colleges.
Sample size calculation
G Power 3.0 software was used to determine the minimum sample size. A minimum of 625 dentists was required for the study.
Questionnaire
A self-fabricated questionnaire was prepared and validated. It was made into Google Form format and the link was emailed and shared among the eligible participants. There were twenty self-explanatory closed-ended questions themed on “Root Canal Treatment practices” among the dentists. There were three sections in the questionnaire: Pre-treatment equipment usage for root canal treatment; preferred methods of instrumentation and the most commonly used techniques during Root Canal Treatment and postoperative drug regimen. The total questions including the demographic questions added up to twenty-eight. Cronbach's alpha value was calculated for each subscale to know the reliability coefficient. A high internal consistency was indicated with α= 0.97.
Pilot study
A pilot survey was hosted with 50 eligible subjects to know about the feasibility, uniform understanding, and difficulty related to the study before the main study. These participants were excluded from the main study. Institutional ethical committee permission was obtained (KIMS/KIIT/IEC/14/2019). All the participating dentists were requested to digitally sign an informed consent form before proceeding with the questionnaire. A copy of the completed responses was mailed to the participants and they were not allowed to edit their responses further.
Statistical Analysis
Data was imported to MS EXCEL Version 2016 from Google Sheet. The data were manually coded in MS Excel and IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM Corp. program was used to statistically interpret the data. Inferential statistics (means and standard deviation) were calculated along with the Chi-square test for the comparison between the group and in-between various zones. PEnglishhttp://ijcrr.com/abstract.php?article_id=3721http://ijcrr.com/article_html.php?did=3721
Iqbal MZ, Al-Saikhan FI, Rajan S, Iqbal MS. Knowledge of Root Canal Treatment and Its Association with Patients’ Demographics–A Cross-Sectional Insight. J Pharmac Res Int 2020;27:1-8.
Kochhar A, Bhasin R, Kochhar G, Dadlani H. COVID-19 pandemic and dental practices. Int J Denst 2020;2020:8894794.
Molyneux L, Mccullough C, Preston AJ, Jarad FD. Apex locator used by general dental practitioners in Merseyside. J Dent Res 2008; 87(I): 389-391.
Fadi J, Sondos A, Carol G, Girvan B, Fox K, James A, et al. Working length determination in general dental practice: A randomised controlled trial. Bri Dent J 2011;211:595-598.
Faculty of General Dental Practice (UK) of the Royal College of Surgeon of England. Selection criteria for dental radiography. London: FGDP(UK), 2004.
European Society of Endodontology. Quality guidelines for endodontic treatment: consensus report of the European Society of Endodontology. Int Endod J 2006;39:921–930.
Lee M, Winkler J, Hartwell G, Stewart J, Caine R. Current trends in endodontic practice: Emergency treatments and technological armamentarium. J Endod 2009;35:35?9.
Gupta R, Rai R. The adoption of new endodontic technology by Indian dental practitioners: a questionnaire survey. J Clin Diagn Res 2013;7(11):2610.
Kohli A, Singh S, Podar R, Dadu S, Kulkarni G. A comparative evaluation of endodontic practice trends in India. Ind J Dent Res 2014 ;25(6):729.
De Moor RJ, Meire M, Goharkhay K, Moritz A, Vanobbergen J. Efficacy of ultrasonic versus laser-activated irrigation to remove artificially placed dentin debris plugs. J Endon. 2010;36(9):1580-3.
Jenkins SM, Hayes SJ, Dummer PM. A study of endodontic treatment carried out in dental practice within the UK. Int End J 2001;34(1):16-22.
Raoof M, Zeini N, Haghani J, Sadr S, Mohammadalizadeh S. Preferred materials and methods employed for endodontic treatment by Iranian general practitioners. Iran End J 2015;10(2):112–116.
Peru M, Peru C, Mannocci F, Sherriff M, Buchanan LS, Pitt Ford TR. Hand and nickel?titanium root canal instrumentation performed by dental students: a micro?computed tomographic study. Eur J Den Edu 2006;10(1):52-9.
Rajbhandari SM, Pradhan B. Evaluation of Sealing Ability of Three Root-end Filling Materials. Orth J Nepal 2015;5(1):27-30.
Cecchin D, de Sousa-Neto MD, Pécora JD, Gariba-Silva R. Cutting efficiency of four different rotary nickel: Titanium instruments. J Conser Dent 2011;14(2):117.
Kuzekanani M. Nickel–Titanium rotary instruments: Development of the single-file systems. J Int Soc Prev Comm Dent 2018;8(5):386.
Mandlik J, Shah N, Pawar K, Gupta P, Singh S, Shaik SA. An in vivo evaluation of different methods of working length determination. J Cont Den Pract 2013;14(4):644
Sam JE, Kumar AA, Maheswari SU, Raja J, Seelan RG, Balaji TR. Comparison of shaping ability of three different rotary instruments in simulated root canals using computer image analysis: An in vitro study. J Ind Acad Dent Spec Res 2015;1;2:8-12.
Thimmanagowda N. A Survey on Nickel-Titanium Rotary Instruments and their Usage Techniques by Endodontists in India. J Clin Diagn Res 2017;11(5): ZC29-ZC35.
Dutner J, Mines P, Anderson A. Irrigation trends among American Association of Endodontists members: A web?based survey. J Endod 2012;38:37?40.
Mines P, Loushine RJ, West LA, Liewehr FR, Zadinsky JR. Use of the microscope in endodontics: A report based on a questionnaire. J Endod 1999;25:755?8.
Kersten DD, Mines P, Sweet M. Use of the microscope in endodontics: Results of a questionnaire. J Endod 2008;34:804?7.
Low JF, Dom TN, Bahrain SA. Magnification in endodontics: A review of its application and acceptance among dental practitioners. Eur J Dent 2018;12(4):610.
Krithikadatta J, Nawal RR, Amalavathy K, McLean W, Gopikrishna V. Endodontic and dental practice during COVID-19 pandemic position statement from the Indian Endodontic Society, IDA and International Federation of Endodontic Associations. Ndodont. 2020; 32:55-66
Jayadev M, Karunakar P, Vishwanath B, Chinmayi SS, Siddhartha P, Chaitanya B. Knowledge and pattern of antibiotic and non-narcotic analgesic prescription for pulpal and a periapical pathologies-a survey among dentists. J Clin Diagn Res 2014;8(7): ZC10.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareMorphometric Variations of Mandibular Foramen and Lingula of Mandible with Gender and Age Using Cone Beam Computerised Tomography
English2935Hayagreev DEnglish Kodialbail AEnglish Shetty SEnglish Sujatha SEnglishIntroduction: Mandibular foramen (MF) is located on the medial surface of mandibular ramus. The inferior alveolar nerve and vessels pass through it and supply the mandibular teeth. Along with the lingula of the mandible, it forms an important bony landmark during oral and maxillofacial surgical procedures and for identifying the site for injection of local anaesthetics. Objective: To study the morphometric variation in the position of the mandibular foramen and lingula and to compare the above measurements in males and females and age groups of < 20 years and > 20 years. Methods: 100 cone beam computerised tomography (CBCT) scans of full skull of both the genders and age group were studied in Ramaiah dental hospital and the location of the mandibular foramen and lingual were measured from the reference points: Base of the mandible, anterior and posterior borders of the ramus of the mandible, sigmoid notch and third molar. Results: The parameter that showed significant variation was; the mandibular foramen and lingula in females was more towards the base than males and among the age group of below 20 years of and adults above 20 years of age, children have their mandibular foramen nearer to the mandibular notch and the posterior border; indicating that the foramen moves downwards and anteriorly with growth. Conclusion: The position of both the mandibular foramen and lingula will vary with age and sex hence the surgeons should consider the age and sex of the patient during osteotomies and nerve block.
EnglishOsteotomies, Mandibular nerve block, Neurovascular bundle, Cone Beam Computerised tomography, Shape of lingula, Oromaxillofacial surgeriesINTRODUCTION
Several dental procedures such as apical curettage of mandibular premolars, amalgam filling, implant treatment, mandibular osteotomies and periodontal surgeries, dental extractions and correction of various jaw abnormalities require the use of local anesthesia during the surgeries. The most common route of local anesthesia is by giving a nerve block to the inferior alveolar nerve which provides anesthesia of teeth, jaw, lip, gingiva and mucous membrane.1
The mandibular foramen (MF) is located on the medial side of the ramus of the mandible through which the neurovascular bundle containing the inferior alveolar nerve and vessels passes. It forms an anterior loop in the mandibular canal of the lower jaw and leaves the canal after splitting into mental and incisive nerves from the mental foramen in the anterior wall of the alveolar bone.2,3 The failure rate of the anaesthesia is reported to be 20 to 25% and the cause being inaccurate positioning of the mandibular foramen.4,5
The lingula is a tongue-shaped bony projection covering the mandibular foramen. Lingula and MF act as important landmark for the correction of deformities like prognathic, orthognathic and retrognathia by conducting osteotomy procedures such as bilateral sagittal split ramus and intraoral vertical- sagittal ramus surgeries. In the above procedures, the excision of bone should be at the level of the lingula to avoid injury to an inferior alveolar nerve.6
Thus locating these anatomical positions accurately is critical to achieve more successful nerve block and prevent common complications like paraesthesia, skin necrosis and haemorrhage during orthognathic surgery.4,7,8 Variations concerning the individual, gender, age, race, assessing technique and degree of edentulous alveolar bone atrophy has also been noted in the mandibular incisive canal, mental foramen and associated neurovascular bundles.9
In children, a variation in the difference between the distance from the mandibular foramen to the anterior border and the posterior border is observed. This variation is caused by regional growth in different directions.10,11 Hence in the above-mentioned procedures, the exact site of operation and anaesthesia will differ in children and adults.
Radiographic images are obtained clinically to identify the position of the mandibular foramen. However, it has the disadvantage of being less accurate. Computed tomography (CT) scans are accurate but expensive and have a high dose of radiation exposure to the patients. On the other hand, Cone-beam computed tomography (CBCT) scans are less expensive and have low radiation exposure doses12 hence is more beneficial to the patients with accurate results.13-15
Moreover, studies conducted on dry bone cannot determine the age and sex of the individual which was the main aim of this study. Hence CBCT scan was used to study the morphometry and variations in the mandibular foramen and lingula in two age group and males and females. This study aimed to compare the position of the mandibular foramen and lingual in both the sexes and in age groups of below 20 years and above 20 years.
MATERIALS AND METHODS
100 CBCT scans of full skull of both genders were taken from the Department of oral medicine and radiology in Ramaiah dental hospital in the period 2014-2017. 50 were of below 20 years and 50 were after 20 years of age. Scans were taken using a Carestream CS 9300 machine at 90 kVp and 6mA with 17*13.5cm field of view. The age, name and gender of the patient were noted. The scan was viewed in cross-sectional slices of 25.5 mm thickness in the sagittal plane. The mandibular foramen on the medial side of the ramus was identified. The shape of the lingula was noted. The presence of a third molar was noted. The location of the foramen and the lingula was assessed by measuring the distances using DIACOM Software. The distance of MF and lingula were measured from the reference points such as base of the ramus, mandibular notch, anterior border of the ramus, posterior border of the ramus, and third molar tooth. The mean of three measurements of each parameter was taken by the same observer to avoid interobserver and intraobserver variations.
Ethical clearance number- DRP/IFP/171- 2/8/2017
Variations in the shape of lingual16, 17 were also noted and were classified into:
Triangular (with a wide base and a narrow rounded or pointed apex, rounded or pointed apex)
Truncated(lingula with somewhat quadrangular bony projection on its top)
Nodular(lingula is nodular and of variable size, almost the entire lingula except for its apex which was merged into the ramus)
Assimilated (lingula is completely incorporated into the ramus) (Figure 1- 4)
RESULTS
The study showed the mean distance of mandibular foramen from the base of the ramus was 25.55±3.35 mm in the males and 23.6±2.75 mm in females, from the mandibular notch, was 22.25±4.35 mm in males and 20.4±2.85 mm in females, anterior border of the ramus of mandible was recorded as 15.5±2.5 mm in males and 16.00±1.9 mm in females, from the posterior border was recorded as 9.4±2.25 mm in males and 9.15±1.85 mm in females, from third molar tooth 19.1±1.9 in males and 18.25±1.9 in females.
The mean distance of lingula from the base of the ramus was 32.05±3.95 mm in the males and 29.1±3.9 mm in females, from mandibular notch was 16.15±3.05 mm in males and 15.6±2.6 mm in females, anterior border of the ramus of mandible was recorded as 15.5±2.5 mm in males and 16.00±1.9 mm in females, from the posterior border was recorded as 14.55±2.1 mm in males and 13.85±2.0 mm in females, from third molar tooth 18.8±1.4 in males and 17.75±1.65 in females.
The shape of lingula was found to be truncated in 37% on the right side and 34% on the left side, nodular on 22% on the right side and 28% on the left side, assimilated in 25% on the right side and 20% on the left side and triangular in 16% on the right side and 18% on the left side (Figure 5-8).
The measurements from mandibular foramen to the base and mandibular notch and also the distance from lingual to the base of the mandible showed significant variations in males and females with a p-value of 0.001, 0.011 and 0.0 respectively.
The measurements that showed significant variations in the age groups below 20 years and above 20 years with p-value Englishhttp://ijcrr.com/abstract.php?article_id=3722http://ijcrr.com/article_html.php?did=3722
Aglarci O S, Gungor E, Altunsoy M, Nur B, Ok E. Three-Dimensional Analysis of Mandibular Foramen Location: A Cone Beam Computed Tomography Study. OMICS J Radiol 2015; 4 (1): 1-3.
Chen Z, Chen D, Tang L, Wang F. Relationship between the position of the mental foramen and the anterior loop of the inferior alveolar nerve as determined by cone-beam computed tomography combined with mimics. J Comput Assist Tomogr 2015; 39(1):86?93.
Eren H, Orhan K, Bagis N, Nalcaci R, Misirli M, Hincal E. Cone-beam computed tomography evaluation of mandibular canal anterior loop morphology and volume in a group of Turkish patients. Biotech Equip 2016;30(2):346-53.
Shalini R, Ravivarman C, Manaoranjitham R, Veeramuthu M. Morphometric. Study on mandibular foramen and incidence of accessory mandibular foramen in mandibles of south Indian population and its clinical implications in inferior alveolar nerve block. Anat cell Biol 2016;49(4):241-48.
Ennes JP, Medeiros RM. Localisation of the mandibular foramen and its clinical impactions. Int J Morp 2009; 27:1305-11.
Sophia MM, Alagesan A, Ramchandran K. A Morphometric and Morphological Study of mandibular lingula and its clinical significance. Int J Med Res Rev 2015;3(2):141-48.
Castells ET, Albiol JG, Baeza AR, Aytes LB, Escoda CG. Necrosis of the skin of the chin: a possible complication of inferior alveolar nerve block injection. J Am Dent Assoc 2008;139(12):1625?30.
Laishram D, Deepti S. Morphometric analysis of mandibular and mental foramen. J Den Med Sci 2015;14(12): 82-86.
Juodzbalys G, Wang HL, Sabalys G. Anatomy of Mandibular Vital Structures. Part II: Mandibular incisive canal, Mental foramen and associated neurovascular bundles in relation with dental implantology. J Oral Maxillofac Res 2010;1(1):e3.
Ahmet E S, Kenan C, Mustafa A. Cone Beam Computed Tomographic analysis of the shape, height, and location of the Mandibular Lingula in a population of children. BioMed Res Int 2013:1-8.
Krishnamurthy NH, Unnikrishnan S, Ramachandra JA, Arali V. Evaluation of the relative position of Mandibular foramen in children as a reference for Inferior alveolar nerve block using Orthopantamograph. J Clin Diagn Res 2017;11(3):71-74.
Chau AC, Fung K. Comparison of radiation dose for implant imaging using conventional spiral tomography, computed tomography, and cone-beam computed tomography. Oral Pathol Oral Radiol Endod 2009;107(4):559?65.
Park HS, Jae HL. A Comparative Study on the Location of the Mandibular Foramen in CBCT of Normal Occlusion and Skeletal Class II and III Malocclusion. Maxillofac Plast Reconstr Surg 2015;37(1):25
Shokri A, Falah-Kooshki S, Poorolajal J, Karimi A, Ostovarrad F. Evaluation of the location of mandibular foramen as an anatomic landmark using CBCT images: a pioneering study in an Iranian population. Braz Dent Sci 2014;17(4):74-81.
Al-Shayyab MH. A simple method to locate mandibular foramen with cone-beam computed tomography and its relevance to oral and maxillofacial surgery: a radio-anatomical study. Surg Radiol Anat 2018;40(6):625?34.
Tuli A, Choudary R, Choudary S, Raheja S, Agarwal S. Variation in shape of the lingula in the adult human mandible. J Anat 2000;197(2):313-17.
Smita Tapas. Variations in the morphological appearance of lingula in dry adult human mandibles. Int J Curr Res Rev 2013;05(24):41-45.
Padmavathi G, Varalakshmi K L, Suman T, Roopashree K. A morphological and morphometric study of the lingula in dry adult human mandibles of South Indian origin and its clinical significance. Int J Health Sci Res 2014;4(6):56-61.
Prajna PS, Poonam K. Morphometric analysis of mandibular foramen and incidence of accessory mandibular foramen in adult human mandibles of an Indian population. Rev Arg de Anat Clin 2013; 5(2):60-66.
Lopes PTC, Pereira GAM and Santos A. Morphological analysis of lingula in dry mandibles of individuals in Southern Brazil. J Morphol Sci 2012;27(3-4):136-38.
Gopalakrishna K, Deepalaxmi S, Somashekara SC, Rathna BS. An anatomical study on the position of mandibular foramen in 100 dry mandibles. Int J Anat Res 2016; 4(1):1967- 71.
Oguz O, Bzkir MG. Evaluation of the location of the mandibular and the mental foramina in dry, young, adult human male dentulous mandibles. West Indian Med J 2002;51(1):14-16.
Sekerci AE, Sisman Y. Cone-beam computed tomography analysis of the shape, height, and location of the mandibular lingula. Surg Radiol Anat 2014;36(2):155?62.
Senel B, Ozkan A, Altug H A. Morphological evaluation of the mandibular lingula using cone-beam computed tomography. Folia Morphol 2015;74(4):497–02.
Arun Kumar G, Mahantesh C, Bhagyashree MP, Sidra I. The morphology and location of the Mandibular lingula in the south Indian population using cone-beam computed tomography -a retro-sectional study. Int J Curr Res 2016;8(03):28466- 69.
Jansisyanont P, Apinhasmit W, Chompoopong S. Shape, height, and location of the lingula for sagittal ramus osteotomy in Thais. Clin Anat 2009;22(7):787?93.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareIncidence of Bacterial and Fungal Infections in Otitis Externa Patient36
English3640Bhuvaneshwar GAEnglish Meenakshi MEnglish Deepak Raj KEnglishEnglish Otalgia, Otitis externa, Staphylococcus aureusINTRODUCTION
Otitis externa is the condition that causes the diffuse inflammation of the external auditory meatal skin which may spread to involve the pinna and the epidermal layer of the tympanic membrane, not extending into the middle ear.1 Otitis externa can be either acute or chronic. Inadequately incompletely improperly treated acute otitis externa becomes chronic otitis externa. In some cases, it may occur in the localized form such as furuncles with severe pain and tenderness, which are confined to the hairy cartilaginous part of meatus only. In immunocompromised individuals, the otitis externa manifest as a more aggressive form and is called malignant otitis externa.
Like all skin in the body, the external auditory canal also has normal bacterial flora and a defence mechanism to protect it from bacterial infection. the predisposing factors that break the normal defence mechanism of the ear are common unhealthy day to day activities like swimming in unclean water, trauma from cerumen removal, use of external devices such as hearing aids for a prolonged duration, and cerumen removal with pins or buds, vigorous cleaning. These factors lead to loss of cerumen causes which in turn causes a fall in pH of the ear canal leading to bacterial growth and water retention, this causes the damage of the epithelial lining of the External AuditoryCanal.2 Other factors to include common skin conditions such as eczema and seborrhea, which if picked up earlier, the progression to otitis externa can be prevented.
The most common symptom associated with otitis externa is severe ear pain which is highly distressing to the patient that it interferes with his day to day activities. The usual aetiology of otitis externa is infective mostly bacterial. Staphylococcus, pseudomonas, klebsiella were the commonly isolated organisms from fungal culture. Previous studies have reported an increasing trend in fungal aetiology of otitis externa, due to increased use of topical antibiotics.3
Our study aimed to determine the incidence of bacterial and fungal agents present in the ear swabs taken from the patient’s with otitis externa and to assess the predisposing factors and clinical characteristics of otitis externa in Saveetha medical college
MATERIALS AND METHODS
It is a prospective observational study conducted at save the medical college hospital, Thandalam, Tamilnadu. Institutional review board approval was obtained (IEC Approval Number: SMC/IEC/2020/03/319), and after the individual, informed consent ear swab was taken from 40 consecutive patients diagnosed with otitis externa. This study was conducted for three months and included 40 patients diagnosed with otitis externa. There were 18 males and 22 females with their ages ranging from above 15 to below 70.
Patients with a history of ear pain, itching, Facial pain, Headache and ear discharge of varied types like (white mucous, thick purulent, thin watery with musty odour, greenish-blue and yellowish discharge) were included for the study.
A detailed history was collected from all patients and a complete ENT examination was carried out by an otolaryngologist. Demographic data, history, symptoms and predisposing factors and examination findings were recorded in excel sheets for each patient. the patient was also asked to grade the pain based on the Numerical Rating Scale pain scale. For the detection of the causative agents, three specimens of the affected external canal were obtained with three separate sterile cotton swabs. The cavum of conchae and external meatus were cleaned with seventy per cent isopropanol before attaining the swabs, to avoid infections.
The first swab was processed for aerobic bacteria in 5% sheep blood, chocolate and MacConkey agar. The second swab was placed into an anaerobic thioglycolate broth and the last was placed in Sabouraud dextrose broth with antibiotics for fungal organisms. Aerobic specimens are inoculated within 60 minutes into 5% sheep blood, chocolate and MacConkey agar and examined after 24 to 48 hours. Anaerobic specimens are inoculated within 60 min into thioglycolate broth and plated on anaerobic blood agar which was examined 48/96/120 hours. Fungal cultures were evaluated for isolation of any fungal growth after incubation at 25 to 26 degree for two weeks.
The results are obtained accordingly after inoculation of the swabs. All the data were entered in excel spare sheets and are analyzed by SPSS software and the statistical significance is calculated
RESULT
It is an incidence and socio-clinical study of bacterial and fungal infection in otitis externa patients in Saveetha medical college hospital, Thandalam, Tamilnadu. It is a perspective and observational type of study. The aim is to determine the causative factors of otitis externa and to investigate whether it was bacterial or fungal organisms causing the infection. The demographic details like age, sex, location, causative predisposing factors symptoms and examination findings are taken into consideration.
Of the 40 patients taken for the study, the total number of males were 18(45%) and the females were 22(55%). Patients between the age of below 20 to above 60 were enrolled for our study, in which the patients between the age of 40-59 were most affected and the ones below 20 were affected the least (Figure 1)
Among the enrolled 40 patients, most of the affected ones were from Chembarambakkam (13) and the others were from Mevalurkuppam(10), Pattabiram(6), Kuthambakkam (5), Maduravoyal (4) and Poonamalle (2) (Figure 2).
In our study, the most common predisposing factor is bathing in water bodies and staying for a longer time in the swimming pool which has affected about 15 of the 40 patients. While the other causative factors are listed in Figure 3.
On observing the symptoms given by the patients, it was revealed that the most common one was otalgia which was found in almost all the patients. Itching (10), Facial pain (10), and headache (18) were the other common symptoms complained about by the patients. The pain score percentage was also obtained from the patients ranging from mild to severe with most of them being on the moderate scale (Figure 4 and Table 1).
Examination findings are summarized in Figure 5. The polymicrobial nature of otitis externa was reflected in the study, the culture medium showed polymicrobial growth in 15% of swab cultures. fungal agents were found in 5% of swab cultures as polymicrobial and isolated growth in 15% (Figure 6).
Among the bacterial species, the most common causative agent was staphylococcus aureus (30%). While the second most common was Pseudomonas Aeruginosa (25%). These were followed by proteus (10%), Moraxella (7.5%) and Klebsiella (5%), most of them were aerobic facultative bacteria. Among the fungal organisms, the common species found were Candida Albicans which is a predominant etiological agent of otomycosis. The distribution of isolates in culture-positive cases is summarized in the table (Figure 7).
DISCUSSION
Otitis externa is one of the most painful inflammatory condition. In our socio-clinical study, about 40 patients diagnosed with otitis externa were enrolled after the local examination. In our study of 40 patients, 55% (22) of them were female and the other 45% (18) were male. Whereas in the study of Battikhi et al. in Oman, 100 patients among were men consisting of 55.5%.4 Cheong et al, a study in Singapore also found a frequency of 52.7% of male among 91 patients.5 Burgas et al. study reported that 56% of people affected were male.6 All the three studies that were being discussed contradicts the findings of our study. However, the study of Hajjartabar reported that 32.1% of patients taken under the study were women, which is following our study.7 The reason for the increased incidence of otitis externa in females can be due to the humidity affecting the ear condition as most of them were housekeepers.
In our study, the middle-aged individuals ranging from 40 - 59 age were affected more but in the case of Rowland et al. study of the UK revealed that otitis externa were common in all the age groups, which seems to contradict our study.8 The reason for this can be due to lifestyle, environmental factors and the jobs of the patients under the study. The most common predisposing factor according to our study was bathing in waterbodies (37%) and frequent head baths (30%), the reason being excessive moisture that elevates the pH and removes the cerumen. when there is no cerumen PH is altered, since the cerumen secretes lysozymes and maintains pH and also Lipid nature of the cerumen prevents water accumulation and epithelial damage.11-13
In our study of 40 patients, otalgia, itching, facial pain and headache were the common symptoms complained by the patients. Tragal tenderness, external auditory oedema and discharge were the clinical findings obtained from the local examination. The study of Al-Assaf et al. reported that pain and ecthymas were the most common symptoms wherein oedema had a low incidence, which contradicts our study.9 The study of Schaefer et al. have reported inflammation, otalgia and itching were the most frequent symptoms which favour our study.10
In our study, swabs were taken from 40 otitis externa patients in which 80% of the causative agents were bacterial. Among the bacteria, the most common causative organism was Staphylococcus aureus which was responsible for about 30% of patients, followed by pseudomonas Aeruginosa which affected 25% of the patients. The study of Murat Enoz et al.11 in turkey which included 267 patients revealed, 68.16% of them was positive for aerobic facultative bacteria, 1.12% were positive for anaerobic bacteria and 30.71% were fungi. Among the aerobic facultative bacteria, staphylococcus aureus (24.34%) was the commonest causative organism followed by pseudomonas Aeruginosa (11.99%), which seems to be following our study. Nogueira et al. study of 27 otitis externa samples also revealed staph aureus to be the most common causative organism.12 However, in the case of Cheong et al. studies consisting of 91 patients in Iran showed that the most commonly cultured bacteria were Pseudomonas aeruginosa (31.6%) followed by Staphylococcus aureus (20%) which contradicts our studies results.13 In Argentina were also found to contradict our studies with Pseudomonas Aeruginosa as the most common bacteria.10,14
In our study, among the 40 patients, 20% of the causative agents were of fungal origin and was comparatively less than the bacterial origin. The most common causative fungal organism was found to be Candida albicans. Incidences of candida Albicans at a percentage of 2.38%, 1.62% and 1.72%, which was found to be under our study.15-17 Whereas Zaror et al. study of 20 patients revealed that the Aspergillus Niger (35%) was the most common one which seems to contradict our study.18 Another study in Iran also reported that hearing loss, otalgia and discharge were the most common ones. The results of our study and the others were not entirely consistent; however, otalgia was the commonest symptom among all the studies.18,19 Otitis externa usually resolve with topical antibiotics and analgesics within a week but in case of delayed presentation, it may extend into other severe complications like chronic external otitis media, mastoiditis, osteomyelitis and the most common malignant necrotizing otitis externa.19 So, the swimmer’s ear otitis externa is a common condition caused by bacteria and fungal which can be treated easily on early detection.
CONCLUSION
Swimmer’s ear is one of the local names given to the medical condition otitis externa. It is an infection of the external ear canal and is commonly seen in primary health care hospitals. It has a prevalence of 1% and the incidence tends to be higher in hot and humid conditions. Otitis externa is usually a clinical diagnosis. It is based on a detailed history and examination of the ear using an otoscope. The mainstay of management in otitis externa involves prevention, aural toileting, topical antibiotics, simple analgesics and health education. No single topical antibiotics regimen is superior. The choice depends upon the causative organisms (bacteria and fungi), patient and the doctor preference, local sensitivity and adverse reactions of the drug. Steroid drops were beneficial when there is evidence of oedema with inflammation. Aural toileting is the most important single factor in the treatment of otitis externa. All the exudates and debris should be meticulously and gently removed.
DECLARATION
Funding: No funding was received for conducting this study
Conflicts of interest/Competing interests: All authors declare that they have no
Code availability MS excel
Author’s contribution: All authors contributed to the study’s conception and design.
Ethical Clearance: institutional ethical committee clearance was obtained.
Acknowledgement:
I would like to thank the faculty of the Department of Otorhinolaryngology of Saveetha Medical College and Hospital for their constant support and guidance in the completion of the research. I would like to thank all others who were involved directly and indirectly in the study and also the patients who participated in the study.
Englishhttp://ijcrr.com/abstract.php?article_id=3723http://ijcrr.com/article_html.php?did=3723
Dhingra PL, Dhingra S. Diseases of ear, nose and throat and head and neck surgery.
Enoz M, Sevinc I, Lapena JF. Bacterial and fungal organisms in otitis externa patients without fungal infection risk factors in Erzurum, Turkey. Braz J Otorhinolaryngol. 2009;75(5):721-5.
Jackman A, Ward R, April M, Bent J. Topical antibiotic induced otomycosis. Int J Pediatr Otorhinolaryngol 2005;69(6):857-60.
Battikhi MN, Ammar SI. Otitis externa infection in Jordan: Clin Microbiol Features Saudi Med J 2004;25(9):1199–203.
Cheong CS, Tan LM, Ngo RY. Clinical audit of the microbiology of otorrhoea referred to a tertiary hospital in Singapore. Singapore Med J 2012;53(4):244–8.
Sanchez BA, Menaches Guardiola MI, Gras Albert JR, Talavera SJ. Descriptive study of infectious ear disease concerning summer. Acta Otorrinolaringol Esp 2000;51(1):19–24.
Hajjartabar M. Pseudomonas aeruginosa isolated from otitis externa associated with recreational waters in some public swimming pools in Tehran. Arch Clin Infect Dis 2010;5(3):142–51.
Rowlands S, Devalia H, Smith C, Hubbard R, Dean A. Otitis externa in UK general practice: a survey using the UK General Practice Research Database. Br J Gen Pract 2001;51(468):533–8.
Al-Asaaf SM, Farhan MJ. Otitis externa in a localized area at the South of Jordan. Saudi Med J 2000;21(10):928–30.
Schaefer P, Baugh RF. Acute otitis externa: an update. Am Fam Physician 2012;86(11):1055–61.
Enoz M, Sevinc I, Lapeña JF. Bacterial and fungal organisms in otitis externa patients without fungal infection risk factors in Erzurum, Turkey. Braz J Otorhinolaryngol 2009;75(5):721-5.
Nogueira JC, Melo Diniz Mde F, Lima EO, Lima ZN. Identification and antimicrobial susceptibility of acute external otitis microorganisms. Braz J Otorhinolaryngol 2008;74(4):526–30.
Cheong C, Tan ML, Ngo RY. Clinical audit of the microbiology of otorrhoea referred to a tertiary hospital in Singapore. Singapore Med J 2012;53(4):244.
Amigot SL, Gomez CR, Luque AG, Ebner G. Microbiological study of external otitis in Rosario City, Argentina. Microbiological study of external otitis in Rosario City, Argentina. Mycoses 2003;46(8):312-5.
Jadhav VJ, Pal M, Mishra GS. Etiological significance of Candida albicans in otitis externa. Mycopathologia 2003;156(4):313-5.
Erkan M, Soyuer U. Otomycosis in Kayseri (Turkey). Rev Iberoam Micol 1991;8:92-94.
Jaiswal SK. The fungal pattern of the ear and its sensitivity pattern. Indian J Otolaryngol 1990, 42: 19-22.
Zaror L, Fischman O, Suzuki FA, Felipe RG. Otomycosis in São Paulo. Rev Inst Med Trop Sao Paulo 1991;33(3):169-73.
Kurnatowski P, Filipiak J. Otitis externa: the analysis of the relationship between particular signs/symptoms and species and genera of identified microorganisms. Wild Parasitol 2008;54(1):37–41.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareProject-Based Learning, an Effective Tool for the Active Teaching-learning Method for First-year Medical Students
English4146Hitesh N. ShahEnglish Dharmik S. PatelEnglish Mitul N. ChhatriwalaEnglishEnglishINTRODUCTION
Poor attendances in classes especially in Biochemistry Subject and poor performances in PG entrance examination of students are a stimulus to think beyond the conventional teaching approach. There are different types of teaching and learning methodologies are available in medical education. Nowadays medical education is also changing from traditional teaching to newer methods like CBL, mini CEX, Problem Base Learning, e-learning and so on. Project-Based Learning is an innovative, systematic teaching method that promotes student engagement through deep investigations of complex questions. During teaching-learning activities, one would have come across one or more problem areas that are hurdles to the educational process. These problems may be unique to an educational set up and therefore may not have been addressed. Though concerted planned problem shooting and try out innovative methods which might circumvent constraints in the system.
A project work within reasonable limits may provide for independent and novel exploration based on an inquiry-driven approach. The educational project may involve inquiry into any of three aspects of the educational spiral to result in identification and solving problem in setting a clear objective, better teaching-learning experiences for the students and improved evaluation procedures.
A project plan would involve the development of a design, evolving a strategy of the procedures, putting them in to practice analysing and discussing outcome and improving the existing setup. Project-Based Learning is an effective teaching method, then traditional practices. An analysis conducted by Purdue University found that Project Based Learning can increase long-term retention of learning material and improve teachers' and students' attitudes toward learning. One explanation that researchers suggest is that both educators and learners are more actively engaged with the subject material.1
The experience of questioning, making mistakes, and pursuing inquiries in an organized, guided process makes PBL different from traditional teaching methods. As ArchF or Kids Co-Founder Karen Orloff explains, “From the first day of the project, the student becomes more receptive to challenges. They are more open to looking at mistakes as positive things as opposed to negative ones.2 Project-based learning activities should always culminate in a final product. There should be a sense of finality in the overall unit of study. Students need to be motivated to complete their work and to answer essential questions. Such experiences provide students with further instances of real-world applications of their work and prepare them for the demands of higher education and today’s workplace.3 Research on Project-Based Learning can take several forms.4 Research can be undertaken to
(a) Make judgments about the effectiveness of PBL (summative evaluation),
(b) Assessor describe the degree of success associated with implementation or enactment of Project-Based Learning (formative evaluation),
(c) Assess the role of student characteristic factors in Project Base Learning effectiveness or appropriateness (aptitude-treatment interactions)
(d) Test some proposed feature or modification of Project-Based Learning (intervention research).
There are different types of teaching and learning methodologies. Now MCI is also moving from traditional teaching to CBME. There are different methods available today like CBL, mini CEX, Problem Base Learning, e-learning and so on. In my opinion Project-Based Learning (PBL) is an innovative, systematic teaching method that promotes student engagement through deep investigations of complex questions. Project-based learning is not done with medical students and I do not have an idea but it is usually applied in other fields like engineering colleges. Put simply: ‘It is learning by doing. This study was taken to assess the effectiveness of project-based learning tool over conventional teaching methods (chalk and board) in undergraduate 1st-year medical students.
MATERIALS AND METHODS
The study was conducted in a private medical college with a yearly admission capacity of 150 students. The study was conducted in the Department of Biochemistry with the involvement of three faculties. Students of 1st MBBS were divided into 3 groups of 50 students each. The project was allotted to one of the three groups with proper guidelines and instruction by faculties. The second group was taught by chalk and board & the third group was taught by case base learning method. Liver function test, Thyroid function tests and Renal function test were the topic for the teaching. First, the Liver function test was taught to all three groups by method allotted, then the Renal function test was taught to all the three groups by teaching method allotted and then the Thyroid function test was taught to all three groups by method allotted. Ethical Permission was taken from the institutional ethical committee with permission letter no. IEC/HMPCMCE/2017/Ex. 65
For each topic/method we did a rotation of faculties and students to remove selection bias and teacher bias. Two weeks was given for the preparation of the project for the given topic. At the end of the sessions, we took feedback and a post-session test through a short MCQ test. Timely feedback is taken. After completion of the project, submission of the project was done. Then feedback was taken from the students, a Post-test was conducted and analysis was done.
Step involved in project formulation: Identify a problem, Plan the project, Schedule, Monitoring and improvement, assessment and Evaluation. No additional burden was given to the students because it was done along with the normal day to day teaching schedule or activity. Teaching and project were done during the planned Biochemistry lecture and tutorial schedule. The project was approved by the institutional ethical committee.
RESULTS
The present study comprises 150 students and 3 faculty members. Out of 150 students, 110 students gave their feedback and were actively involved in the study. All the students were from 1st-year MBBS. Questions for feedback for all three-teaching methodology was used as per below and the Likert scale used for the evaluation:
Q1= It helps in developing communication skills among us
Q2= Student can learn the subject at his own pace
Q3= It enhances research aptitude
Q4= It gives opportunity to express creativity which develops more interest in the subject
Q5= this allows you to work as a team
Total 110 students gave their feedback for Project-based learning based on Likert’s scale.
Statistically, a significant difference was found between post-test marks for all topics among the three groups. The group with project-based learning method performed very well compared to other teaching methods which were consistent for all teaching methods and students. One to one interview was done with involved faculties. All faculties were positive about project-based learning and future implementation in the routine curriculum.
DISCUSSION
In the current scenario of medical education, we are still using age-old teacher-centric teaching methods like didactic lectures and tutorials. We need to upgrade medical education from teacher-centric to student-centric methods like case-based learning, Project-based learning, problem-based learning, student seminars, role play etc. Up-gradation of teaching methodology needs time. We have tried to study project-based learning which is one of the student-centric and interactive methods. We have done feedback evaluation and MCQ evaluation for Case-based learning, Project-based learning and Chalk & board method and compared them with each other. We have tried to evaluate not only the subject knowledge but also tried to give more emphasis on other learning aspects like research aptitude, communication skills, inter person relation, creativity in subject and teamwork.
We have observed a significant difference in student feedback taken for all three different methods and three different topics. While analysing the feedback received from the students for project-based learning, we have found a significant difference between the three groups for all five feedback questions. Project-based learning emerged out as a winner when we analysed the MCQ score received after conducting the MCQ test for all three groups. Thomas et al. showed that project-based learning enhanced professionalism and collaboration on the part of teachers and increased attendance, self-reliance, and improved attitudes towards learning on the part of students. Similar to our observations, Thomas et al., reported that students and teachers both believe that Project Base Learning is useful and valuable as an instructional method.4 Although it is well-established that active learning provides significant practical and theoretical advantages over passive learning, teachers are often seen reluctant to employ these active learning strategies in routine teaching practice.5
One Indian study, Patel et al also demonstrated that 76% of student participants liked Project-based learning compared to other methods.6 Very scanty reference is available on project-based learning in medical education. More researches in this field required to reach a definitive conclusion. Bédard et. al. considered project-based learning as innovative, especially from a student’s perspective.7 Project-based learning strengthens the bond between student & teacher. They learn empathy, passion, compassion, and resiliency. They push student’s ability towards Self-directed learning.
CONCLUSION
In this 21st century, e-learning is going to be the leading tool for medical education. Project-based learning leads to enhanced self-directed learning followed by increasing interest in the subject. The project given among the group leads to an increase in the ability to work as a team. Project-based learning build bonds between students and also improve bonding with teachers. Sometimes, Projects also develops research aptitudes among the students.
Acknowledgement: I am grateful to undergraduate students and faculties of the institution of the Department of Biochemistry, as they have spare time for this project. 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.
Declarations: No funding was required for this project. IEC permission was taken before conducting this project.
Conflicts of interest/Competing interests: No
Authors' contributions: All authors have contributed to the project equally. In the formation of the protocol, IEC approval was taken by the 1st author. Data collection and statistics has been done by all three authors. All three authors have given inputs in manuscript formation and worked hard for this study and its implementation in routine departmental practice.
Englishhttp://ijcrr.com/abstract.php?article_id=3724http://ijcrr.com/article_html.php?did=3724
Blumenfeld PC, Soloway E, Marx RW, Krajcik JS, Guzdial M, Palincsar A. Motivating Project-Based Learning: Sustaining the Doing, Supporting the Learning. Educ Psychol 1991:26(3-4), 369-398.
Knoll, M. The project method: Its vocational education origin and international development. J Indus Teacher Educ 1997:34(3):59-80.
Polman JL. Designing Project-Based Science: Connecting Learners through Guided Inquiry. New York: Teachers College Press, Columbia University. 2000
Thomas JW. A Review of Project-Based Learning. A report prepared for The Autodesk Foundation. San Rafael, CA. 2000. https://www.bie.org/files/researchreviewPBL_1.pdf.
Benek-Rivera J, Matthews VE. Active learning with jeopardy: Students ask the questions. J Manage Educ 2004; 28:104-18.
Patel JR, Patel DS, Desai R, Parmar J, Thaker R, Patel ND, et al. Evaluation of student seminar in medical education: students’ perspective. Int J Curr Res Rev 2015;7(7):6-8
Bédard D, Lison C, Dalle D, Côté D, Boutin N. Problem-based and project-based learning in engineering and medicine: determinants of students’ engagement and persistence. Interdisc J Problem-Based Learn 2012;6(2).
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareBlood Lactate Levels and Hematological Parameters in Medical Students before and after Half Marathon
English4751Indira Ashok HundekariEnglish Nisha GuptaEnglish Nilima N. DongreEnglishBackground: Prolonged and intense physical exercise causes multiple significant changes in the body. These changes can lead to health disorders and deterioration of physical fitness. Objective: Marathon runners require medical attention and the performance of laboratory assays. Hence we planned to study blood lactate and haematological parameters in young healthy subjects before and after the marathon Methods: The study group comprises 19 healthy medical students aged between 20-25 years who are amateur nonprofessional runners. Blood lactate level, Anthropometric parameters and haematological parameters were estimated before and after the half marathon, using standard assay procedures. Results: We found a significant increase (P< 0.001) in blood lactate level after the marathon as compared to before the marathon. We also confirmed leukocytosis after the half marathon and decreased percentages of lymphocytes and eosinophils; while the percentage of monocytes, haemoglobin concentration, HCT, RBC, MCH, MCV, and MCVC after the marathon remained unchanged. Conclusion: Marathon running is a prolonged and intense physical effort that leads to several changes in the organism, as demonstrated by the results of haematological parameters and blood lactate analysis. The growing popularity of long-distance running, especially among amateurs, indicates the importance of biochemical investigations during such activity.
EnglishHalf marathon, Blood lactate, Leukocytosis, Haematological parameters, Amateur, Nonprofessional runnersINTRODUCTION
Physical inactivity is considered to be one of the main causes of primary hypertension, independently of weight status. Physical activity levels are becoming lower among children and adolescents worldwide, demonstrating that new generations are more sedentary than the previous ones. This raises concerns about which strategies could help children and adolescents to increase their physical activity levels, as physical activity in childhood has been demonstrated to be an effective intervention to combat obesity and hypertension in adult life.1
In recent years, the practice of marathons has become very popular. Moreover, much attention has been drawn to the promotion of physical exercise to prevent diseases.2 The marathon is a long-distance running race with an official distance of 42.95 km usually run as a road race. It is one of the original modern Olympic events in 1896. Each year the world witnesses more than 800 marathon events with a vast variety of participants. The half marathon is a road running event of 21.0975 km (half the distance of a marathon). It is not a part of the world championships or Olympic programs. But the event gained its championships in 1992 in the form of the IAAF world half marathon championships. Its popularity has kept growing & it is now one of the most popular road events.3
The blood lactate level has been used as an indicator of the ability to perform endurance exercise in clinical practice.4 Hematological disturbances after exercise, such as haemolysis and/or iron deficiency are well documented5 but of little concern from a health perspective. Prolonged and intense physical exercise causes multiple significant changes in the body. These changes can lead to health disorders and deterioration of physical fitness.6 Participants in marathon races may require medical attention and the performance of laboratory assays. Hence we planned to study blood lactate & physiological parameters
before and after the half marathon in young healthy medical students from BLDE (Deemed to be University), Shri B M Patil Medical College Hospital and Research Centre, Vijayapur.
MATERIALS AND METHODS
The present study was carried out in the Department of Biochemistry, BLDE (Deemed to be University) Shri B. M. Patil Medical College, Hospital and Research Centre, Vijayapur. A random selection method was used for the selection of 30 subjects from our University. Before the study, informed consent was obtained from the students and the experimental procedures were reviewed and approved by the BLDE (Deemed to be University) Human Research Ethical Committee [IEC letter no. BLDE (DU)/IEC/27/2017-18].
Selection of the subjects: Medical students from our University who are healthy volunteered and involved in various sports, athletes, non-smokers, non-alcoholics and not on medications for any acute or chronic illness were included in this study. We invited medical students from our University who are amateur nonprofessional, male runners. Of 30 subjects recruited, 24 runners agreed to take part in our study. First, the subjects underwent a health examination to check their health and to reject unfit individuals. They received a talk beforehand in which the study was explained to them, and once they understood they gave consent for the study. None of the participants experienced an adverse medical event during or after the race as they were doing exercise for at least 30 minutes of moderate-intensity physical activity for 5 or more days a week.
At baseline, the study participants were asked to complete a standardized questionnaire to gather information on physical characteristics such as exercise during the last year and personal information such as eating habits, allergy, medication for any illness etc. The anthropological measurements were made before the marathon and biochemical parameters were assessed before and after the half marathon in the study group. The subjects were instructed to refrain from intense physical activity at least 24 hours before the marathon. All participants submitted a written consent form.
After a night’s rest, they ate a light breakfast or a fruit of their choice at 7:00 am. During the run, the runners nourished themselves with prepared food and drinks served at a special stand. 5 ml venous blood samples were collected from the subjects under aseptic conditions, before starting the half marathon and after the marathon. The serum was separated by centrifugation at 3,000 rpm for 10 minutes, at room temperature. Then all samples were immediately placed at 40 C until they were processed, to get accurate and reproducible results.
Blood Lactate by colourimetric method (VITROS LAC slide method) using VITROX chemistry products LAC slides – Commercial kit.
EDTA-blood, to determine haematological parameters by automated cell counter analyzer; SysmaxKx- 21
Statistical analysis
All the data collected has been analyzed and expressed as mean ± SD. The statistical analysis of data was done by student’s ‘t’ test and Pearson’s correlation test using SPSS latest version. P< 0.05 is considered statistically significant. Correlation of body fat percentage and blood lactate level before and after half marathon was analyzed with Pearson’s correlation test.
RESULTS AND DISCUSSION
Out of twenty-four runners, nineteen runners completed the race. However, five runners did not finish the race and were therefore excluded from the study analysis. Ages of all the participants were ranged from 19 to 24 years with anthropometric parameters as shown in Table 1. All the participants were normotensive.
Participation in long-distance running events has grown significantly in the last decade. The completion time for professionals is less than 2 hrs 30 minutes7 while in our study group completion time ranged between 3 h 10 minutes to 3 h 40 minutes. Christine Bekos et al. reported that the time required for a half marathon was 117.0 ± 2.8 minutes.8
Heart rate is an important variable to determine physical exercise intensity. We observed a significant increase (PEnglishhttp://ijcrr.com/abstract.php?article_id=3725http://ijcrr.com/article_html.php?did=3725
Siegrist M, Lammel C, Haller B, Christle J, Halle M. Effects of a physical education program on physical activity, fitness, and health in children: The Juven TUM Project. Scand J Med Sci Sports 2013;23:323–330.
Jastrzebski Z, Radziminski MZL, Konieczna A, Kortas J. Damage to liver and skeletal muscles in marathon runners during a 100 km run with regard to age and running speed. J Human Kinetics 2015;45:93-102.
IAAF competition rules for road races. Int Assoc Athletics Federations. 2009.
Svedahl K, MacIntosh BR. Anaerobic threshold: the concept and methods of measurement. Can J Appl Physiol 2003;28(2):299-323.
Gledhill N, Warburton D, Jamnik V. Haemoglobin, blood volume, cardiac function, and aerobic power. Can J Appl Physiol 1999;24:54–65.
Kami?ska J, Podgórski T, Pawlak M. Variability of selected hematological and biochemical markers in marathon runners. Trends Sport Sci 2015;3(22):125-132.
Orquín-Ortega E, Vega-Ruiz V, García AR, López-Araque B. Biochemical changes in popular runners after a marathon (Stress Test). Arch Med Deporte 2016;33(5):306-311.
Bekos C, Zimmermann M, Unger L, Janik S, Hacker P, Mitterbauer A, et al. Non-professional marathon running: RAGE axis and ST2 family changes concerning open-window effect, inflammation and renal function. Sci Rep 2016;6(1):32315.
Diamond TH, Smith R, Goldman AP, Myburgh DP. Holter Monitoring and marathon running. Reproduced by Sabinet Gateway under license granted by the publisher dated 2012:14-15.
Halliwell JR, Taylor JA, Hartwig TD, Eckberg DL. Augmented baroreflex heart rate gain after moderate-intensity, dynamic exercise. Am J Physiol 1996;270:R420– R426.
Rossow L, Yan H, Fahs CA, Ranadive SM, Agiovlasitis S, Wilund KR, et al. Post-exercise hypotension in an endurance-trained population of men and women following the high-intensity interval and steady-state cycling. Am J Hypertens 2010;23: 358–367.
Ferri A, Adamo S, La Torre A, Marzorati M, Bishop DJ, Miserocchi G. Determinants of performance in 1,500-m runners. Eur J Appl Physiol 2012;112:3033-3043.
Daniels SR. International differences in secular trends in childhood blood pressure: a puzzle to be solved. Circulation 2011;124:378–380.
Power SK, Howley ET. Exercise Physiology: Theory and application to fitness and performance, 9th Edition, Baltimore, MD: Lippincott Williams & Wilkins. 2014.
Traiperm N, Gatterer H, Burtscher M. Plasma electrolyte and haematological changes after marathon running in adolescents. Med Sci Sports Exerc 2013;45(6):1182-7.
Jastrzebski1 Z. A 100-Km Run In Relation Runners. Int J Occup Med Envt Health 2016;29(5):801–814.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareAntipsychotic Drugs Induced Movement Disorders: A Pharmacist Led Study
English5256Jeena JoseEnglish Santosh PrabhuEnglish Nandakumar UPEnglish Sharad ChandEnglish Juno J. JoelEnglishIntroduction: Drug-induced movement disorder is one of the major complications among patients undergoing antipsychotic drug therapy. Objective: The study aims to assess the antipsychotic drugs induced movement disorders in hospitalized patients with psychiatric disorders. Methods: A prospective observational study was carried out in a tertiary care teaching hospital for eight months. A total of 110 patients diagnosed with various psychiatric disorders and prescribed antipsychotic drugs were enrolled in the study. The movement disorders identified were documented and evaluated for causality assessment by using Naranjo’s Algorithm and WHO Probability Scale. Severity was assessed by Modified Hartwig and Siegel scale and preventability was assessed by using Modified Schumock and Thornton’s criteria. Data were analyzed by applying descriptive statistics. Results: Out of 110 patients followed, 25 patients developed 25 incidents of movement disorders. It was found more among male patients. The incidence of Parkinsonism (40%) was higher and was then followed by akathisia (32%), dystonia (24%) and tardive dyskinesia (4%). Causality assessment reported the majority of adverse drug reactions (ADRs) as ‘possible’. The severity assessment showed that 76% of the ADRs were moderately severe and 24% were mild reactions. The majority of the reactions were found probably preventable. Conclusion: Antipsychotics are one of the major choices of drugs among psychiatric patients and they, in turn, can cause several adverse outcomes that can lead to a need for a modified therapeutic approach. Proper monitoring can prevent some possible and predictable adverse reactions.
English Psychiatry, Antipsychotics, Movement disorders, Causality assessment, Severity assessment.INTRODUCTION
The drug-induced disorder is one of the major causes of hospitalization and poor therapeutic outcomes.1,2 Drug-induced disorders are adverse drug reactions.3 Antipsychotic drugs are meant for treating schizophrenia and other psychiatric disorders and their therapeutic efficacy is well established. Yet, many of these drugs have different side effect profiles. It is evidenced that second-generation antipsychotics have lesser effects when compared to first-generation antipsychotics.4,5 Ever since the antipsychotic effect of chlorpromazine was discovered there was an intense use of the drug. Within a short period, the parkinsonian side effects were identified.5,6 Akathisia is a type of disorder that involves motor restlessness with discomfort especially in the limbs of the patient. These symptoms that appear in the initial stages of the therapy are more stressful and can lead to poor medication adherence.7 Similarly, it can happen with dystonia which is an involuntary movement disorder characterized by a recurrent spasm that subsequently leads to unusual movements or changing postures.8 Drug-induced parkinsonism is more common and causes considerable disability during maintenance treatment, most commonly in elderly patients. The patients may experience slow movements, flexed postures and soft speech.9 Tardive dyskinesia is also characterized by unusual involuntary movements but it reflects especially on the face and can vary in severity.10 The pharmacist-led study can identify the incidence of ADRs and other drug-related problems.11,12 With this background the current study is focused on identifying the incidence of antipsychotic-induced movement disorders in a sample of patients with psychiatric disorders.
MATERIALS AND METHODS
A pharmacist-led prospective observational study was conducted for eight months. Institutional ethics committee approval was obtained before the initiation of the study. Informed consent was obtained from the patient/patient’s party for taking a role in the study. All the inpatients of either gender aged above 18 years diagnosed with psychiatric disorders and prescribed with antipsychotics were included in the study. A suitable data collection form was designed to document the patient's age, gender, diagnosis, drug therapy details including drug, dose, duration of therapy and route of administration. These details were obtained from the patient’s medical records. The enrolled patients were monitored daily. Any movement related disorders observed during the study was documented with the help of treating psychiatrists. The identified events were subjected to causality assessment using the WHO probability scale and Naranjo’s scale. Severity was assessed by Modified Hartwig and Siegel scale and preventability by using Modified Schumock and Thornton’s criteria. Descriptive statistical analysis was carried out using Statistical Package for Social Sciences.
RESULTS
Patient characteristics
Out of the total 110 patients enrolled in the study, 87 (79.1%) were males and 23 (20.9%) were females. The categorization according to the gender and various age groups of the patients is presented in Table 1.
Distribution of the patients according to the psychiatric disorders
Among the enrolled patients, the majority were diagnosed with paranoid schizophrenia 39 (35.5%), followed by bipolar affective disorder 26 (23.6%). The details are presented in Table 2
Distribution of patients based on antipsychotics prescribed
Overview of the antipsychotic drug prescriptions revealed that 82 (74.5%) patients were prescribed with second-generation antipsychotics and 28 (25.5%) patients received first-generation antipsychotics.
Distribution of patients based on movement disorders identified
In the study, 25 (22.72%) patients reported a total of 25 incidents of movement disorders. The identified antipsychotic drug-related movement disorders were Parkinsonism, akathisia, dystonia and tardive dyskinesia. Details on the identified movement disorders are summarized in Figure 1.
Categorization of study subjects with movement disorders based on their gender and age.
Out of the total 110 patients, 21 male and 4 female patients developed at least one type of movement disorder. The male patients showed a higher incidence of movement disorders when compared to females (Table 4). Patients belonging to the age group of 30-39 years were found to have the highest incidence of movement disorders (36%). More details are summarized in Table 5.
Drugs suspected to cause movement disorders
In the present study, the movement disorders were found to be most commonly associated with the patients who received second-generation antipsychotics. The suspected second-generation antipsychotic drugs were quetiapine, risperidone, amisulpride, olanzapine and aripiprazole. Similarly, the suspected antipsychotic drugs of the first-generation included haloperidol and fluphenazine. Figure 2 summarizes the details of drugs responsible for movement disorders.
Assessment on various types of movement disorders
On a causality assessment based on the WHO probability scale, the majority of the movement disorders were found to be belonging to the category of possible 13 (52%), followed by probable 10(40%). According to Naranjo’s algorithm, it found that 12 (48%) ADRs were possible and 11 (44%) were probable. The severity assessment based on Modified Hartwig and Siegel scale showed that 19 (76%) of the ADRs were moderately severe and 6 (24%) were mild reactions. The majority of the reactions were found belonging to the severity Level 3 (10), followed by Level 4b (5), Level 2 and 4a (4 each) and Level 1 (2). As per Modified Schumock and Thornton’s criteria, the majority of the ADRs were found to be probably preventable 20 (80%), followed by definitely preventable, 5 (20%)
Distribution of various movement disorders identified based on the suspected drugs
The study evaluated various types of movement disorders based on the suspected antipsychotic drugs. The details are presented in Table 7.
DISCUSSION
Movement disorders are one of the main adverse outcome associated with antipsychotic drug therapy. The current study showed that female patients were less when compared to males. Among these, 4 female and 21 male patients were presented with antipsychotic drug-induced movement disorders. The study conducted by Asif et al, also found that the male patients were more susceptible to drug-induced movement disorders like tardive dyskinesia and akathisia.13 Considering age-wise categorization of the study population, the current study found that out of 110 patients, the majority (33%) belonged to the age group of 30-39 years, 28% of patients were found to be in the age group of 18-29 years and 12% belonged to 40-59 years. A previous study conducted by Cascade EF et al. showed that 24% were in the age group of 18-39 years and 45% of patients belonged to 40-59 years.14 Thus, there is a wide difference in the population when considering the age group.
The most commonly diagnosed psychiatric disorders among the enrolled study subjects were paranoid schizophrenia which accounted for 39%, followed by bipolar disorder. Whereas, in a study conducted by Sengupta et al, it was reported that bipolar disorder (27%) were the most common diagnosis made, followed by schizophrenia (24%).15 Antipsychotics are the primary drug of choice in the treatment of psychiatric illnesses. In this study, usage of the second generation (74.5%) antipsychotics were found to be higher than the first-generation agents (25.5%). The present study result was found similar to the study carried out by Meltzer et al, as second-generation antipsychotics were found to have a higher usage profile than the first generation.16 Among the various antipsychotic drugs prescribed, olanzapine accounted for the highest percentage (24.5%). Similar findings were seen in the study conducted by Sengupta et al, in which olanzapine was found to be prescribed among 31.82% of the patients.15
Out of 25 identified movement disorders, the majority were suspected to be due to Quetiapine and risperidone drug therapy. Similar findings were seen in the study conducted by Piparva et al, which were among a total of 83 ADRs, the majority were caused due to risperidone and olanzapine.17 The possibility of antipsychotics induced dystonia is common among patients with psychiatric disorders. Antipsychotics induced movement disorders are a common issue associated with the therapy. The antipsychotics show a higher rate of adverse reactions in patients undergoing therapy where the movement disorder is considered to be the major one. In this study, it was observed that 22% of the patients developed movement related disorders. Among these, parkinsonism and akathisia showed a higher rate of incidence with the percentage of 40% and 32% respectively, followed by dystonia 24%, and tardive dyskinesia 4%. The previous study conducted by Janno et al, reported that 61% of the patients were presented with antipsychotic drug-induced movement disorders with a high incidence of akathisia 31.3%, followed by parkinsonism 24% and tardive dyskinesia 32%.18 The present study results were in association with the previous study suggests that the incidence of akathisia and parkinsonism could be higher than other antipsychotic drug-induced movement disorders. In this study, the occurrence of dystonia was noted to be 24% among all the other identified movement related disorders. A study conducted by Addonizio G et al. reported that 31% of patients developed dystonia during antipsychotic therapy.19 These reports were found to be comparable with the present study.
CONCLUSION
The study established the incidence of various types of antipsychotics induced movement disorders in this sample population. Antipsychotics are one of the major choices of drugs in the management of psychiatric conditions and they, in turn, can cause several adverse outcomes that can lead to a need for a modified therapeutic approach. The current study reported Quetiapine and Risperidone as the major suspected drugs that caused movement related disorders. The commonly encountered movement disorders were parkinsonism, akathisia and dystonia. Causality analysis based on Naranjo’s scale and WHO scale evidenced that the majority of movement disorders had a possible relationship with the suspected drug. The preventability assessment showed that the majority of the reactions were probably preventable. With these reports, the study suggests that the incidence of movement-related disorders can be controlled by regularly monitoring the patients who are prescribed antipsychotics that are found to have a higher risk of developing such adverse effects.
FUNDING: This work did not receive any financial support from any organization or funding agencies.
ACKNOWLEDGMENT: We Authors are thankful to the Department of Psychiatry, Justice K. S. Hegde, Charitable Hospital, Nitte (Deemed to be University) for their support during the study.
CONFLICT OF INTEREST: There is no conflict of interest
Englishhttp://ijcrr.com/abstract.php?article_id=3726http://ijcrr.com/article_html.php?did=3726
Chand S, Bhandari R, Girish HN, Sukeerthi D, Sah SK, Voora L. Isoniazid induced psychosis. J Global Pharma Tech 2019;11(5):11-14.
Rachana J, Shastry CS, Mateti UV, Sharma R, Nandakumar UP, Chand S. Incidence and associated factors of adverse drug reactions in the general medicine department of a tertiary care teaching hospital. Int J Pharmac Res 2019;11(3):177-184.
Kurian A, Babu B, Punnoose B, Chacko CS, Rao M, Chand S, et al. Cisplatin-induced peripheral neuropathy: an observational descriptive study. Int J Res Pharm Sci 2020;11(03):3585-3589.
Barnes TRE, McPhillips MA. Critical analysis and comparison of the side effects and safety profiles of the new antipsychotics. Br J Psychiatry 1999;174(suppl 38):34–43
Rawal KB, Chand S, Luhar MB. A comparative study on relative safety and efficacy of chlorpromazine and risperidone. Int J Res Pharmac Sci 2020;11(02):1539-1544.
Hall, RA, Jackson, RB, Swain, JM. Neurotoxic reactions resulting from chlorpromazine administration. JAMA 1956;161(3): 214–218.
Halstead SM, Barnes TRE, Speller JC. Akathisia: Prevalence and associated dysphoria in an in the patient population with chronic schizophrenia. Br J Psychiatry 1994;164:177–83.
Satterthwaite TD, Wolf DH, Rosenheck RA, Gur RE, Caroff SN. A meta-analysis of the risk of acute extrapyramidal symptoms with intramuscular antipsychotics for the treatment of agitation. J Clin Psychiatry 2008;69(12):1869–1879.
Tarsy D. neuroleptic-induced extrapyramidal reactions: classification, description, and diagnosis. Clin Neuropharmacol 1983;6(1):S9–26
Blanchet PJ. Antipsychotic drug-induced movement disorders. Can J Neurol Sci 2003;30(1): S101–7.
Roy DA, Shanfar I, Shenoy P, Chand S et al. Drug-related problems among chronic kidney disease patients: A pharmacist-led study. Int J Pharmac Res 2020;12(04):79-84.
Voora L, Sah SK, Bhandari R, Shastry CS, Chand S, Rawal KB, Nandakumar UP, Vinay BC. Doctor of pharmacy: boon for the healthcare system. Drug Invention Today 2020;14(1):53-158.
Asif U, Saleem Z, Yousaf M. Gender wise clinical response of antipsychotics among schizophrenic patients: A prospective observational study from Lahore, Pakistan. Int J Psychiatry Clin Pract 2017;22(3):177-183.
Cascade EF, Karali AH, Citrome L. Antipsychotic use vary by patient age. Psychiatry (Edgmont). 2007;4(7):20–23.
Sengupta G, Bhowmick S, Hazra A, Datta A, Rahaman M. Adverse drug reaction monitoring in psychiatry out-patient department of an Indian teaching hospital. Indian J Pharmacol 2011; 43(1):36.
Meltxer DO, Basu A, Meltzer HY. Comparative effectiveness research for antipsychotic medications; How much is enough? Health Affairs 2009;28(5):794-808.
Piparava KG, Buch JG, Chandhrani KV. Analysis of adverse drug reactions of atypical antipsychotic drugs in psychiatry OPD. Indian J Psychol Med 2011;33(2):153.
Janno S, Holi M, Wahlbeck K. prevalence of nueroleptic induced movement disorders in chronic schizophrenic inpatients. Am J Psychiatry 2004;161(1):160-163.
Addonizio G, Alexopoulos GS. Drug-induced dystonia in young and elderly patients. Am J Psychiatry 1988;145(7):869.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareBio Ceramics: A Modern Approach to Cementsin Endodontics
English5761Kajol RelanEnglish Manoj ChandakEnglish Pradnya NikhadeEnglish Pooja ChandakEnglishThere is an exponential growth in Endodontics due to various advances in materials used in Endodontics. Bioglass was a new material introduced in dentistry. Among them are Bioceramics that are biocompatible. They include ‘alumina and zirconia, bioactive glass, glass ceramics, coatings and composites, Hydroxyapatite and resorbable calcium phosphate’. Bioceramic types of cement can be widely used for dentinal tubule closure. The voids between the dentinal walls and obturating material can be homogenously sealed by bioceramics. Bio ceramics have bioactivity that helps bone repair and neoformation due to their interaction with periapical tissues. Thorough knowledge of newer bioceramic materials is necessary to ensure the appropriate selection of material according to the clinical situation. The objective of this article is to review the various bioceramic materials and to choose the appropriate material for successful endodontic treatment.
English Bioceramics, Bioglass, Bio dentin, Calcium silicate-based types of cement, Calcium phosphate-based types of cementINTRODUCTION
There is an exponential growth in Endodontics due to various advances in materials used in Endodontics. Bioglass was a new material introduced by L.L Hench and others in 1969. Various Glasses and Ceramics can bond to living bone was also observed by them.1 Earlier Calcium hydroxide was used. Calcium hydroxide is used in various pulp therapies. It is used as a pulp covering agent, in apexification, as an endodontic sealer, perforation repair material.2 The inorganic, non-metallic materials prepared by heating raw minerals at high temperatures are the Ceramics. Among them are the Bioceramics that are biocompatible.1 The brilliant biocompatibility is due to the resemblance to the biological procedure of forming Hydroxyapatite. This is also due to the ability to induce Regenerative response from periapical tissues.3 Bio ceramics are osteoinductive materials. During the bone healing process, after coming in contact they absorb osteoinductive materials. Currently, bone graft materials are used in extraction socket healing. This is because these materials are inert and also can induce healing.4 They include ‘alumina and zirconia, bioactive glass, glass ceramics, coatings and composites, Hydroxyapatite and resorbable calcium phosphate’. MTA became popular in Endodontics as the first generation bioceramic cement. There is the prevention of bacterial adhesion as bioceramics form porous powders that contain nanocrystals that having a diameter of 1-3 nm.5 Bioceramic cement can be widely used for dentinal tubule closure. The voids between the dentinal walls and obturating material can be homogenously sealed by bioceramics. Bioceramics have bioactivity that helps bone repair and neoformation due to their interaction with periapical tissues.
CLASSIFICATION
Bioceramics can be classified as6,7
Bioinert: These materials do not interact with biological systems. eg: Alumina, Zirconium.
Bioactive: These are tough tissues that are able of undergoing interfacial communications with the surrounding tissue. eg: ‘Bioactive glass, Hydroxyapatite, Bioactive glass ceramics, calcium silicates’.
Biodegradable: They are soluble/ Resorbable. They are ultimately replaced or incorporated into the tissue. eg: Tricalcium phosphate, Bioactive glass.
BIOCERAMICS IN ENDODONTICS
Calcium Silicate based :
Types of cement:
Portland Cement
Mineral Trioxide Aggregate (MTA).
Biodentin
Sealers :
Endo CPM Sealer
MTA Fillapex
BioRoot RCS
TechBiosealer
Calcium Phosphate/ Tricalcium Phosphate/ Hydroxyapatite based
The mixture of Calcium silicates and Calcium phosphates
iRoot BP
iRoot BP Plus
iRoot FS
Endosequence BC sealer
Bioaggregate
Tech Biosealer
Ceramicrete
PROPERTIES OF BIOCERAMICS8,9
Bio ceramics have excellent biocompatibility and is non-toxic. They do not shrink upon setting they expand a little after completion of setting. They do not produce any significant inflammatory response when used during obturation and in root repair. They form a chemical bond amid dentin and filling materials and form hydroxyapatite. They have a high pH (12.8) during the start of 24 hrs of setting. They are powerfully antibacterial, have hydrophilic nature, have outstanding sealing ability, sets fast ( 3 to 4 hrs), small particle size, easy to use. They have excellent physical properties and it has improved convenience and delivery method.
CALCIUM SILICATE BASED BIO CERAMICS
Portland Cement
Joseph Aspdin, in 1824 introduced a material Portland cement (PC) and patented it. It was obtained from a calcining mixture of limestones from Portland in England and silicon argillaceous materials.10 It is an easily available material and cheap. As MTA, it is available as grey and white.11
Discolouration:- Grey PC shows discolouration compared to white PC.
Solubility:- PC showed little solubility and improved washout resistance
comparing to MTA.
Bioactivity:- PC showed lesser bioactivity as compared to MTA. Calcium ion release and hydroxyapatite crystal formation are there with grey as well as white PC.
Antibacterial properties:- PC has powerful action against bacteria and fungi against E. faecalis, Micrococcus luteus, Staph aureus, staph epidermidis, Pseudomonas aeruginosa, Candida albicans.12
Sealing ability:- As perforation repair material, when checked by protein leakage method, white PC has better sealing when compared to white and grey MTA.
Limitations:- PC releases a high quantity of lead and arsenic, hence the safety of PC is questionable. The seal of restoration can be jeopardized because of its high solubility. Crack formation in the tooth occurs due to excessive setting expansion.
Mineral trioxide aggregate (MTA)
MTA had been the 1st bioceramic material effectively used in endodontics. It was introduced by Dr. Mahmoud Torabinejad in 1993. The development of this cement was founded on Portland cement, in Loma Linda University – California. It has osteoconductive, osteoinductive, and biocompatible properties. MTA was used as ‘retrograde filling material and perforation closing’. The material contents, physical and chemical properties of PC and MTA are comparable. Portland cement, contains ‘Tricalcium silicate (3CaO?SiO2), dicalcium silicate (2CaO?SiO2), tricalcium aluminate (3CaO?Al2O3) and calcium sulfate (2CaSO4?H2O)’. MTA is adding has bismuth oxide – it is a nonsoluble substance to give the material radiopacity. MTA – a calcium silicate cement has ‘tricalcium silicate, dicalcium silicate, and tricalcium aluminate’. Material has two forms – grey and white. Grey coloured MTA was available up to 2002. In the same year, WMTA was presented as ProRoot MTA. This was introduced to overcome the disadvantage of discolouration caused by GMTA.11
Properties of MTA
Compressive strength: It is ~ 40 MPa in 24 hrs and ~ 67 MPa in 21 days.
Setting reaction: The setting reaction of MTA is exothermic. It requires hydration of the powder resulting in a paste that matures over time. The Tricalcium silicate and dicalcium silicate reacting with water and producing calcium silicate hydrates (C-S-H) and calcium hydroxide [Ca (OH) 2].
2[3CaO.SiO2] + 6H2O ---->3CaO.2SiO2.3H2O + 3Ca(OH)2
2[2CaO.SiO2] + 4H2O ---->3CaO.2SiO2.3H2O + Ca(OH)2
7Ca(OH)2 + 3Ca(H2PO4)2 ----> Ca10(PO4)6(OH)2 + 12H2O
Accelerator in setting is Calcium chloride. Retarder in setting is Sodium hypochlorite. these affect the formation of calcium hydroxide.13
Setting time: The powder liquid ratio for MTA is 3:1. As noted by Torabinejad et al, the setting time of grey ProRoot MTA is 2 hrs 45 min. As noted by Islam et al the setting time for White MTA is 2 hrs 20 min and for grey, MTA is 2 hrs 55 min.11
pH: Initial pH of hydrated MTA is 10.2. The pH 3 hrs after mixing rises up to 12.5.
Pushout bond strength and Flexural strength: Push-out bond strength of MTA as noted by Aggarwal V et al. After 24 hours is ~5.2 ± 0.4 MPa. After 7 days, the set cement had a strength that increased to 9.0 ± 0.9 MPa.14. After placing moist cotton pellet on the MTA during setting for 24 hrs, Walker et al noted increased flexural strength as ~14.27±1.96MPa.15
Porosity and Microhardness: The porosity depends on the amount of water added for paste, bubble entrapment, or pH value. MTA microhardness is affected adversely by low pH, less humidity, more condensation pressure.
Sealing ability, Particle size, and Biocompatibility: MTA materials have low microleakage compared to traditional materials while using as an apical restoration and when 3mm of MTA remained after root-end resection. Reducing the thickness of MTA causes microleakage. The particle size of MTA affects the handling characteristics of MTA. Small particle size increases the contact with the liquid. This results in increased early strength and ease of handling. Grey MTA has a larger particle size than white MTA. MTA is not mutagenic, is not neurotoxic, and does not produce side effects on microcirculation. MTA also has an anti-inflammatory effect on pulp. MTA also has osteoconductive, cementoconductive, cementoinductive effects.
Advantages :
Calcium hydroxide is in such a way which gives calcium ions for cell attachment and proliferation.
High pH affects bacteria.
Cytokine production modulation.
Hard tissue migration and differentiation occur.
Provides biological seal by forming hydroxyapatite on MTA surface.
Limitations :
Prolonged sitting time.
High cost and difficulty in handling.
No known solvent is there for the material.
Once placed it is difficult to remove.
Biodentin
Biodentin was commercially available in 2009 ( Septodont, Saint Maur des Fosses, France). It is based on calcium silicate cement. Biodentin is prepared using MTA based technology with better physical and handling properties than MTA. Biodentin is fast setting than MTA hence reduces bacterial contamination.
Properties of Biodentin :
Setting reaction: Setting reaction is the same as MTA that results in the formation of Calcium silicate hydrogel (C–S–H) and Ca(OH)2. The nucleation site for calcium silicate hydrogel is provided by Calcium carbonate. Hence the induction period is reduced and it causes the cement to set fast, It also improves the microstructure. The polymer formed is hydrosoluble that improves handling and there is a reduction in viscosity of cement.16
Setting time: Biodentin has a working time of 6 minutes. Its start setting time is 9-12 minutes and the completed setting time is 45 minutes. By adding Calcium chloride the setting time of biodentin is accelerated.16
Compressive strength and elastic modulus: Compressive strength reaches up to 100 MPa in 1st hour. The strength keeps on increasing up to 200 MPa at 24 hrs. This value is more than that for the Glass ionomer cement. The strength reaches 300 MPa after 1 month. At this time the value stabilizes that is comparable to natural dentin ( 297 MPa). The Elastic Modulus of Biodentin is 22 GPa that is similar to dentin which is 18.5 GPa.16
Pushout bond strength and Flexural strength: Biodentin has more pushout bond strength than MTA at 24 hrs. Contamination with bleeding does not affect the pushout bond strength whereas it does in the case of MTA. The flexural strength of Biodentin after 2 hrs was 34 MPa.16
Microhardness and sealing ability: Microhardness of Biodentin was 51 VHN after 2 hrs. The value reached 69 VHN after 1 month. Natural dentin has a hardness value of 60-90 VHN. Biodentin creates a stable anchorage along with bacteria tight effect.16
Antibacterial activity, pH, and Biocompatibility: pH of Biodentin is 12.5 that is bacteriostatic, and disinfect the dentin. Biodentin has no toxic and adverse effects on cell function. TGF – B1 ( growth factor) is secreted from pulp cells due to biodentin. This causes angiogenesis, progenitor cell recruitment, cell differentiation, and mineralization.16
Endo CPM sealer (EGO SRL, Buenos Aires, Argentina)
It is an MTA based calcium silicate cement. It has the same or improved physical, chemical, and biological properties compared to MTA. It has the same composition as that of MTA, calcium carbonate is added for reducing the pH to 10 of the complete set cement. This limits the surface necrosis of the nearby tissue and allows the alkaline phosphatase action. It has ‘satisfactory radiopacity, hydroxyl and calcium ion release, antibacterial activity, biocompatibility ( stimulation of mineralization), no cytotoxicity’. However, the microleakage of the sealer is more than that of MTA.11
MTA Fillapex (Angelus, Brazil)
It is an MTA based salicylate resin root canal sealer. It contains 13.2 % MTA. It has a higher radiopacity. It releases calcium ions that help in bone healing and tissue regeneration. It has a higher flow and low film thickness. This helps easy penetration into the lateral and accessory canals. It can be simply removed if retreatment is essential. It has less solubility hence outstanding seal inside the canal is maintained.17
EXPERIMENTAL CALCIUM ALUMINO-SILICATES
EndoBinder (Binderware, São Carlos, SP, Brazil): It is a new calcium aluminate based endodontic cement. It is produced by conserving the properties and clinical applications of MTA and elimination of traces of ‘Magnesium oxide (MgO), and Calcium oxide (CaO) and ferric oxide (FeO)’. These elements result in the expansion of material that is not desired. Ferric oxide (FeO) is accountable for discolouration.17
Generex A (Dentsply Tulsa Dental Specialties, Tulsa, OK, USA): It is based on calcium silicate material. It has little resemblances to ProRoot MTA but is mixed with unique gels in place of water that is used for MTA. However, it is difficult in handling as compared to MTA. It is used mostly for perforation repair and retrograde fillings.17
Capasio (Primus Consulting, Bradenton, FL, USA): It is made up of ‘bismuth oxide, dental glass and calcium alumino-silicate with a silica and polyvinyl acetate-based gel’. Capasio as well as MTA promoted apatite deposition after exposing it to synthetic tissue fluid hence can be concluded that it has mineralizing property. It can penetrate dentinal tubules when used as root-end filling material.17
Calcium Phosphate based Ceramics: They were developed by Hench in 1971. He developed Bioglass that was a Ca and P containing glass-ceramic. He also showed that it bonded chemically with host bone via a CaP rich layer.17
Compressive strength: For porous ceramics, it was 30-170 MPa. For dense ceramics, it was 120-917 MPa.
Uses :
Bone substitute.
Bone graft material.
Pulp capping materials.
Active restorative materials with ACP as filler
Limitations :
less strength.
caused fatigue fracture.
failure in load-bearing situations.
MIXTURE OF CALCIUM SILICATES AND CALCIUM PHOSPHATES
Bio aggregate (Verio Dental Co. Ltd., Vancouver, Canada): Biaggregate is made up of nanoparticles of ‘tricalcium silicate, calcium phosphate, silicon dioxide. This shows increased performance than MTA. Tantalum oxide is added that acts as a radiopacifier and it does not contain aluminium. Tricalcium silicate is the main component. Bioaggregate has no aluminium and contains additives like ‘calcium oxide and silicon dioxide. It has greater calcium release as compared to MTA. It is more biocompatible, has a better sealing ability, higher fracture resistance, and acid resistance than MTA. It has a better ability for inducing odontoblastic differentiation and mineralization than MTA in pulp capping.11
Setting reaction: Calcium silicate hydrate and calcium oxide are produced by the hydration of tricalcium silicate. ‘Calcium silicate hydrate’ gets deposited around cement grains. Calcium oxide is reacted with silicon dioxide and forms extra calcium silicate hydrate. Hence calcium hydroxide is reduced in aged cement. While in MTA angelus, no additions were done but still, calcium hydroxide was present in aged cement.18
Endosequence BC sealer [Brasseler USA]: It is not soluble, radiopaque, and aluminium free material. It is based on calcium silicate cement. It has ‘Zirconium oxide, calcium silicates, calcium phosphate monobasic, calcium hydroxide, filler, and thickening agents. It requires the presence of water to set and harden.18
Setting reaction : The hydration reaction of calcium silicates is as follows
2[3CaO-SiO2] + 6H2O →3CaO2SiO2-3H2O+ 3Ca(OH)2
2[2CaO-SiO2] + 4H2O → 3CaO2SiO2-3H2O+ Ca(OH)2
The precipitation reaction (C) of calcium phosphate apatite is as follows:
7Ca(OH)2 + 3Ca(H2PO4)2 →Ca10(PO4)6(OH)2 + 12H2O
No mixing is required and can be applied straight into the root canal. The working time can be more than 4 hrs at room temperature. However, in very dry root canals, it can be greater than 10 hrs.18
EndoSequence Root Repair Material/IrootSP/ IrootBP (ERRM; Brasseler, Savannah, GA)
It mainly consists of ‘calcium silicate, monobasic calcium phosphate, zirconium oxide, tantalum oxide, and filler agents’. Paste form is marketed in already loaded syringes. Also marketed in a putty form that can be moulded. The time of working for cement is 30 min. The reaction starts in presence of moisture. The final set is achieved after 4 hrs. However, it has a lesser sealing ability than MTA. The antibacterial property of this cement is similar to that of MTA. ERRM has no cytotoxic effect.18 As compared to MTA and Biodentin, ERRM is considered to have superior sealing ability for furcation repair.19
Endodontic and Restorative uses of Bioceramics
Bio ceramics are used as sealers along with Gutta-percha.
They are effective as pulp capping agents and dentin substitute.
They can be used during apexification and regenerative endodontics.
They are used as a retrograde filling material and repairing perforation.
They can be used as a canal locator owing to their excellent flowability and radiopacity.
They can be used in resorption.
They can be used in dentin hypersensitivity and dentin remineralization.
CONCLUSION
Bio ceramics are not currently used materials for endodontic use. They present various advantages as compared to conventional cement. Bio ceramics have a wide range of applications in restorative dentistry and endodontics. Thorough knowledge of newer bioceramic materials is necessary to ensure the appropriate selection of material according to the clinical situation. The tricalcium silicate-based materials have various biological advantages and have increasing use in endodontic therapy in the future.
Conflict of Interest:- None
Acknowledgement:- Authors would like to thank Dr Nikhil Mankar for his valuable support.
Funding support:- Nil.
Englishhttp://ijcrr.com/abstract.php?article_id=3727http://ijcrr.com/article_html.php?did=37271. Hench LL. The story of bioglass. J Mater Sci Mater Med. 2006;17: 967–978.
2. Chandak MG, Modi RR, Rathi BJ, Gogiya RJ, Bhutada P. In vitro comparative assessment of diffusion of ion from calcium hydroxide with three different phytomedicine pastes through dentin. Wor J Dent 2018; 9(5):377-371.
3. Damas BA, Wheater MA, Bringas JS, Hoen MM.Cytotoxicity comparison of mineral trioxide aggregates and EndoSequence bioceramic root repair materials. J Endod 2011;37:372-375.
4. Shilpa BS, Dhadse PV, Bhongade ML, Puri K, Nandanwar J. Evaluation of the effectiveness of platelet-rich fibrin for ridge preservation after atraumatic extraction. Adv Dent Res 2017;4:294-300.
5. Hermansson L. Nanostructural bioceramics: Advances in Chemically Bonded Bioceramics. CRC Press 2014.
6. Best SM, Porter AE, Thian ES, Huang J. Bioceramics: Past, present and for the future. J Eur Ceram Soc 2008;23:1319–1327.
7. Hickman K. Bioceramics. Internet (Overview) April 1999. http://www.csa.com/discoveryguides/ archives/bceramics.php.
8. Prati C, Gandolfi MG. Calcium silicate bioactive cement: Biological perspectives and clinical applications. Dent Mater 2015;31(4):351-370.
9. Utneja S, Nawal RR, Talwar S, Verma M. Current perspectives of bio-ceramic technology in endodontics: Calcium enriched mixture cement - review of its composition, properties and applications. Restore Dent Endod 2015;40(1):1-13.
10. Viola NV, Tanomaru Filho M, Cerri PS. MTA versus portland cement: Review of the literature. Rev Sul-bras Odontol 2011;8(4):446-452.
11. Parirokh M, Torabinejad M. Calcium silicate-based cements in mineral trioxide aggregate: Properties and clinical applications. Hoboken, NJ, USA: John Wiley & Sons, 2014.
12. Parirokh M, Torabinejad M. Mineral trioxide aggregate: A comprehensive literature review--part i: Chemical, physical, and antibacterial properties. J Endod 2010;36(1):16-27.
13. Roberts HW, Toth JM, Berzins DW, Charlton DG. Mineral trioxide aggregate material use in endodontic treatment: A review of the literature. Dent Mater 2008;24(2):149-164.
14. Aggarwal V, Singla M, Miglani S, Kohli S. Comparative evaluation of push-out bond strength of proroot mta, biodentine, and mta plus in furcation perforation repair. J Conserv Dent 2013;16(5):462465.
15. Walker MP, Diliberto A, Lee C. Effect of setting conditions on mineral trioxide aggregate flexural strength. J Endod 2006;32(4):334-336.
16. Malkondu O, Karapinar Kazandag M, Kazazoglu E. A review on biodentine, a contemporary dentine replacement and repair material. Biomed Res Int 2014;2014:160951.
17. Saxena P, Gupta SK, Newaskar V. Biocompatibility of root-end filling materials: Recent update. Restore Dent Endod 2013;38(3):119-127.
18. LeGeros RZ. Calcium phosphate materials in restorative dentistry: A review. Adv Dent Res 1988;2(1):164-180.
19. Duraivel D, Fayeez A, Poorni S, Diana D, Srinivasan MR. Management of Non-Vital Teeth with Open Apex Using Endosequence Root Repair Material, Mineral Trioxide Aggregate and Biodentin-A Case Series. Int J Curr Res Rev 2017;9(22):26.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareThree-year Study of Hydatid Cyst at Unusual Sites in a Tertiary Care Centre
English6267Rukhsana AkhterEnglish Duri MateenEnglish Naheena BashirEnglish Aiffa AimanEnglishIntroduction: Hydatidosis is a zoonotic infection due to the larval stage of the tapeworm echinococcus. In adults, the liver represents the prevalent site and the lungs are the second commonest site. Although these are common sites, they can occur at any site including the spleen, pancreas, peritoneum, retroperitoneum, central nervous system, soft tissues and breast. Objective: To present the histopathological spectrum of hydatid cyst at unusual sites in our hospital over three years Methods: The present retrospective study was conducted in the Department of Pathology, SKIMS during a period of 3 years from July 2016 to June 2019 Results: A total no. of 12 cases that were diagnosed as Hydatid Cyst at unusual sites on HPE during the study period were included. The male and female ratio of incidence found to be 1:1.4. Maximum no of cases i.e. 3 occurred in the brain, 2 in the spleen, 2 in thigh, 1 each in breast, omentum, kidney, sacral ala, omentum and mediastinum. Conclusion: The hydatid cyst can present in any part of the body and no site is immune. These unusual locations often produce nonspecific symptoms. Hydatid cystic disease should always be suspected in all cystic lesions of radio imaging investigations particularly in endemic areas to prevent life-threatening complications and avoid unnecessary radical surgeries.
EnglishHydatid cyst, Zoonotic infection, HydatidosisINTRODUCTION
Hydatid disease or hydatidosis (HD) is caused by the larval stage of parasite Echinococcus Infestation by which can result in encystation in various organs commonly involved organs include the liver (75%) and lungs (15%), while the remaining 10% occurs in other body organs including spleen, kidney, pancreas, peritoneum, retroperitoneum, central nervous system, soft tissues, and the breast.1,2 Theoretically, it can occur at any site except teeth, hair, and nails.3 Possible dissemination through lymphatic channels accounts for cases with hydatid cysts at uncommon sites.4,5 The exact percentage of site involvement varies and the exact incidence of unusual locations is difficult to ascertain as they are only reported as case reports.6 Breast is a rare site of involvement accounting for only 0.27% of all cases of Hydatid diseas.7-9 Cerebral involvement is very rare(13%), and more common in children.10 Cerebral hydatid cysts are usually supratentorial, the infratentorial lesions are quite rare. Intracranial hydatid cysts are commonly solitary. Multiple intracranial cysts are rare.11,12 The incidence of hydatid disease of bone from various studies is reported to be 0.5–4%. About 60% of cases of bone hydatidosis affect the spine and pelvis, 28% the long bone and 8% the ribs and scapula.13 Skeletal lesions in hydatidosis tend to present with pain or pathological fractures following trivial injuries.14
MATERIALS AND METHODS
The present retrospective study was conducted in the Department of Pathology, SKIMS during a period of 3 years from July 2016 to June 2019. All the cases of hydatid that presented at unusual sites like kidney, spleen, retroperitoneum, brain, bone and omentum were included in the study. Specimens received were fixed in formalin; HP diagnosis was made on routine H&E sections.
RESULTS
A total no. of 12 cases that were diagnosed as Hydatid Cyst at unusual sites on HPE during the study period were included. The youngest patient reported was 7years old, whereas the highest age was 60yrs (table 1). Males were 5 in number and females were 7; Male and female ratio of incidence found to be 1:1.4. Maximum no of cases i.e. 3 occurred in the brain, 2 in the spleen, 2 in thigh, 1 each in breast, omentum, kidney, sacral ala, and mediastinum (Table 2). The clinical presentation of the patients depended on o the site of the cyst ranging from headache and brain cysts and swelling and pain at the other sites (Table 3)
DISCUSSION
Hydatid disease is a parasitic infection caused by the larval form of Echinococcus granulosus and it is endemic in many sheep-raising communities, including South America, Spain, France and Italy, Eastern European countries.15,16 Our state, Kashmir, is endemic for hydatid disease.17 The adult echinococcus granulosus, a 5 mm long hermaphroditic tapeworm produces eggs that are released in the stool of infected canines.18,19 Animals such as cows, sheep and humans act as intermediate hosts and release embryos in the duodenum and enter into circulation by penetrating the intestinal mucosa.20 The liver acts as the first filter, while the lungs act as a second filter and thus, the liver is the most common site affected (75%), followed by lungs (15%), muscles (4%), kidney (2%), spleen (2%), bone (1%) etc. Only 15% of the embryos are free to develop cysts in other organs of the body.21,22
Hydatid cysts of the breast are extremely rare to find, even in endemic areas, accounting for only 0.27% of all cases.23 A total of 20 cases of breast hydatid were reported in Tunisia which forms the largest case series to date. The breast can be primarily infected or secondarily as a part of disseminated hydatidosis.23,24 Clinically, a hydatid cyst of the breast generally affects women in the age group of 30-50 years usually presenting with a painless, slowly increasing lump in the breast, of long duration without axillary lymphadenopathy. Ultrasonography and mammography are very effective in the evaluation of this mass. Despite its high cost, MR imaging has also been used in further evaluation of the mass.25 Serological investigations–indirect hemagglutination test, may be used for diagnosis and in the follow-up of patient.22 Preoperative diagnosis can be made by fine-needle aspiration cytology (scoliosis, hooklets or laminated membrane can be identified), but the use of fine-needle aspiration remains controversial with only a few studies describing this method without complications.21,26 but puncturing of the cyst may lead to an anaphylactic reaction and secondary cyst development due to spillage of hydatid fluid.27 Our case was a 45-year-old female, with swelling in the right breast with mild pain. On examination, there was swelling about 3x2 cms, soft to cystic inconsistency. FNAC was done which yielded 60 ml of clear fluid and a diagnosis of fibrocystic changes of the breast was made on microscopy.USG breast revealed a thick-walled round to oval complex infected cystic lesion measuring 69x61x54 mm in the outer quadrant of the right breast with internal septations and associated inflammatory changes in the adjacent breast parenchyma. The cyst along with the adjacent inflammatory tissue (pericyst) was removed subsequently. On histopathological examination of the specimen, the laminated membrane of the hydatid cyst was seen with chronic inflammatory infiltrate rich in eosinophils in the surrounding fibro collagenous tissue.
Cerebral involvement is very rare(13%), and more common in children.10 Cerebral hydatid cysts are usually supratentorial, the infratentorial lesions are quite rare. Intracranial hydatid cysts are commonly solitary. Multiple intracranial cysts are rare.11 Patients with intracranial hydatid cysts usually present with focal neurological deficit and features of raised intracranial pressure? the latter may be due to the large size or due to interference with the pathway of CSF. The typical intracranial hydatid cysts caused by Echinococcus granulosus, present as well defined solitary cystic lesions in the middle cerebral artery territory in parietal lobes, although they can be seen in any location including skull vault, extradural, intraventricular, meningeal, posterior fossa and brainstem.28 Operative diagnosis of hydatid cysts can be made by USG and confirmed by a CT scan. Magnetic resonance imaging is also of considerable value in intracranial hydatidosis. Surgically, intact cyst excision is the ideal treatment. Medical treatment with albendazole seems to be beneficial both preand postoperatively.11,29 The definitive diagnosis can be made by histopathologic examination.30 All three cases in our study were children with cerebral involvement. One case had multiple (three) cysts. Preoperative diagnosis was made on MRI. Surgically intact cysts were excised and histopathology was consistent with hydatid cyst. Incidence of hydatid disease of bone from various studies is reported to be 0.5.12
Primarily isolated bone hydatid is a very rare occurrence. The lesions in bone may lie dormant for 10 to 20years.31 The spine is the common site of infection.32 Hydatid disease of the spine usually spreads over the spine by direct extension from pulmonary, abdominal or pelvic infestation and most commonly affects the thoracic (52%), followed by the lumbar (37%) and then the cervical and sacral spine.33 Skeletal lesions in hydatidosis tend to present with pain or pathological fractures following trivial injuries.14 The most common radiological manifestation of skeletal hydatid disease is a lucent expansile lesion with cortical thinning. Bone hydatid disease lacks a typical clinical appearance and image characteristics on Xray or CT scan are similar to those of tuberculosis, metastases, giant cell tumour or bone cysts.34 Magnetic resonance imaging shows distinctive diagnostic features of bone hydatid disease, especially in the spine. The only de?nitive treatment when a bone is involved is complete resection of the involved area with a wide healthy margin. The combination of antihelminthic therapy, wide resection and the use of polymethylmethacrylate (PMMA) gives the best outcome in the treatment of bone hydatidosis.33 Our case was a young 16-year-old female with mild pain in the sacral region. She was already operated on in the past for hydatid cyst liver. Intraoperative findings revealed a large cyst with daughter cysts in the sacral ala area. HPE revealed laminated membranes of hydatid cyst.
The prevalence of splenic involvement ranges between 0.9% and 8%.35-37 Splenic HC generally develops using systemic dissemination or intraperitoneal spread from a ruptured liver cyst. Isolated splenic involvement is not very frequent.38 Splenic hydatidosis should be differentiated from other splenic cystic lesions, such as epidermoid cyst, abscess, hematoma, post-traumatic pseudocyst, neoplasms like lymphangioma and haemangioma.39,40 We had two cases of splenic hydatid cyst. One patient was a young 21-year-old male with disseminated hydatid disease. The second patient was elderly male 60 years and was being evaluated for CBD growth. On HPE he was found to be having two hydatid cysts in the spleen along with Adenocarcinoma of the Gall bladder in the background of Xanthogranulomatous cholecystitis.
Soft-tissue HC occurs in 0.5-4.7% of patients living in endemic areas38,41, the growth of the cyst within a muscle is difficult due to the contractility of muscles and presence of lactic acid.36,38 HC has an affinity for muscles of the neck, trunk and limbs. The increased vascularity and decreased activity of these muscle groups is the suggested cause for this increased affinity.36,38 We had two cases of soft tissue hydatid both in the thigh. One case presented as a thigh abscess. Other case had radiology suggestive of hydatid with positive hydatid serology.
Renal involvement is rare (1-4%).36,38 It is reported as the common site following liver and lung in several articles.42 They are however mostly solitary and located at the upper pole or cortex.38 Multilocular HCs can be misdiagnosed as simple renal cysts, cystic nephroma, and cystic variants of renal cell carcinoma38 and infected HCs can be misdiagnosed as renal abscess.38 The mediastinal hydatid cyst is uncommon but it should be included in the differential diagnosis of the mediastinal cyst in endemic parts of the world.43 The omental and retroperitoneal hydatid cysts are very uncommon, but these cysts can become huge.44
CONCLUSION
The hydatid cyst can present in any part of the body and no site is immune. These unusual locations often produce nonspecific symptoms. Hydatid cystic disease should always be suspected in all cystic lesions of radio imaging investigations, particularly in endemic areas to prevent life-threatening complications and avoid unnecessary radical surgeries.
Englishhttp://ijcrr.com/abstract.php?article_id=3728http://ijcrr.com/article_html.php?did=37281. Engin G, Acunas B, Rozanes I, Acunas G, Hydatid disease with unusual localization. Eur Radiol 2000;10:1904-12.
2. Kiresi DA, Karabacakoglu A, Odeh K, Karakose S. Uncommon locations of hydatid cysts, Acta Radiol 2003;44:622-36.
3. Hamamci EO, Besim H, Korkmaz A. Unusual locations of hydatid disease and surgical approach, ANZ. J Surg 2004;74: 356-60.
4. Saidi F, Nyhus LM, Beker JR, Fsicher JE. Treatment of echinococcal cyst. Mastery of Surgery. 3rd Edn. Little, Brown and Company 1998:1035–2.
5. Prousalidis J, Tzardioglou K, Sgouradis L, Katsohis C, Aletras H. Uncommon sites of hydatid disease. World J Surg 1998;22:17–22.
6. Zippi M, Siliquini F, Fierro A. Diffuse abdominal hydatidosis: role of magnetic resonance imaging.ClinTer2007;158(3):231–3.
7. Vege A, Ortega E, Cavada A. Garijo F. Hydatid cyst of the breast: Mammographic findings. Am J Roentgenol 1994;162:825-826.
8. Tukel S, Erden I, Ciftci E, Kocak S. Hydatid cyst of the breast. MR imaging findings (letter). Am J Roentgenol 1997;168:1386-7.
9. Taori KB, MahajanSM, Hirawe SR,Mundhada RG. Hydatid disease of the breast. Ind J Rad Imag 2004;14(1):64-65.
10. Aras AM, Serarslan Y, Davran R, Evirgen O, Yilmaz N. A medically treated multiple cerebral hydatid cyst diseases. J Neurosurg Sci 2010 ?54(2):79–82.
11. CiureaAV, FountasKN, ComanTC. Longterm surgical outcome in patients with intracranial hydatid cyst. Acta Neurochir (Wien) 2006?148:421–6.
12. Torricelli P, Martinelli C, Biagini R, Ruggieri P, De Cristofaro R. Radiographic and computed tomographic findings in hydatid disease of bone. Skeletal Radiol 1990?19:435–9.
13. Yildiz Y,Bayrakci K,Altay M, Saglik Y. The use of polymethylmethacrylate in the management of hydatid disease of bone. J Bone Joint Surg Br 2001?83(7):1005–8.
14. Wani R, Wani I, Malik A, Parray F, Wan A, Dar A. Hydatid disease at unusual sites. Int J Case Rep Images 2012;3:1-6.
15. Grosso G, Gruttadauria S, Biondi A, Marventano S, Mistretta A. Worldwide epidemiology of liver hydatidosis including the Mediterranean area. World J Gastroenterol 2012;18(13):1425–1437
16. Kaplan M, Aygen E, Özyurtkan MO, Bakal Ü. Cystic echinococcosis cases in Firat University Hospital between 20052007. F?rat Uni Health Sci Med J 2010; 24:109-13.
17. Khuroo MS. Hydatid disease: Current status and recent advances. Ann Saudi Med2002;22:56–4.
18. Mushtaque M, Mir MF, Malik AA, Arif SH, Khanday SA, Dar RA. Atypical localization of hydatid disease: Experience from a single institute. Niger J Surg 2012;18:2-7.
19. ?ulafi? DJ, Kati?-radivojevi? s, Kerkez M, Vuk?evi? M, rankovi? V, stefanovi? D. Liver cystic echinococcosis in humans-a study of 30 cases. Helminthologia 2007;44:157-61.
20. Garcia LS, Shimizu RY, Bruckner DA. Sinus tract extension of a liver hydatid cyst and recovery of diagnostic hooklets in sputum. Am J Clin Pathol 1986;85:519-521.
21. Das DK, Choudhury U. Hydatid disease: an unusual breast lump. J Indian Med Assoc 2002;100: 327–328.
22. Mujawar P, Suryawanshi KH, Nikumbh DB. Cytodiagnosis of isolated primary hydatid cyst of the breast masquerading as a breast neoplasm: A rare case report. J Cytol 2015;32: 270-272.
23. Moazeni-Bistgani M. Isolated hydatid cyst of the breast that developed after breastfeeding. J Surg Case Rep J Surg Case Rep 2016;2016(5): rjw071.
24. Ouedrago EG. Hydatid cyst of the breast: 20 cases. J Gynecol Obstet Biol Reprod 1986;15: 187-194.
25. Tukel S, Erden I, Ciftci E, Kocak S. Hydatid cyst of the breast. MR imaging findings (letter). Am J Roentgenol 1997;168: 1386-7.
26. Mirdha BR, Biswas A. Echinococcosis: presenting as palpable lumps of the breast. Indian J Chest Dis Allied Sci 2001; 43: 239–241.
27. Mirdha BR, Biswas A. Echinococcosis: presenting as palpable lumps of the breast. Indian J Chest Dis Allied Sci 2001;43: 239–241.
28. Ba'assiri A, Haddad FS. Primary extradural intracranial hydatid disease: CT appearance. Am J Neuroradiol 1984;5(4):474–5.
29. Akdemir G, Daglioglu E, Seçer M, Ergüngör F. Hydatid cysts of the internal acoustic canal and jugular foramen. J Clin Neurosci 2007;14(4):394–6.
30. Tüzün M, Hekimoglu B. CT findings in skeletal cystic echinococcosis. Acta Radiology 2002 Sep;43(5):533–8.
31. Hooper J, McLean I. Hydatiddiseaseofthefemur: report of a case. J Bone Joint Surg Am 1977;59(7):974–6.
32. Sapkas GS, Stathakopoulos DP, Babis GC, Tsarouehas JK. Hydatid disease of bones and joints: 8 cases followed for 4–16 years. Acta Orthop Scand 1998;69(1):89–4.
33. Karadereler S, Orakdögen M, Kiliç K, Ozdogan C. Primary spinal extradural hydatid cyst in a child: Case report and review of the literature. Eur Spine J 2002;11:500–3.3 3.
34. Martin J, Marco V, Zidan A, Marco C. Hydatid disease of the soft tissues of the lower limb: findings in three cases. Skeletal Radiol 1993?22(7):511–4.
35. Ertabaklar H, Dayan?r y, Ertu? s. research to investigate the human cystic echinococcosis with ultrasound and serologic methods and educational studies in different provinces in Ayd?n/ turkey. Turkish J Paras 2012; 36: 142-6.
36. Demirci E, Altun E, Çal?k M, suba?? ID, ?ipal s, Gündo?du ÖB. Hydatid cyst cases with different localization: region of Erzurum. Turkish J Parasitology 2015;39:103-7.
37. Özekinci S, Bak?r ?, M?zrak B. Evaluation of cystic echinococcosis cases given a histopathologic diagnosis from 2002 to 2007 in Diyarbakir. Turkish J Paras 2009;33:232-5.
38. Polat P, Kantarci M, Alper F, suma s, Koruyucu MB, Okur A. Hydatid disease from head to toe. Radiog 2003;23:475-94.
39. Sawarappa R, Kanoi A, Gupta M, Pai A, Khadri s. Isolated splenic hydatidosis. J Clin Diagn Res 2014;8:nD03-nD04.
40. Pukar MM, Pukar SM. Giant solitary hydatid cyst of spleen- A case report. Int J Surg Case Reports 2013;4:435-7.
41. Sachar S, Goyal S, Goyal S, Sangwan S. uncommon locations and presentations of hydatid cyst. Ann Med Health Sci Res 2014;4:447-52.
42. Geramizadeh B. unusual locations of the hydatid cyst: A review from Iran. Iran J Med Sci 2013;38:2-14.
43. Traibi A, Atoini F, Zidane A, Arsalane A, Kabiriel H. Mediastinal hydatid cyst. J Chin Med Assoc 2010;73:3-7.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareSocio-Cultural Determinants and Diabetes Mellitus in Rural India: A Qualitative Study
English6873Shilpa GaidhaneEnglish Quazi Syed ZahiruddinEnglish Mahlaqua Nazli KhatibEnglish Sonali ChoudhariEnglish Manoj PatilEnglish Abhay GaidhaneEnglishIntroduction: Cultural beliefs, traditional practices and social factors are some of the major determinants of health and disease. So is true for chronic diseases like Diabetes Mellitus requiring long term management. Objective: To understanding the broader socio-cultural context as important background information for effective care of Diabetics. Methods: We used ‘Explanatory Model Interview Catalogue’ interviews of 25 diabetic persons were conducted. Results: It was found that perception about Diabetes is influenced by traditions, customs and ethos. In Diabetes sign/s don’t manifest early and therefore it is usually ignored till it interferes with day to day living of individuals. Following the dietary advice was the most difficult part of diabetes care due to cultural barriers. Additionally, diabetes is so common in society is not considered to be of sufficient priority by the family. Barriers to care-seeking are health illiteracy and cost of care. Diabetics are used to taking complementary treatment along with conventional treatment, which sometimes proves to be hazardous. Language plays a key role in effective diabetes care. Due to socio-cultural factors, females often face problems in receiving appropriate care. Cultural assessment is recommended at initial assessment for identification of cultural issues in care, planning for culturally relevant and acceptable intervention and evaluation. Conclusion: Cultural values, beliefs, customs, the family pattern may be used as clues for planning diabetes care. The cultural assessment needs to focus on elements relevant to the presenting problem, necessary intervention, and participatory evaluation.
English Diabetes, Cultural determinants, Barriers for care, Cultural assessment, Rural India BACKGROUND
Globally by 2025, the adult population will increase by 64% with more than 35% of them will develop diabetes, with a consequential increase in people with diabetes by nearly 122%.1 Nearly 51 million people in India are living with Diabetes and this is expected to increase to 87 million by 2030, accounting for 20% of the world’s population of Diabetics.2,3 The last decade saw a rapid increase in the prevalence of diabetes in India.4
Optimal glycemic control for a person with diabetes requires him to undertake multiple steps which are complex and integrated, such as dietary modification, medications adherence, regular physical activity, quit tobacco use in any form and regular follow-up for monitor blood glucose.5 Social and cultural belief and traditional practices affect diabetes prevention and care at all levels like perception about diabetes, its assessment and diagnosis, care-seeking behaviour, expectation from the health care system. Since most of these activities are also influenced by a variety of social and cultural factors, therefore, understanding the broader social and cultural context can serve as important background information for effective diabetes care.6
Diabetes care providers need to acquire the necessary competencies for assessment and understanding the socio-cultural factors for diabetes prevention and management.7 With this background, the present study was conducted to explore the social and cultural issues and their potential influence on diabetes prevention and management in India and to develop a broad framework to guide health care providers for cultural assessment of persons with diabetes.
MATERIALS AND METHODS
This was a qualitative study, conducted in the rural part of central India. Data were collected by in-depth interviews. Study respondents were 25 people with type II Diabetes Mellitus and currently taking treatment. Written informed consent was taken and confidentiality of information was assured.
We used the Explanatory Model Interview Catalogue (EMIC) semi-structured interviews guides. Respondents were first asked about concepts of health and disease in general and then were asked more specifically about concepts of aetiology and prevention of Diabetes mellitus. Subsequent questions were around social, cultural practices and to catalogue potential influences of these social and cultural practices on diabetes prevention and management in rural India. The questions were open-ended so that the interviewer could probe more on concepts of interest to the study. This approach was used as it is useful in studying the illness meaning as well as understanding the social and cultural factors affecting the care of illness.8
Approval was obtained from the Institutional Ethics Committee of DMIMS. Trained Researchers conducted the interviews in the local language (Marathi) for about 30 to 40 minutes. All interviews were recorded, and the recordings were transcribed and coded. Category headings were generated from the data. Two independent researchers verified the apparent accuracy of the category system and after discussion; minor modifications were made to it.
RESULTS
Among 25 study respondents, 15 were male and 10 were female. Age ranges from 36 years to 62 years and all of them were from rural areas and five were illiterate. All respondents were on anti-diabetic medication.
Respondents mentioned the way people perceive any illness is influenced by their cultural tradition and customs. Respondents highlighted that people in rural areas often try home remedies for ailments, before going to the doctor. Most of the respondents also shared that people believe that diabetes is caused by excessive consumption of sweets and sugar. Particularly chronic illness like diabetes, which shows clinical signs and symptoms or complications in the very late stage of the disease, access to care and treatment is usually ignored till it interferes with their day to day living. One respondent stated that
“We take home remedies when we are sick, but diabetes is not considered a serious illness because it neither shows signs and nor it interferes with day to day work. We tend to ignore the treatment of diabetes even if it is diagnosed, till serious problems occur.”
Respondents mentioned they received advice from their doctors for dietary modification. However, many felt that this was the most challenging. Religious festivals and rituals, other social and cultural factors were perceived as the main barriers to following dietary advice. One respondent opined -
“Sweets are prepared during festivals and it is a ritual to serve sweets as Prasad (offerings shared with other devotees after prayer) which we cannot refuse.”
Respondents mentioned, in Indian rural areas, usually a common meal is prepared for the entire family and many felt that it is cumbersome to prepare a separate diabetic meal for one single person in the household. Respondents also find it challenging to take frequent meals at short intervals, due to their work pattern in farms. The usual dietary or meal pattern is taking morning and evening tea and two meals in a day and occasionally snacks in the evening. One male respondent expressed -
“I go to the farm for work early in the morning, so mostly, we take morning tea and go to work. I carry my food with me for lunch, which I eat between 1 and 2’o clock in the afternoon. Then I have dinner in the night when I am back at home.”
Respondents said the awareness among people from rural areas regarding diabetes was inadequate. Many are not aware of the availability of diabetes diagnosis, treatment and care services. Diabetes does not receive enough priority by the family due to a lack of obvious clinical signs at early stages. Lack of awareness regarding diabetes care and the importance of regular treatment, Indirect cost of care was found to be an important barrier. As per one of the respondents-
“We think why should we see a doctor if we don’t feel to be sick (not having sign and symptoms of illness). If we go to the hospital, the entire daytime gets invested in the hospital and we lose our wages. We need money to go to hospital and private doctors (doctors from the private sector) charge fees also”.
Respondents stated often people with diabetes on conventional anti-diabetes treatment under modern medicine, also use other treatment, like home remedies or some herbal formulations. Participants informed this is a very common practice, but many of those who are on alternative forms of treatment ignores the regular treatment under modern medicine. One participant narrated -
“After getting diagnosed as diabetic 4 years back, I am on regular medication. As per my uncle, excessive consumption of sweets is the cause of diabetes and consuming bitter items help a lot to control blood sugar. I am taking my medications regularly and also drinking Neem juice daily which is too bitter”
Respondents observed often people with diabetes, seeking care felt stressed and not able to follow the advice given by their healthcare providers. One of the reasons mentioned by participants was communication or language barriers and failure of doctors or care providers to understand the social and cultural determinants. One respondent opined -
“Doctors are always in a hurry as they have more patients waiting for them. Many times, we do not understand what he (doctor) said. Doctors in-between speak English or other languages which is difficult for us to understand. The treatment paper (prescription) is also written in English.
Female respondents talked about various social and cultural factors that act as a barrier to access health care. Females ignore their health and lack sufficient support from family for the care of their illness. Males also agree with the challenge’s female with diabetes to access care and treatment and follow the advice. One female respondent narrated-
“I work at home only and do not go for farm work. My job is to cook food. I have to take care of my children and husband and consider their choices before cooking foods. I remain engaged for an entire day with the house(hold) works get very little time for myself. My husband is unaware of what drugs I am taking for diabetes, as he is quite busy in his work. Often, I go to the hospital alone.
One more female respondent said
“Amongst all family members in a home, the women usually eat last. For them, it is a bit challenging to follow doctors’ advice. The problem is more if there are too many members in the home (joint family).
It was also observed that respondents, even female respondents were not aware of gestational diabetes or diabetes during pregnancy.
Framework to guide health care providers to undertake the cultural assessment to plan culturally appropriate care for people with diabetes
Based on the findings of the present study and literature review the study proposes a framework for cultural assessment. The framework provides a systematic approach for the analysis of beliefs, values, and practices for determining treatment and care needs.9 Cultural assessment may be done at various stages of treatment and care (Table 1).
DISCUSSION
The study finds out that culture is interpreted and negotiated by people in diverse ways, which influence their beliefs regarding diabetes in a rural community. The various themes that emerged around the influence of cultural factors on diabetes from the study are discussed below.
Beliefs regarding aetiology treatment and care for people with diabetes
Sociocultural factors influence how people perceive their overall health, illness and practices related to it.9,10 Home treatment, self-medication or the use of herbs for treating illness is deeply rooted in Indian culture. Ritual healings from spiritual healers are not uncommon. Ayurveda, the Indian system of medicine, which is culturally accepted in the Indian community for ages, states that the persons are healthy till their body fluids are in a state of equilibrium or else the illness crop up. Diabetes has been referred to in Ayurveda as a ‘Madhumeha’ occurring due to inactivity, laziness, lack of exercise, excessive sleep and excessive use of yoghurt, meat and soup of domestic, aquatic and marshy land animals, consumption of unmatured/non-aged grains, products of jaggery and sweets.10,11
The study also highlights that sociocultural factors shape the perceptions of people regarding diabetes. Similar to findings in the present study, other studies also reflected on the common perception of Indian people that diabetes is caused due to excessive consumption of sweets.11,12 Another misbelief is that consuming bitter vegetables or herbs can reduce blood sugar.13,14 Significant risk factors for diabetes mellitus like stress and worry, genetic or hereditary predisposition are ignored. People also believe that smoking and alcohol are not related to diabetes mellitus or its complications. Diabetes is not considered a socially unacceptable or stigmatized disease nor does the disease and its complications are considered significant as it appears very late.
Beliefs around nutrition and dietary habits
Culture, religion and economic condition play a major role in dietary habits and practices. Oil and sugar are an integral part of the typical Indian diet. Cultural aspects of dietary practices include the identification and methods of food preparation, selection of condiments, time and frequency of meals. Meals symbolize the ritual social aspects. For example, a non-vegetarian diet is strictly not consumed by many communities. Keeping fast is the usual practice among Hindus and Muslims. India is known for a variety of religious festivals. Sweets and high-fat foods are integral representations of festivals and celebrations. Sweets are shared and gifted as a ritual in most festivals.
Dietary management is one of the most important components of a package of care for people with diabetes. This study identified that one of the significant barriers to diabetes care was an inability to practice dietary recommendation due to sociocultural beliefs. In line with dietary habits, a sedentary lifestyle is also a major risk factor for Diabetes. A study by Gaidhane et al., revealed that nearly half of the adolescents had a sedentary lifestyle especially in the age group of 15–19 years. More girls had a sedentary lifestyle compared to boys which were attributed to social and cultural factors. In another study out of 26 diabetics, around 10.4% had a sedentary lifestyle.
Beliefs regarding care-seeking behaviour
Disease management decision is closely linked to socio-cultural background and resources available.15 Sociocultural factors influence access to the health care delivery system and how the family interact with the health care practitioners.9 Similar to findings in the present study, other studies also mentioned that even though people and the community do not consider diabetes as a stigmatized disease. Most people do not respond well to diabetes prevention, screening and care programs. The barriers include cultural beliefs, changing priorities and limited access to services.9,10 Low health literacy, lack of knowledge related to diabetes services, misconceptions about diabetes, lack of family and social support, lack of patients involvement are some of the determinants influenced by culture responsible for the limited success of the programme.11,12 Some misbeliefs result in wasting time by patients on folk medicines. This causes a delay in diabetes care until sign and symptoms of some complications emerge.12-14
This study identified that the use of home remedies and herbal formulations is popular among people with diabetes. Similar findings were observed in many other studies. People with diabetes taking conventional modern medicine (allopathic medication) frequently use folk and locally available herbal medicine as home remedies and consider it as either supplements or complementary treatment.15-17 Prayer, acupuncture, massage, hot water therapy, biofeedback, and yoga have been frequently used by persons with diabetes 16. Diabetics consuming juices of bitter herbs is common.13,14 The desire for early and maximum benefit are the most common reasons for using these remedies.18 A clear understanding of these self-care practices is crucial for Health care providers to modify treatment strategies and evaluation of outcomes. Mostly, providers are unaware of patients taking such medication.13 It is important for treating physician to be aware that many patients with diabetes may be using complementary medication that may have potential interactions with conventional medicines or have some toxic effect.16
The severity of an illness is often judged by people from the amount of pain, disability, and discomfort experienced in routine activities.9,10 People hesitate to seek health care until daily living and functioning are affected.19 This study reflects similar findings. Diabetes care providers usually get annoyed with diabetes patients for ignoring blood sugar monitoring which is helpful for early diagnosis and management of complications. Family and social support are highly recommended for adherence to diabetic care. 9 These factors highly influence effective diabetes care.9,19,20
Communication between people and diabetes care providers
Languages and local dialects keep changing across different cultures and societies. These differences also mark a significant barrier in communication. Health literacy is highly influenced by cultural beliefs and education, thereby affecting a person’s ability to obtain, interpret, and understand information about health and healthcare service.21 Care providers’ inability in communicating effectively often results in stress among care providers, poorer client understanding of the disease, less recall of information, decrease client satisfaction and premature termination of care. Our study also reported that language and communication between provider and person with diabetes are critical barriers for diabetes care. Services of a trained translator or bilingual family member can help out in such situations. But the issue of confidentiality needs to be kept in mind. Culturally adapted printed materials in patient’s primary language should be given so that the information is available to patients, their family members and other people in their support system.20,21 Diabetes care providers, to ensure effective communication with persons with diabetes needs to present themselves as a colleague, establish ties with family and friend of patients, supportive and personalized approach, demonstrating respect, avoiding confrontation and use therapeutic silence and touch.22 In a study by Gaidhane et al, 2014 assessing the challenges of primary health care providers, it was found that lack of clear guidelines (92.2 %), lack of facility for investigations (69 %), limited supply of drugs (68 %), the perception that diabetes is difficult to manage at primary care level (93.1 %) and low confidence of patients in primary care level (72.4 %) were some challenges for diabetes care at primary care level.24,25
Women and diabetes
Women are often considered as the custodian of family values and culture in India. This responsibility to maintain deeply rooted social and cultural practices and pass them on to younger generations can make it difficult for them to successfully make lifestyle changes leading to poor health outcomes.23 This study revealed that women with diabetes find it challenging to follow the advice of diabetes care provider due to these social and cultural practices. Women find it difficult to follow the care advice given by doctors and self-medication is very common in them. Furthermore, around 7% - 17% of women of childbearing age are reported to have gestational diabetes 24,25. Effective diabetes management during pregnancy is highly influenced by cultural beliefs, practices and the overall status of women in the family.23
CONCLUSION
To conclude, improving diabetes care needs a better understanding of the sociocultural determinants. To address these issues in prevention and care services for diabetes providers needs competencies for assessment and planning socially and culturally appropriate interventions. To deliver these culturally appropriate intervention and effective continuum of diabetes care needs innovative models with the multi-disciplinary team, including the lay caregiver. These specific interventions are well aligned with the local context and likely to have a significant impact on diabetes care. However, such models need to be tested and evaluated. Respondents knowledge and beliefs about Diabetes and its care found to be determined by their tradition, customs and ethos observed in their society for generations. Hence, cultural values, beliefs, customs, the family pattern may be used as clues for planning diabetes care. Such interventions are likely to have a significant impact on overall diabetes care. The cultural assessment needs to focus on elements relevant to the presenting problem, necessary intervention, and participatory evaluation.
Conflict of Interest: Nil
Funding: Nil
Authors contribution:
Shilpa Gaidhane: data collection and manuscript preparation
Quazi Syed Zahiruddi: Conceptualization of topic Data analysis, manuscript preparation
Mahlaqua Nazli Khatib: Data collection, manuscript writing and editing
Sonali Choudhari: Data interpretation, manuscript writing and editing
Manoj Patil: Data interpretation, manuscript writing and editing
Abhay Gaidhane: Conceptualization of topic, preparation of tools, Data analysis, manuscript preparation
Englishhttp://ijcrr.com/abstract.php?article_id=3729http://ijcrr.com/article_html.php?did=3729
King H, Aubert RE, Herman WH. Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections. Diabetes Care 1998;21(9):1414-1431.
Sicree R, Shaw J, P Z, editors. Diabetes and impaired glucose tolerance. In D. Gan (Ed)., Diabetes Atlas. International Diabetes Federation. Third Edition, Published by International Diabetes Federation, Belgium, 2006; 5(15):103-106.
Mohan V, Vassy J, Pradeepa R, Deepa M, Subashini S. The Indian Type 2 Diabetes Risk Score also Helps Identify those at Risk of Macrovascular Disease and Neuropathy (CURES-77). JAPI 2010;58:430-433.
Mohan V, Sandeep S, Deepa R, Shah B, Varghese C. Epidemiology of type 2 diabetes: Indian scenario. Indian J Med Res 2007;125:217-230.
Heisler M, Smith DM, Hayward RA, Krein SL, Kerr E. How well do patients’ assessments of their diabetes self-management correlate with actual glycemic control and receipt of recommended diabetes services? Diabetes Care 2003;26:738-743.
Tripp-Reimer T, Choi E, Kelley LS, Enslein JC. Cultural Barriers to Care: Inverting the Problem. Diabetes Spectr 2001;14(1):13-22.
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Tripp-Reimer T, Choi E, Kelley LS, Enslein JC. Cultural Barriers to Care: Inverting the Problem. Diabetes Spectrum 2001;14(1):13-22.
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Singh J, Singh R, Gautam CS. Self-medication with herbal remedies amongst patients of type 2 diabetes mellitus: A preliminary study. Ind J Endocrinol Metab 2012;16(4):662-663.
Sushama S, Nandita T. Study on Self-Medication and Self Diet-Management by Women of Indore City, India. Res J Recent Sci 2012;1:354-356.
Chacko E. Culture and therapy: complementary strategies for the treatment of type-2 diabetes in an urban setting in Kerala, India. Soc Sci Med 2003;56(5):1087-1098.
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Lawton J, Ahmad N, Hallowell N, Hanna L, Dougla M. Perceptions and experiences of taking oral hypoglycaemic agents among people of Pakistani and Indian origin: a qualitative study. Br Med J 2005; 3(2):1134-1136
Tripp-Reimer T: Cultural assessment. In Nursing Assessment: A Multidimensional Approach. Bellack J, Bamford P, Eds. Monterey, Calif., Wadsworth Health Sciences, 1984: 226–246
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareStudy of Knowledge on Radiation Hazards and Radiation Protection among Medical College Students in Coastal Karnataka
English7477Nanjesh Kumar SEnglish Pavan KumarEnglish Rahul HedgeEnglish Avin B.R. AlvaEnglish Sathvik RaiEnglishIntroduction: The use of ionizing radiation in medical imaging for diagnostic and interventional purposes has risen dramatically in recent years with a concomitant increase in exposure of patients and health workers to radiation hazards. Objective: To study the knowledge on radiation hazards and radiation protection among MBBS students in Dakshina Kannada district. Methods: A cross-sectional study was conducted among 134 medical students. The study comprised of administration of standardized semi-structured pre-tested questionnaire to obtain information on socio-demographic characteristics, knowledge of radiation hazards and radiation protection. Knowledge was scored, +1 was given for the correct answer and 0 for the incorrect answer. Scoring was done. Statistical analysis was performed using Microsoft Excel 2016 software and descriptive statistics were expressed. Results: The participants were aged between 18 to 22 years above, most of them were females. 93.27% of subjects had good knowledge of radiation hazards. 78 % of subjects had good knowledge of radiation personal protective devices. 6 % of subjects had poor knowledge of both radiation hazards and radiation protection. Conclusion: In conclusion, the students in the present study had good knowledge of radiation hazards but show relatively poorer knowledge of radiation protection. We are recommended that the curriculum of medical college be expanded further to provide better exposure to radiation protection and its practice so that these students on graduation will be well-grounded with the best principle of radiation protection. This in turn helps in the protection of the patients, operator and public from the harmful effects of radiation.
EnglishRadiation, Students, Radiation protectionINTRODUCTION
X-rays are a type of ionizing radiation. The use of ionizing radiation in medical imaging for diagnostic and interventional purposes has risen dramatically in recent years.1 As a result of this concomitant increase in exposure of patients and health workers to radiation hazards. X-rays have the potential to cause harmful effects and are liable to cause cancer and genetic damage.2,3 The reports from different studies demonstrated a dramatic rise in the prevalence of adverse health effects following exposure to ionizing radiation over the past two decades,4,5 the documented evidence of poor knowledge of radiation safety among various cadres of health workers at risk of occupational exposure shows the enormity of the problem at hand.6-8
The principle of radiation protection is to do those things that will minimize exposure of the patient, health workers and the public to provide benefits for the patient from the use of radiography. Medical students should have a thorough knowledge of radiation hazards and their protection protocols. The knowledge related to radiation is provided to all students during undergraduate training in colleges. Eventually, these students will start working in the radiology department after the completion of the course. Hence, their knowledge in radiation hazards and radiation protection protocols are provided in the medical curriculum is comparatively less. This makes us study the knowledge on radiation hazards and radiation protection among MBBS students.
MATERIALS AND METHODS
A cross-sectional study was done among 2nd-year MBBS students of a Medical College in Dakshina Kannada from January 2020 to February 2020. All the students in 2nd-year MBBS were included in the study by the Universal sampling Technique method. The study was comprised of 134 students. A pre-tested structured questionnaire was used for the collection of data. Informed consent was taken from all the students and confidentiality was assured about the information obtained during the study. The participants were told to answer the questions and were not allowed to discuss the matters in the questionnaire. The questionnaires consisted of 13 questions. The First 8 questions were regarding the knowledge on radiation hazards and the last 5 questions were related to knowledge on radiation protection. The responses were collected within 30 min. Exclusion Criteria: All those who were absent during the time of study and not willing to participate were excluded from the study. Ethical clearance was taken from the institutional ethics committee.
Statistical analysis was performed using Microsoft Excel 2016 software and descriptive data were expressed as frequencies and presented in the form of tables. Knowledge was scored, +1 was given for the correct answer and 0 for the incorrect answer. Scoring was done. Score 0-2 was considered as poor knowledge, 3-5 considered as average knowledge and >5 as good knowledge. Similarly scoring for radiation protection less than 2 was poor knowledge, 2 to 3 is average and more than 3 is good knowledge.
RESULTS
Table 1 shows that majority of students belonged to age 20. Female (58.96%) were more than the Males (41.04%). More students were belonging to Kerala (38.80%) followed by Karnataka (32.08%).
Table 2 shows the knowledge on radiation hazards in which more than 92% of the study subjects have given correct answer for all the questions on radiation hazards. Only in acute radiation sickness, 82.05% of study subjects were given correct answer followed by the cataract of the eye lens 86.56%.
In Table 3 the knowledge on radiation protection was comparatively less for gonad shields (55.22%) and thyroid shields (62.68%) as a protective device among study subjects.
In table 4 knowledge score on radiation hazards was good at 78.35% and the average among 14.92% of study subjects. Knowledge score on radiation protection was good at 48.50% and above average among 29.85% of the study subjects.
DISCUSSION
This study was conducted among second-year MBBS students. A total of 134 students was included in the study. It comprises 55 males and 79 females. The minimum age of the study subject was 19 years and the maximum age was 24 years.
In the present study, 93.27% of study subjects were given correct response to the questions given to assess knowledge on radiation hazards. The study was done by Srivastava, et al on knowledge, attitude, perception toward radiation hazard and protection showed that after the evaluation of overall response among 174 students, 104 (59.8%) showed a correct response.9 The study done by Nagaraj, et al. on Knowledge and perception toward radiation protection protocols among dental students showed that the overall correct responses given by PG students and interns were 75.5% and 55.5%, respectively, for the questions given to assess knowledge on radiation hazards.10
The study done by Salaam AJ et al. on-Knowledge Attitude and Practice of Radiology among Final Year Medical Students in Jo's university teaching hospital in Nigeria showed that out of 124 students only 28.2%students responded that the practice of radiology is hazardous.11 In the present study 133 (99.25%) students stated that exposure to radiation causes the hazards like Congenital malformations in babies delivered by pregnant women exposed to ionizing radiations and Cancers such as skin cancer, leukaemia.
In the present study, 78 % of study subjects had given correct response to the questions given to assess knowledge on radiation protection. The study conducted by Nagaraj, et al. on Knowledge and perception toward radiation protection protocols among dental students showed that the overall correct responses given by postgraduate students and interns were 80% and 65.5%, respectively, for the questions given to assess perception towards radiation protection.10 The study done by Eanbulele and Igbinedion on an assessment of Dental students’ knowledge of radiation protection and practice in Benin showed that Knowledge of radiation protection was abysmally poor with a mean score of 0.92 ± 0.80.12. The study done by Vidal V et al. on Radiology as seen by medical students, a survey showed an acceptable level of awareness of radiation protection.13
In the present study knowledge on the use of a personal protective device for reducing radiation exposure was good for the use of lead apron (95.52%) and less for thyroid shields (62.68%) as a protective device. The study done by Nagaraj et al. on Knowledge and perception toward radiation protection protocols among dental students showed that the majority of the participants used protective measures like a lead apron and lead barrier, but only 58% of PG students and 38% of interns used thyroid collars for their patients.10 Similar study conducted by Zope et al. among trainee dentists of Aurangabad found that their knowledge on radiation protection was satisfactory.14 In the present study sample size less and includes only 2nd-year MBBS students. Similar studies should be carried out on a large scale at the institutional and national level for better implementation of radiation protection protocols in the MBBS curriculum.
CONCLUSION
The students in the present study did have good knowledge of radiation hazards but show relatively poorer knowledge of radiation protection. This calls for more theoretical along with practical training of the undergraduate students for safety protocols and ethical practice in the field of radiation and protection. We recommend that the curriculum of MBBS in medical college be expanded further to provide better exposure to radiation protection and its practice so that these students on graduation will be well-grounded with the best principle of radiation protection. This in turn helps in the protection of the patients, operator and public from the harmful effects of radiation.
Acknowledgement: - We wish to thank all the 2nd year MBBS students who are participated in the study.
Conflict of interest --Nil
Source of funding- Nil
Englishhttp://ijcrr.com/abstract.php?article_id=3730http://ijcrr.com/article_html.php?did=3730
Karjodkar F. Textbook of Dental and Maxillofacial Radiology. 2nd ed. India: Jaypee Brothers Medical Publishers (P) Ltd.; 2009.
Park K. Park’s textbook of preventive and social medicine. 24th ed. Jabalpur, India: M/s Barnasidas Bhanot; 2017. 781-782.
Linet MS, Slovis TL, Miller DL, Kleinerman R, Lee C, Rajaraman P, et al. Cancer risks associated with external radiation from diagnostic imaging procedures. CA Cancer J Clin 2012;62(2):75-100.
National Council on Radiation Protection and Measurement. NCRP Report No. 160, Ionizing Radiation Exposure of the Population of the United States. Available at: https://ncrponline.org/publications/reports/ncrp-report-160-2/
Bury B. X-ray dose training: are we exposed to enough? Clin Radiol 2004;59:926.
Shiralkar S, Rennie A, Snow M, Galland RB, Lewis MH, Gower-Thomas K. Doctors' knowledge of radiation exposure: a questionnaire study. Br Med J 2003 16;327(7411):371-2.
Lee CI, Haims AH, Monico EP, Brink JA, Forman HP. Diagnostic CT scans, assessment of patients, physicians and radiologist awareness of radiation dose and possible risks. Radiology 2004;231:393-98.
Booshehri M, Ezoddini-Arkakani F, Nozari H. Evaluation of dentists awareness about personnel and patients national protection in Yazd dental office. Sci Res 2012;4(8):490-92.
Srivastava R, Jyoti B, Jha P, Shukla A. Knowledge, attitude, perception toward radiation hazards and protection among dental undergraduate students: A study. J Int Oral Health 2017;9:81-7.
Nagaraj T, Sreelakshmi N, James L, Veerabasaviah BT, Goswami RD, Balraj L. An assessment of knowledge and perception of postgraduate students and interns toward radiation protection protocols: A questionnaire-based study in dental colleges. J Med Radiol Pathol Surg 2016;3:5-9.
Salaam AJ, Danjem SM, Salaam AA. Knowledge Attitude and Practice of Radiology among Final Year Medical Students. Int J Sci Res 2016;6(1):161-167.
Enabulele JE, Igbinedion BO. An assessment of Dental Students’ knowledge of radiation protection and practice. J Educ Ethics Dent 2013;3:54-9.
Vidal V, Jacquier A, Giorgi R, Pincau S, Moulin G, Petit P, et al. Radiology as seen by medical students. J Radiol 2011;92: 393-404.
Zope AB, Kale LM, Sodhi SK, Kadam VD, Kale AM. Awareness of Radiation Protection Among Trainee Dentists of Aurangabad, Maharashtra: A Questionnaire Based Study. Int J Curr Res Rev 2019;11(15):1-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareAnalyzing Efficiency and Slack of Tertiary Hospitals of Punjab: A Case of Data Envelopment Analysis
English7883Singh PritpalEnglish Angra PrikshatEnglishEnglishData envelopment analysis, Input slack, Efficiency, Return to scale, Performance indicators, Operational researchINTRODUCTION
This research focuses on studying the operational efficiency of tertiary hospitals of Punjab. A study to find association was conducted with the help of analysis of data envelopment technique, which is used to find out the efficiency of tertiary medical hospitals considered for the study. Data envelopment analysis focuses on finding efficiency through input /output-based model which follows linear mathematical formulas.1,2 As the demand for healthcare services in India is increasing because of many reasons which include awareness for a preventive health checkup, Increasing population, Complexity of disease and availability are major contributors to this. Demand for health services is increasing but the availability of health services are still a big issue.2 Among health service providers in specialized care, the Private sector in Punjab is at the forefront and covering most of the area and population for providing health services. But still according to world health statistics report India is performing below average with 9 beds for 1000 patients which is very below the global average. Govt. hospitals in form of community health centres and civil hospitals also started improving their infrastructure to provide health services at a specialized level but still bed to patient ratio is not improving from last many years as compared to the global average which is a matter of concern.3,4 A considerable amount of money invested by government bodies and private sector to improve infrastructure to improve performance of services provided to people and to increase the availability of services to all but as a population of the country is huge that much infrastructure is not enough. In that case, it will become very important for hospitals whether private or government to optimally utilize their existing resources, Data envelopment analysis is a technique that is formulated to find operational efficiency in form of logical and scale efficiency of the organization and to decide their benchmark and operate according to benchmark or if there is no benchmark then set the benchmark.5 Health and healthcare services are too different aspect which needs to be distinguished, Health is related to person and healthcare services does not only involve providing hospital services but also to provide preventive services and post medical checkup services also. In the present circumstance, it has turned out to be difficult for hospitals in Punjab to guarantee increasingly productive methods for administrations. Under the current conditions, it is fundamental to discover the fitting asset blend and its use. So also, it is important to distinguish sources of relative cost wastefulness – specialized and allocate both.5,6 The centre point of this study is on surveying the hospitals in efficiency terms, for example, the perfect measure of inputs to deliver a given degree of output. The other inspiration driving this investigation has been to see how to address the issue of benchmarking in hospitals.
Organizational Structure of health Sector in Punjab
In Punjab, both the public and the private division assume a vital job in providing medicinal services administrations. It is the Department of Health and Family Welfare under the Public part which is in charge of preventive health services benefits in Punjab. There is a four-level structure of medicinal services conveyance framework in the State. This contains Sub Health Centers (SHCs)/dispensaries at the base giving the fundamental human services administrations to a population of 3000-5000 individuals. Above it, there is Primary Health Centers (PHC) serving a population of 20000-30000 individuals.6 It likewise fills in as a referral unit to six subcentres. Above Primary Health Centers there are Community Health Centers (CHC) which serves a population of 80,000 to 1.20 lac and a referral unit to four PHCs. This entire extent of SHCs, PHCs and CHCs goes under essential level healthcare where administrations are constrained. To help primary human services administration there are secondary level medicinal services.The information in Table 1 beneath demonstrates that since the 1990s, there was no impressive measure of increment in the hospital framework in Punjab.
MATERIALS AND METHODS
Research Question
This research focuses on analyzing the operational efficiency of hospitals and finding slack in the input of tertiary hospitals of Punjab to set the benchmark for inputs as comparable to outputs using data envelopment analysis.
Ethical Approval
Ethical approval of this study is taken from the senior medical officer of each district for selecting their hospital data into the study and for private hospitals data is collected after taking due permission from an administrative officer of the hospital where data is not present online on their website
Study design
Data was collected from 48 hospitals in form of inputs and outputs decided for calculating efficiency from 1st January 2018 to 31st December 2018 and the selection of hospitals was made from the list of the hospitals being run by doctors registered with the Indian Medical Association. Government and private tertiary level hospitals with bed strength of more than 40 were chosen for study from the Jalandhar, Hoshiarpur, and Amritsar and Ludhiana districts of Punjab. Hospitals are selected based on quota sampling. Quota sampling is done on basis of the size of the hospital, according to the objective of this research different sized hospitals are required and three different sizes of tertiary hospitals are considered i.e. 16 Small sizes hospital having bed strength between 40 and 70, 16 medium sizes between 70 to 100 and 16 large size hospitals having bed strength more than 100.
Data analysis
Envelopment study of data is a linear mathematical programming-based method for estimating the efficiency of the general execution of hierarchical units of hospital considering the availability of various data sources in form of input and outputs. DEAOS free online \\tool was used for calculating efficiency. This study introduces the input /Output technique and uses a manual proportion of effectiveness, i.e.: how relative efficiencies can be settled around the centre on inefficient units set.7,8 Efficiency is usually considered in the range of [0, 1]. Efficiency requires a typical arrangement of loads to be applied to overall units and loads is given to each input as per the DEA model. 9,10
Inputs and outputs Variables from the hospital for data envelopment analysis
Inputs data collected is in form of number of beds, number of doctors, Nurses, Outpatient department hours per week of working, laboratory hours per week and paramedical staff supporting major staff doctors and administrative staff. Outputs for calculating efficiency are Outpatient visits, Inpatients and laboratory cases, Maternal and child healthcare all these are types of cases treated and the number of cases. Basically for efficiency calculation input and output are required. Data of some of the hospitals are collected through secondary sources and for some hospitals data is collected by visiting hospitals and meeting administrative officers of hospitals after taking due permission from SMO of the district. Outpatient and inpatient are two very important parameters to calculate efficiency in previous studies efficiency is calculated on basis of these two only, But in this study laboratory cases and maternal and child healthcare is also included which gives proper efficiency of variable return to scale which is technical efficiency. All the outputs are in form of the number of cases treated. Data is collected from hospitals from annual book release and by directly visiting the hospitals. The study includes the outputs efficiently arranged. Those can be isolated into faculty, resources, or assets and administrations.
RESULTS
In first stage efficiency of hospitals were analyzed, data envelopment analysis was utilized to analyze and evaluate the efficiency of the hospital and in the second stage, slack values were analyzed ( Taable 2).
Slack Value in Large size Hospital
Slack values are value which is added to inequality constraint to convert into to equality .Slack values of large size hospitals mostly working at either increasing return to scale or diminishing return to scale all the values are derived from data envelopment analysis of data collected .hospitals can employ even 19 per cent fewer doctors to achieve the same output of outpatients. .With the same number of inputs they can cater to a large number of outpatient’s (i.e. 65000) ( Table 3).
Slack Value in Medium and Small Size Hospital
Hospital administrators have three options to them for optimally utilizing wasteful assets use: Expanding network of hospital. Decreasing hospital inputs; or Hospital organization process changes in medical hospitals.11,12All together for the wasteful medical hospitals to have gotten moderately productive, as a gathering, they would have expected to build their outpatient division visits more than (18.05%) and in small size hospitals patient visits can be increased to 9.5% ( Table 4 and 5).
DISCUSSION
Present research indicates that smaller hospitals have an efficiency more than the larger size and mid-size medical hospitals as demonstrated in the above table smaller size hospitals average efficiency is .80. The mean efficiency of medium size hospitals is .75 and the large hospital is .71. As per our outcomes, small size medical hospitals are generally more efficient. The objective of small, medium and big size hospitals are different as some concentrate more on care and quality some on quantity. Big size hospitals will in general increment their physical, innovative and medicinal work limit in request to understand the requirement of far-reaching care. Nature of care may essentially increment in parallel with the addition of these limits. Strangely, huge size medical hospitals are not performing like small and medium-size medical hospitals as far as scale effectiveness. As results estimate large size hospitals don‘t work at an ideal scale size. , big size hospitals may frame smaller patient consideration units inside their association. Along these lines, large size medical hospitals not just take out the negative impact of their non-ideal scale size, yet besides they make explicit treatment units for patients.
Other than efficiency estimation this DEA model also provided important information about return to scale of hospitals, Outcomes uncovered that all hospitals understudy would result in:
The constant return to scale in 4 (8.33%) medical hospitals, suggesting that their healthcare administration outputs would increment to a similar extent. This implies hospitals were working at their most gainful scale sizes.14,15
Increasing return to scale in 23 (47.9%) medical hospitals, suggesting that their healthcare administration outputs would increment by a more prominent extent. These medical hospitals subsequently expected to expand their size to accomplish ideal scale, for example, the scale at which there is a steady return to scale in the connection among inputs and outputs.16,17
Decreasing return to scale in 21(43.7%) hospitals, inferring that their healthcare administration outputs would increment by a small extent. medical hospitals would have expected to decrease their size to accomplish ideal scale.18,19
Slack values are valued which is added to inequality constraint to convert into equality. The present study uncovers immense slack in the utilization of assets, for example, specialists, Beds. With better observing, medical hospitals will have the option to serve more patients with existing assets and in the current situation in the healthcare area in India, the ideal use of assets in the segment is vital. in the first stage efficiency of hospitals are calculated and only 4 % of hospitals are working at an efficient scale and 44 % of hospitals are inefficient and now in this stage research is to find out the cause of inefficiency that will cause input slack in Hospitals. In this stage, analysis is applied to find whether these medical hospitals ideally use contributions for human services to give out-persistent and good administrations to the overall population if not what is the actual reason for inefficiency and how much each hospital can contribute to out to reach efficiency.
CONCLUSION
As indicated by research outcomes and findings, small size hospitals are generally more efficient and have higher patient satisfaction as compared to other hospitals. Medical hospital likewise concentrates on the reasons for low efficiency before reconfiguring their entire hospital structure. The organization through decentralized set-up and the small zone level authorities screens these associations and study slack of every hospital. The activity of government is essential in ensuring that finding slack is used effectively. This will require making execution based pointers to screen the slack in the input of hospitals and plan to manage to particularly work on which area. In this research also many slacks are identified in each hospital infrastructure use which can be regulated to other paces if it is surplus. Moreover when an organization is big then management must ensure efficiency consideration. The health care industry can adopt Benchmarking scheme of their services with the best one in the same field to improve efficiency. The reason for benchmarking in medicinal services is to improve effectiveness, nature of care, understanding healthcare and patient satisfaction.
RECOMMENDATIONS
DEA data envelopment analysis can be applied in the organization to solve the proper staffing problem. Utilizing information to examine staff distribution can prompt operational productivity. Information on patient volume can be recorded and medical hospital staff can be suitably designated dependent on the equivalent. The present research demonstrates that smaller medical hospitals have a more significant level of effectiveness than bigger and medium-size emergency hospitals as appeared in the above table smaller size hospitals normal efficiency is .80. So two hundred bed hospitals are more efficient than one 200 bed hospitals. In a country like India here Population is very high small hospitals with more outreach is required. Healthcare operations management is urgent for the effective working of healthcare administrations, particularly when the medicinal services segment is experiencing a lot of changes.
FUTURE SCOPE OF STUDY
This study provides the idea about how to evaluate the efficiency of tertiary hospitals. This methodology can act as a tool to benchmark efficiency for hospital authorities for best in that area. The technique utilized right now i.e. Data envelopment analysis to distinguish the hospitals on basis of efficiency, which can improve their administration. In past, the checking and assessment of these foundations have stayed a significant issue. The administration through decentralized set-up and the area level healthcare specialists can screen these foundations. The job of the government is very basic in guaranteeing that hospital infrastructure is utilized optimally. This will require creating execution based pointers to screen these awards using data envelopment analysis. The procedure recommended right now help healthcare agencies to recognize moderately less efficient medical hospitals. The methodology suggested in this research can be used by the Department of Health and Family Welfare to develop benchmarks for monitoring and evaluating the performance of both public and private hospitals. Based on the findings the steps can be initiated to improve the efficiency of resource use in hospitals. DEA can be applied to compare hospital performance after Electronic Medical record system implementation
Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed
Financial Support and sponsorship: Nil
Conflict of interest: No conflict of interest.
Author Contribution:
Dr Pritpal Singh and Prikshat Kumar conceived the idea. Dr Pritpal Singh developed the theory and performed the computations. Prikshat Kumar verified the analytical methods and encouraged Dr Pritpal Singh to investigate and supervised the findings of this work. Both authors discussed the results and contributed to the final manuscript. Dr Pritpal Singh and Prikshat Kumar wrote the manuscript.
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2. Bhat R, Verma BB, Reuben E. An empirical analysis of district hospitals and grant-in-aid hospitals in Gujarat state of India. Health Policy Development Network (HELPONET), 2001;13(2):1-40.
3. Hassan M, Tuckman HP, Patrick RH. Hospital length of stay and probability of acquiring infection. Int J Pharm Health Mark 2010;4(3):24?38.
4. Ghosh B, Bhadia U. A study on the inpatient system in a state hospital of Calcutta. Indian J Commu Med 1990;15(1):135?149.
5. Mogha SK, Yadav SP, Singh SP. Performance evaluation of Indian private hospitals using DEA approach with sensitivity analysis. Int J Manag Eco 2012;11(2):1-2.
6. Singh PP, Farhan M, Asif M. An Empirical Study on Association of Operational Efficiency and Customer Satisfaction in Tertiary Hospitals in Punjab. Int J Manag Eco 2019;10(9):295-301.
7. Oussofiane A, Dyson RG, Thanassoulis E. Applied data envelopment analysis. Eur J Oper Res 1991;5(2):1-15.
8. Jat TR, Sebastian MS. Technical efficiency of public district hospitals in Madhya Pradesh, India: A data envelopment analysis. Glob Health Act 2013;(6:2):17-42.
9. Kirigia JM, Emrouznejad A, Sambo LG, Munguti N. Using data envelopment analysis to measure the technical efficiency of public health centers in Kenya. J Med Syst 2004;2(8):155-66.
10. Sheikhzadehl Y, Roudsari AV, Vahidi RG .Public and private hospital services reform using data envelopment analysis to measure technical, scale, allocative, and cost efficiencies. Health Promot Perspect 2012;2(2);28-41.
11. Singh Z. Aging: The triumph of humanity-are we prepared to face the challenge? Indian J Public Health 2012;5(6):189-195.
12. Davey S, Raghav SK, Muzammil K, Singh JV, Davey A, Study on the role of rural health training centre (RHTC) as a supporting component to a primary health care system for NRHM programme in district Muzaffarnagar (UP). Int J Res Med Sci 2014;2(6):53-61.
13. Austin MJ, Shawcross DL. The outcome of patients with cirrhosis admitted to intensive care. Curr Opin Crit Care 2008;14(2):202-7.
14. Charif I, Saada K, Benajah D, Abkari ML. Predictors of Intra-Hospital Mortality in Patients with Cirrhosis. J Gastroenterol 2014;14(4):141-8.
15. Wong F, Bernardi M, Balk R, Christman B, Moreau R, Garcia-Tsao G, et al. Sepsis in cirrhosis: report on the 7th meeting of the International Ascites Club. Gut 2005;54(5):718-25.
16. Viasus D, Garcia-Vidal C, Castellote J, Adamus J, Verdaguer R, Dorca J, et al. Community-acquired pneumonia in patients with liver cirrhosis: clinical features, outcomes, and usefulness of severity scores. Med. 2011;90(2):110-8.
17. Alsherif A, Darwesh H, Badr M, Eldamarawy M, Shawky A, Emam A. SOFA Score as a Predictor of Mortality in Critically Ill Cirrhotic Patients. Life Sci J 2013;10(2):178-181.
18. Hamza RE, Villyoth MP, Peter G, Joseph D, Govindaraju C, Tank DC, et al. Risk factors of cellulitis in cirrhosis and antibiotic prophylaxis in preventing recurrence. Anna Gastroent 2014;2:28.
19. Jalan R, Fernandez J, Wiest R, Schnabl B, Moreau R, Angeli P, et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol 2014;60(6):1310-24.
20. Maiwall R, Kumar S, Chaudhary AK, Maras J, Wani Z, Kumar C, et al. Serum ferritin predicts early mortality in patients with decompensated cirrhosis. J Hepatol 2014;61(1):43-50.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareReview on Constipation in Adults
English8488Monali P. WalkeEnglish Sheetal SakharkarEnglishConstipation is a gastrointestinal tract condition that can lead to abnormal stools, uncomfortable storage and passing with pain and stiffness. Acute constipation may required intestines to close, and that may also require surgery. Constipation occurs due to improper diet, Diseases conditions can causing secondary reason forgot constipation. Prevalence of constipation 16 % in adult worldwide (ranging from 0.7 % to 79 %); Prevalence present in adults 60 to 110 years of age at 33.5 %. Great Britain given opinion which is based on the study conducted on healthy person concluded that three bowel movements per week and three bowel movements per day, 99 % of the population an accurate evaluation of the symptom must provide an aware and guided background of the relevant characteristics. Initial history and physical examination, rectal examination, Endoscopy, Anorectal manometry, Barium enema, Colonic transit study are important tools for the diagnosis of Constipation. Pharmacological treatment Bulk-Forming Agents, Stimulants, osmotic agents, Stool Softeners and Emollients, Traditional Chinese Medicine and last one is surgical treatment is given to client for relieving constipation. Abnormal stools, uncomfortable storage and passing with pain and stiffness occurred in constipation. There are lots of risk factor responsible for getting constipation like diet, disease condition etc. For treatment need to medication and also surgical treatment is also available for treating constipation.
English Constipation, Cause, Diagnosis of constipation, Pharmacological treatmentINTRODUCTION
Constipation is a condition of the gastrointestinal tract which can lead to abnormal stools, uncomfortable storage passage with the feeling of stiffness and pain. Acute constipation may cause a close of the intestine, and that also need to conduct surgery.1 There is no any till ideal constipation definition. Therefore, the main initial approaches can be considered in history and physical examination. By given selfly –reporting constipation and with the help of the formal parameters, several meanings are defined. Other definitions of chronic constipation have been considering in a scientific way like secondary causes like medication, systemic diseases or may be neurological. It is deemed idiopathic or may primarily cause constipation.2
Pathogenesis is multifactor which can put the effect of genetic predisposition, lack of sufficient fluid intake capacity, decreased mobilization, socioeconomic status, disruption of the hormonal balance, side effects of medicinal products. Constipation is a chronic basically issue of the gastrointestinal tract that causes several community expenditures with an approximate incidence of 1% to 80%, where the disease is distinguished by broad regional variability. It may be led to a broad prevalence of constipation rates.3-5
DEFINITION
Constipation is not a disorder, just a symptom. Constipation is more generally regarded as infrequent bowel movements, typically less than 3 stools a week. Nevertheless, individuals may have other grievances, including:
Straining of intestinal movements
Excessive time required for a bowel movement to pass
Rough stools
Pressure with intestinal movements secondary to strain
Pain in the abdomen
Bloating abdominally.
The feeling of an incomplete evacuation of the intestines.
PREVALENCE AND EPIDEMIOLOGY
In studies, constipation is described differently, most of the questionnaire-based research study will result from the organic condition. 16% of adult constipation (ranging from 0.7% to 79%) worldwide prevalence of constipation. Prevalence was attributed to 33.5 per cent in adults aged 60 to 110 years).5 This state is heterogeneous, associated with client quality of life and health care facility use. Iran has a constipation rate of 1.4 per cent to 37 per cent. Age refers to the high prevalence of chronic constipation.6-8
EPIDEMIOLOGY OF CONSTIPATION
Great Britain's opinion on health individuals reported that 99 % of the population had three bowel movements in a week and three bowel movements in a day.7 52% of constipation was described as straining revealed by Sandler and Dross man to move through faecal material. In the survey conducted on young adults who do not seek medical attention, the phase of going through hard stools was felt by 44 %, it was only the uncommon movement of stools felt by 32 %, and 34 % were unable to pass.
RISK FACTOR
The following are factors that may increase your risk of chronic constipation:
Be an older adult
Being a woman
Dehydrated being
Eating a diet deficient in fibre
Getting little or no physical activity
Taking certain medications, including sedatives, opioid pain medications, some antidepressants
Take certain drugs, including sedatives, opioid pain medications, certain antidepressants, or blood pressure control medications
Having a mental health condition including anxiety or an eating disorder8
CAUSES
Constipation most often happens when waste or stool passes too slowly or can not be easily removed from the rectum via the digestive tract, which can cause the stool to become harsh and dry. Many potential causes of chronic constipation.10
Diet
A low-fibre diet, low fluid intake, or dieting can cause or worsen constipation. Dietary fibre helps minimise colonic transport time, raises the bulk of stool but softens stool at the same time. Diets low in fibre, therefore, can contribute to primary constipation.9
Medications
Many drugs have side effects of constipation. Some include opioids, diuretics, antidepressants, antihistamines, antispasmodics, anticonvulsants, tricyclic antidepressants, antiarrhythmics, beta-adrenoceptor antagonists, antidiarrheals, ondansetron-like 5-HT3 receptor antagonists, and aluminium antacids.
Medical conditions
Metabolic and endocrine disorders that may lead to constipation include hypercalcemia, hypothyroidism, hyperparathyroidism, porphyria, chronic kidney disease, pan-hypopituitarism, diabetes mellitus and cystic fibrosis. Constipation is normal in people with muscle and myotonic dystrophy, too.
Psychological
A recurrent cause of constipation is the voluntary withholding of the stool. The choice of withholding may be attributed to reasons such as pain fear, public bathroom fear, or laziness. A mixture of reinforcement, water, fibre, and laxatives can be effective in solving the issue when a child keeps in the stool.
Congenital
A variety of birth-related illnesses may cause constipation in children. As a group, they are rare, the most common being Hirschsprung's disease (HD). Congenital structural defects can also lead to constipation, including anterior anus displacement, anus imperforation, strictures, and small left colon syndrome.10
Blockages in the colon or rectum
Blockages may delay or interrupt the passage of the stool in the colon or rectum. Includes causes:
Narrow skin tears around the anus (anal fissure)
A blockage (bowel obstruction) in the intestines
Colon carcinoma11
Problems with the nerves around the colon and rectum
The nerves that cause muscles in the colon and rectum to contract and pass stool through the gut may be affected by neurological disorders. Includes causes:
Damage to body working nerves (autonomic neuropathy);
Multiple Sclerosis
Parkinson's illness12
Difficulty with the muscles involved in the elimination
Pelvic muscle problems that require bowel movement can cause chronic constipation. Such issues can involve:
Impossibility of relaxing pelvic muscles to facilitate bowel movement (anism)
Pelvic muscles, which do not adequately manage relaxation and contraction (dyssynergia).13
Conditions that affect hormones in the body
In your body, hormones help regulate fluids. Constipation can result from diseases and conditions that upset the hormone balance, including:
Parathyroid gland overactive (hyperparathyroidism);
Breastfeeding
Underactive (hypothyroidism) thyroid14
PATHOPHYSIOLOGY
Although the frequency of bowel movements is mostly concentrated on in the definition of constipation, consumers can have a wide variety of concerns. The frequently cited lower limit of appropriate stool frequency is three per week and two or fewer stools per week can be used as one of the Rome criteria. The frequency was only one out of six in this summary (including straining, hard stools, and a feeling of incomplete evacuation). Symptoms have been described as straining (decreasingly significant), painfully hard stools, unproductive urges, infrequency and a feeling of incomplete evacuation in patient records.15
SYMPTOMS
The main symptoms of constipation are:
Difficulty passing stool
Straining when passing stool
Passing less stool than usual
Lumpy, dry, or hard stool
Passage of liquid faecal seepage
Infrequent passage of stool
Frequent but non productive desire to defecate
Straining at stools
Nausea and vomiting
Anorexia
Abdominal distention
Dull headache
Pain with defecation
A loss of appetite16
DIAGNOSTIC EVALUATION
Variables may be identified for clinical evaluation like stool frequency, consistency, symptom intensity, prolonged obstruction and history of avoiding a defecation call, and feeling of insufficient evacuation. To determine common constipation signs (alarming signs), medical history and environmental causes and also medicines.17,18
Endoscopy: Procedures such as flexible sigmoidoscopy (FS) or colonoscopy are useful by using chronic laxative and mucous lesions to obtain evidence of the cause of unexplained symptoms.17
Anorectal manometry: It is a diagnostic tool for evaluating the activity of anurectomal strain, which can also show rectal compliance with rectal reflexes, rectal sensation etc.
Balloon expulsion testing: It is used for the measurement of dssynergic defecation in addition to anorectal manometry. In addition, BET was administered as part of pelvic floor dyssynergy identification or to separate patients with constipation without pelvic dyssynergy.18
Barium enema: It is a colon X-ray technique for evaluating improvements or structural defects of the colon filled with contrast like metallic material (barium).
Colonic transit study: For recording, a client may need to swallow a capsule with either a radiopaque marker or a wireless device. The movement of the capsule through the colon will be documented on X-rays for several days.19
COMPLICATION
1. Faecal incontinence: Overflow through moving through isolated obstructing bolus may cause fresh faecal matter to complicate the diagnosis of chronic constipation unless a rectal examination has been performed.
2. Haemorrhoids: In the anorectal junction plexus and anterior venous anastomoses, excessive stress and intra-abdominal pressure raise venous pressure.
3. Anal fissure: During the evacuation of hard stool, trauma and sudden tearing of the anal mucosa is an indicator of the situation, but the internal anal sphincter spasm is assumed to be the perpetuating cause that triggers the relative ischemia.20
PHARMACOLOGICAL TREATMENT
Chronic constipation medications can be classified as bulk forming agents, stool softeners and emollients, osmotic agents, stimulants, chloride channel activators.
Bulk-Forming Agents: This agent is used in fibre supplements. With the water, these agents can be extended to increase the bulk of the stool and also to increase bowel movements. E.g. Ex. Psyllium (ispaghula husks), polycarbophil of calcium, methylcellulose.
Stool Softeners and Emollients: Usually used stool softener such as Sodium docusate that has a deterrent effect. There is no other known research that compares its independent efficacy with placebo; one double-blind randomised trial showed docusate in chronic constipation was lower than psyllium.
Osmotic Agents: Because of its hyperosmolar existence, agents such as polyethene glycol (PEG), lactulose, sorbitol, and magnesium hydroxide often absorb and retain water and promote stool movement. The stools increase in softness and thickness.
Stimulants: Stimulants work on the colon's myenteric plexus and boost peristaltic contractions. They also elevate water absorption from the lumens. Ex. Senna, Bisacodyl
Chloride Channel Activators: These are essentially the bicyclic fatty acids that can help activate chloride from 2 channels to increase the secretion of intestinal fluid in the apical gastrointestinal epithelium membrane.20,21
Other Treatments: Lactobacillus and Bifid bacteria should be considered to be associated with harmful pathogens that are bound to the enterocyte surface and then protect the mucosa as symbiotic flora present in the large intestine. These probiotic bacteria are used for the treatment of chronic constipation and other inflammatory bowel diseases. A retrospective study has confirmed that bifid bacterium supplementation can be used for the treatment of dietary hypo-caloric constipation.
SURGICAL TREATMENT
If surgical treatment has failed in constipated patients and the use of colon through mechanical emptying can also be administered to clients with slow bowel movements using an enema system as an alternative to treating patients. Colectomy with ileorectal anastomosis can be used in patients with refractory sluggish transit constipation as a treatment option.21
NURSING MANAGEMENT
Encourage the client to take 2000 to 3000 mL/Day of fluid, if not medically contraindicated.
Enable the client to eat at least 20 g of dietary fibre a day (e.g. raw fruits, fresh vegetables, whole grains)
Regular exercise and activity
NURSING DIAGNOSIS
Constipation related to pain on defecation
Constipation related inactivity
Constipation related decreased dietary intake
DISCUSSION
Constipation is a condition of the gastrointestinal tract which can lead to abnormal stools, uncomfortable storage passage with the feeling of stiffness and pain. Acute constipation may cause the closure of the intestines, and that also need to conduct surgery. 24. 2% is the prevalence of functional constipation. Age is associated with a High prevalence of chronic constipation. There are many risk factors are can be discussed which can cause constipation like Age and gender distribution, medication, diet, Disorders. Diagnostic evaluation, complication and its management included in this review.
CONCLUSION
In the general population, the prevalence is 16% (Range between 0.7 % and 79 %). Clearly understanding the pathophysiology of chronic constipation and information regarding the pharmacological agent's efficacy and safety can help physicians treat and manage constipation symptoms. The efficacy of various treatment methods has been given. Substantial frustration in patients does not have to be avoided. It comes to mind that who required for identifying the components in their terms. Complete history, full physical, digital rectal evaluation and detailed evaluation. Lubiprostone and linaclotide can be considered as two beneficial medications if the effects are not minimized by the laxatives. It is worth noting that biofeedback therapy is a valuable tool to boost symptoms of bowel and dyssynergic defecation. When medical care of constipated patients has failed, surgical procedures can be implemented.
Acknowledgement: Authors acknowledge the immense help received from Principal Dr. Seema Sing, Dept. Of MSN,SRMMCON. Sawangi (M), Wardha, Author also thankful Ms. Ranjana Sharma HOD of dept. of MSN, Sawangi (Meghe), Author also Thankful Guide Ms. Sheetal Sakharkar, Clinical Instructor, Dept. Of MSN, Sawangi (Meghe), for her guidance. The author acknowledges 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
Financial support: Self
Englishhttp://ijcrr.com/abstract.php?article_id=3732http://ijcrr.com/article_html.php?did=37321. Bronner F. Nutritional Aspects and Clinical Management of Chronic Disorders and Diseases. CRC Press; 2002.Vol 1.352
2. Camilleri M, Thompson WG, Fleshman JW, Pemberton JH. Clinical management of intractable constipation. Ann Intern Med 1994;121(7):520–528.
3. FORCE T. Guidelines for the diagnosis and therapy of the vein and lymphatic disorders. Int Angiol 2005;21(2):68-107.
4. Abbott RD, Petrovitch H, White LR, Masaki KH, Tanner CM, Curb JD, et al. Frequency of bowel movements and the future risk of Parkinson’s disease. Neurology 2001;57(3):456–462.
5. Schnabel L, Buscail C, Sabate J-M, Bouchoucha M, Kesse-Guyot E, Allès B, et al. Association between ultra-processed food consumption and functional gastrointestinal disorders: Results from the French NutriNet-Santé cohort. Am J Gastroenterol 2018;113(8):1217–1228.
6. Cutler DM, Ghosh K, Messer KL, Raghunathan TE, Stewart ST, Rosen AB. Explaining the slowdown in medical spending growth among the elderly, 1999–2012. Health Aff (Millwood) 2019;38(2):222–229.
7. Walter S, Hallböök O, Gotthard R, Bergmark M, Sjödahl R. A population-based study on bowel habits in a Swedish community: prevalence of faecal incontinence and constipation. Scand J Gastroenterol 2002;37(8):911–916.
8. Pearce J, Hunter JO. Nutrition and the Gastrointestinal Tract for Athletes. Sport Exerc Nutr. 2011;264–280.
9. Gant SG. Diseases of the Rectum, Anus, and Colon: Including the Ileocolic Angle, Appendix, Colon, Sigmoid Flexure, Rectum, Anus, Buttocks, and Sacrococcygeal Region, C by Samuel Goodwin Gant With 1128 Illustrations on 1085 Figures and 10 Insets in Colors Saunders Company; 1923.
10. de Lorijn F, Reitsma JB, Voskuijl WP, Aronson DC, Fiebo J, Smets AM, et al. Diagnosis of Hirschsprung’s disease: a prospective, comparative accuracy study of common tests. J Pediatr 2005;146(6):787–792.
11. Rees PM, Fowler CJ, Maas CP. Sexual function in men and women with neurological disorders. Lancet 2007;369(9560):512–525.
12. Catto-Smith AG. 5. Constipation and toileting issues in children. Med J Aust 2005;182(5):242–246.
13. Albain KS, Barlow WE, Shak S. Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal women with nodepositive, oestrogen-receptor-positive breast cancer on chemotherapy: a retrospective analysis of a andomised trial. Lancet Oncol 2010;11:55–65.
14. Gordon JS. The Effectiveness of Reflexology as a Adjunct to Standard Treatment in Childhood Idiopathic Constipation A Single Blind Randomised Controlled Trial [PhD Thesis]. Edinburgh Napier University; 2007.
15. Whorton JC. Inner hygiene: constipation and the pursuit of health in modern society. Oxford University Press, USA; 2000.
16. Avila-Rencoret FB. A Novel Endoscopic Scanning-Probe Device for Rapid Screening of Gastrointestinal Dysplasia [PhD Thesis]. Imperial College London; 2014.
17. Lam TJ. Clinical approach to anorectal disorders. 2015; Thesis. Research VU University Amsterdam, graduation VU University Amsterdam. unknown (vumc.nl)
18. Kathpalia H, Sharma K, Doshi G. Recent trends in Hard Gelatin capsule delivery System. J Adv Pharm Educ Res 2014;4(2).
19. Andrews GR. Diarrhoea and constipation in geriatric practice. Cambridge University Press; 1999:152–158.
20. Bao HF, Liu L, Self J, Duke BJ, Ueno R, Eaton DC. A synthetic prostone activates apical chloride channels in A6 epithelial cells. Am J Physiol-Gastrointest Liver Physiol. 2008;7(3):172-6.
21. Wallis M, McKenzie S, Gyett S, Rayner K, Ellem F, Gass E, et al. Help patients win the constipation battle: Best practice in the prevention and treatment of constipation in adults under 65 years. J Adv Pharm Educ Res 2003;4(5):23-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareTo Study the Correlation of CRP Levels with Functional Ability in Chronic Obstructive Pulmonary Disease Patients in Tertiary Health Care in Western UP
English8994Singh YogitaEnglish Mittal SantoshEnglish Singh Dhirendra PratapEnglishIntroduction: Chronic Obstructive Pulmonary Disease (COPD) is a common, preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. The chronic airflow limitation that is characteristic of COPD is caused by a mixture of small airways disease (e.g. Obstructive bronchiolitis) and parenchymal destruction (emphysema), the relative contributions of which vary from person to person. 1 Objective: The present study aims to investigate whether an increased concentration of high sensitivity (hs) CRP is related to the degree of lung function impairment, systemic inflammation, body composition, exercise capacity, and quality of life in patients with advanced COPD. Methods: A cross-sectional study was conducted in the Department of Medicine of LLRM Medical College and Associated SVBP Hospital Meerut in 2019-2020. Sixty-one Patients with Chronic Obstructive Pulmonary Disease of age 35 years and above undergoing treatment Meerut were included in this study. Each subject has undergone a thorough workup for history and physical examination to fulfil the inclusion & exclusion criteria, Routine Hematological & Biochemical Investigations were carried out. Results: Mean age of the patients was 56.16 years. Most of the patients were in the age group 56-65 (44.26%). The majority fell in the range of 36-65 years (85.24%). The majority of the patients were males (77.05%). Females were few 14 (22.95%). The hsCRP levels correlated negatively with FEV1 (p-0.000) and 6-minute walking distance (p-0.000). Correlation between hsCRP levels and BMI was also negative though not significant (p-0.32). BODE index and hsCRP levels had a highly significant positive correlation (p-0.000). Conclusion: High sensitivity C-reactive protein levels correlated significantly with functional ability parameters in chronic obstructive pulmonary disease patients. There was a significant correlation with forced expiratory volume in 1 second, exercise capacity assessed by six-minute walking distance test and, Body-mass index, airflow Obstruction, Dyspnea, and Exercise( BODE index). However, the levels did not correlate significantly with body mass index.
EnglishChronic Obstructive Pulmonary Disease (COPD), CRP, BODE INDEX, BMI, hsCRP, Forced expiratory volume in 1 second (FEV1).INTRODUCTION
COPD represents a disease state characterized by poorly reversible airflow limitation that is usually both progressive and associated with an abnormal inflammatory response of the lung. Among the leading causes of death and disability, COPD is the one that is rising most rapidly. COPD is currently the sixth-leading cause of death and the 12th leading cause of morbidity worldwide.2 By the year 2020 COPD is expected to be the third leading cause of death and the fifth leading cause of disability. The World Bank estimates that COPD is responsible for more than 29 million disability-adjusted life years (DALY) and 1 million years of life lost per annum.
Cigarette smoking is the most important risk factor leading to the development of COPD. Smoking accounts for nearly 90% of cases of COPD. Yet, for unknown reasons, only 20% of Cigarette smokers develop COPD. COPD is the major cause of mortality and morbidity in India. In most non-tubercular chest clinics in India, COPD constitutes 25-30 % of the cases. In various studies by Jindal et al and Malik et al. on different populations in north India, its prevalence varied from 1% in urban nonsmokers to 21% in rural smokers.3-6 Disease is equally prevalent in rural and urban India. Males are more affected than females. Traditionally COPD has been viewed as an inflammatory disease of the lungs but several studies have shown that this pulmonary inflammation may also be detected in the systemic circulation. This has been shown by increased circulating concentrations of interleukin-6 and acute phase reactants such as CRP in COPD patients.
As reviewed by Can et al. several systemic inflammatory mediators, like tumour necrosis factor-alpha (TNF), ILs, APPs, CRP, LBP and leukocytes are increased in COPD. CRP increases in systemic inflammation as compared to healthy controls. The Higher Level of CRP in COPD has been scrutinized in the Third National Health and Nutrition Examination Survey.7 Which showed that 41% of patients with moderate COPD (FEV1> 50- 80%pred) had a CRP above 3 mg/l and 6% above 10 mg/l. while as much as 52% of patients with severe COPD (FEV121 kg / m2 at the enrollment into the study.
All the patients had FEVI/FVC ratio Englishhttp://ijcrr.com/abstract.php?article_id=3733http://ijcrr.com/article_html.php?did=3733
Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis management and prevention of Chronic Obstructive Pulmonary disease. Updated 2017. Global Initiative for Chronic Obstructive Lung Disease, 2019
World Health Organization. World health statistics 2008. Geneva: BMJ Publishing Group, 2008.
Jindal SK. A field study on follow up at 10 years of the prevalence of COPD and PEFR. Ind J Med Res B 1993;98:20-6.
Malik SK. Profile of chronic bronchitis in North India- The PGI experience (1972-1985). Lung India 1986;4:89.
Jindal SK, Malik SK. Tobacco smoking and non-neoplastic respiratory disease(Proceedings of the UICC workshop "Tobacco or health".) In: Tobacco, and health: the Indian scene. Sanghavi LD, Notani P, eds. Tata Memorial. Centre, Bombay: 1983;p30.
Malik SK, Bchcra D, Jindal SK. Reverse smoking and COPD. Br J Dis Chest 1983;77:199.
Mannino DM, Gagnon RC, Petty TL, Lydick E. Obstructive lung disease and low lung function in adults in the United States: data from the National Health andNutrition Examination Survey, 1988-1994. Arch Intern Med 2000;160:1683-89.
Romain Pauwels. COPD: The Scope of the Problem in Europe. Chest 2000;117:332-5
Redelmeier DA, Bayoumi AM, Goldstein RS. Interpreting small differences in functional status: the six-minute walk test in chronic lung disease patients. Am J Respir Grit Care Med 1997;155:1278-82.
Pride NB, Soriano JB. Chronic obstructive pulmonary disease in the United Kingdom: trends in mortality, morbidity and smoking. Curr Opin Pulmon Med 2002;8:95-101.
Goris AHC, Schols AM, Weling-Sheeoers CAP. Tissue depletion about physical function and quality of life in patients with severe COPD. Am J Respir Crit Care Med 1997;155:A498.
Chailleux E, Fauroux B, Binet F. Predictors of survival in patients receiving domiciliary oxygen therapy or mechanical ventilation: a 10-year analysis of ANTADIR Observatory. Chest 1996;109:741-9.
de Torres JP, Cordoba-Lanus E, Lopez-Aguilar C. C-reactive protein levels and clinically important predictive outcomes in stable COPD patients. Eur Respir J 2006; 27:902-7.
Mannino DM, Ford ES, Redd SC. Obstructive and restrictive lung disease and markers of inflammation: data from the Third National Health and Nutrition Examination. Am J Med 2003;114(9):758-62.
Koechlin C, Couillard A, Cristol JP. Does systemic inflammation trigger local exercise-induced oxidative stress in COPD? Eur Respir J 2004;23(4):538-44.
Broekhuizen R, WoutersEF, Creutzberg EC. Raised CRP levels mark metabolic and functional impairment in advanced COPD. Thorax 2006;61:17-22.
BPinto-Plata VM, Mullerova H, Toso JF. C-reactive protein in patients with COPD, control smokers, and non-smokers. Thorax 2006;61:23-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareClinical Characteristics of a Severe Headache and Its Impact on Personal Life of Patients
English95100Reshu GuptaEnglish Prahlad DhakarEnglish Jitendra AhujaEnglish Raman GroverEnglishIntroduction: Headache and its consequent suffering may bring about limitation in daily activities and patients’ job performance leading to an economic burden on society. Objective: The study aimed to identify characteristics of a severe headache and its impact on the personal life of patients. Methods: The present study was a cross-sectional hospital-based study conducted at the outpatient department of Medicine at RUHS College of Medical Sciences, Jaipur and associated hospital. It comprised of data collected from 100 patients complaining of headache due to multiple causes and demographic and clinical variables were obtained thereof. A detailed history followed complete physical examination. Patients were asked to fill up and complete a structured questionnaire to obtain the headache characteristics. All analyses were stratified by age and gender. Final diagnoses were made as per criteria laid down by the International Headache Society. Results: Common migraine (28.99%) and vascular headache (28.99%) constituted the majority of cases of the primary headache; with tension headache comprising only 6%. The mean age of the study population was 32.66 ± 14.63 years with an average age of onset being 26.05 ±32 years. Primary headache was found to be more common among married patients (82%) as compared to singles with females outnumbering males. Males were more likely to be fatigued and miss work. Mood changes and appetite loss were more common in females. Conclusion: There is a significant number of serious headache sufferers in Rajasthan who experience a profound social as well as personal impairment as a result of their illness. Further research is recommended to evaluate the extent of interpersonal and personal disability due to this disorder.
EnglishCommon Migraine, Vascular headache, Tension headache, Mood changesINTRODUCTION
Headache or Cephalalgia is a very common disabling neurological disorder and a major causative factor responsible for public ill-health. Headache and its consequent sufferings represent a tangible personal and social burden worldwide. This highly prevalent disorder is shown to have a significant impact on the patients’ quality of life and job performance leading to a considerable economic burden on society.1,2 However, on account of its episodic nature and the lack of associated mortality, it has not figured highly on the radar of public health initiatives. Nonetheless, frequent and severe headaches have a major impact on the quality of life, of which patients are the best source of information.3 Although most patients receive their treatment in the primary care setting, headache remains a significant component of a neurologist’s practise and domain.
Its prevalence is estimated at 11% - 48% in children6 and 6% -71% in adults.4,5 A higher prevalence has been found in Europe and North America4,6,7 than in Asian and South American countries.8,9 Significant sex differences have been found in multiple epidemiological studies of headache.10
Amongst the primary headaches, tension headache is the most common followed by migraine and cluster headache which is the rarest but most severe type. Out of these primary headaches, migraine has received the most attention from medical researchers, and a large number of studies have examined its correlates. The importance of primary headaches is also emphasized by their global distribution, duration (the majority being life-long conditions) and debilitation that imposes lifestyle restrictions among the large population. 47% population, in general, is estimated to have suffered from any kind of headache at least once within the last year. The recent publication of the Global Burden of Disease survey in 2010 (GBD, 2010) highlights headache as one of the common causes of disability worldwide.11 Other studies reveal tension-type headache and migraine as the second and third most prevalent disorders in the world (after dental caries); Migraine being the seventh highest.12
Headache is an important ailment and one of the leading reasons for outpatient visits to consultants specialized in Neurology and Internal Medicine. Its impact on the disability it imposes is less well documented, so the present study was designed to identify and analyze characteristics of a severe headache and study its impact on the personal lives of patients.
MATERIALS AND METHODS
The present study was a cross-sectional hospital-based study conducted in close association with departments of Internal Medicine, Physiology and Biochemistry at Rajasthan University of Health Sciences College of Medical Sciences and associated group of hospitals after approval from the institutional ethical committee. After obtaining individual informed consent, data from 100 patients attending the outpatient department of Internal Medicine at the associated hospital and complaining of headache due to multiple causes such as meningitis, anaemia, thrombosis, stress, etc. were used to obtain demographic and clinical variables. A physician evaluated the patients with a detailed history followed by a complete physical examination. Each patient was asked to fill up and complete a structured questionnaire to obtain the demographic data and characteristics of their headache. Demographic information in the questionnaire included variables like age, gender, marital status and occupation. The demographic questionnaire was followed by neutral screening questions for headache e.g. “Is this the first attack of the headache of your life?” and “Is this worst headache ever?” etc.). Questions investigating the characteristics of headache like the duration and site of pain, severity, time frame of onset, type of pain, the interval between episodes, aggravating and relieving factors, associated symptoms and possible related conditions were also included in the questionnaire. All analyses were stratified by age and gender. Final diagnoses were made as per the criteria laid down by the International Headache Society (International Classification of Headache Disorders (ICHD)-3 Beta).13
RESULTS
The mean age of the study population (10-75 years) was 32.66 ± 14.63 years. The average age of onset was 26.05 ± 5.32 years. There was no significant difference in mean age between males (32.41 ± 15.86 years) and females (32.92 ± 13.37 years).
Primary headache was found to be more common in married patients (82%) as compared to those who were single; with females outnumbering males (Table 1). The age distribution revealed that the maximum number of cases belonged to the patients between 20 to 30 years followed by a gradual decline, particularly the following menopause in females (Figure 1).
Descriptive analysis of various types of primary headache amongst 20-30 years old patients (n=35) is depicted in Figure 2. The common migraine (n=10, 28.99%) and vascular headache (n=10, 28.99%) constituted the majority of cases of the primary headache, whereas tension headache was the least accounting for only 6%.
An attempt was made to assess the personal impact of 100 cases with five predesigned questions (Table 2). All cases (100%) had complaint of the worst ever headache and the key finding in the majority of individuals (92%) was persistent pain despite measures being taken. It was even observed that the majority of individuals (67%) had complaint of the past headache of a different character. Because of observing the activity of onset of headache, the predominant finding was its appearance while doing a routine activity rather than watching television or working at the office (Table 2).
In the majority of the cases, the headache was gradual in onset (61%), lasting for 1 to 5 days duration (64%) and located diffusely (70%). The typology of pain (squeezing/pressing) was almost the same in the cases which accounted for approximately 45%, but the respondents were only 12% in case of mixed typology. The associated symptoms were widely varied in the respondents except that all (100%) of the individuals had nausea/vomiting or photophobia followed by giddiness and vertigo in 86% of the cases (Table 3).
The respondents (answerable in yes or no) were of varied opinions regarding perception of headache except for sleep and work, which signified that sleep and work were significantly affected (Table 4). The majority of the respondents had perceived mood changes (96%) and fatigue (89%) followed by giddiness (74%) and loss of appetite (71%). Males were more likely to be fatigued and miss office/work. Mood changes and appetite loss were more common in females. The visual component of sensitivity to bright light and blurred vision was perceived by almost half of the respondents. Visual hallucinations were found in none of them.
DISCUSSION
Headache has a substantial effect on the patients’ state of wellbeing, quality of life and work-oriented performance leading to personal, professional and socio-economical deficits. Not consistent with the epidemiology of headache, the patients consulting physician in our study were almost the same concerning gender though females outnumbered males very slightly. However, according to a Canadian population-based epidemiological study, Migraine is about thrice as common in females as in males.10 The female to male ratio in our overall referred population was 1.04:1, reflecting the gender-biased prevalence in the general population. A study conducted on dental students in India also reported a higher prevalence in females as compared to males.11-13 Our population of patients was also similar to other clinic-based studies of headache in terms of age and various demographic features.14-18 Sufferers in our study fell into the most productive years of their lives i.e. 20 to 40 years. More than three quarters (82%) of our study population was married with headaches leaving bad repercussions on family relations and activities. Lipton et al. established that the prevalence of migraine varies as a function of age. Migraine is most prevalent between the ages of 25 and 55. Part of the reason the condition has such a big impact in the workplace is that it affects people during their peak productive years.19
A considerable strength of the study was the use of a common questionnaire on the study population to avoid any bias. The aspects of personal impact identified in Table 4 are worth dwelling on, because they signal effects that are constant and/or cumulative, not merely present during headache episodes. Such consequences are serious impositions on life, particularly the effects on education, career and earnings.
In a Canadian study, over 70% of referrals accounted for migraineurs and tension-type headaches made up a much smaller proportion (7.9%) of the referrals.10 In contrast to this, migraine was the second most dominant diagnosis in our referred patient population. It was of course likely that a significant proportion of our migraine population had tension-type headaches as well. In a study conducted in North America, Gerth et al. reported that migraineurs are absent from work for almost 17 days each year. Also, sufferers reported only 46% effectiveness while at work with migraine symptoms.19,20 Von Korff et al. reported headache induced decreased work effectiveness, and while working with headache, in the order of 41% for migraine and 24% for other headache types.21 In an American study, Hu et al. estimated huge annual indirect costs incurred by employers because of migraine. Almost 85% indicated a reduced capacity to perform housework or chores.22 Additionally, Matilde Leonardi and Alberto Raggi in their narrative review described the multifactorial aspect of the burden of migraine in everyday life including work-related activities.23
While contemplating the burden of headache, we tried to distinguish between individual and societal burden. The individual burden was determined by symptoms during attacks, by anticipation of symptoms between attacks, and by the reduced quality of life in people suffering from this disorder as compared with the general population. The results showed that family, social, and recreational activities were impacted severely in sufferers of headache. As far as work was concerned, absenteeism and reduced effectiveness was observed in patients especially males. In tune with the above studies, our study also showed a profound debilitating effect of headache on work and family life.
Conclusion
It can be concluded that there is a significant number of serious headache sufferers in Rajasthan who experience social as well as personal impairment as a result of their illness. Further research is recommended to evaluate the extent of interpersonal and personal disability due to this disorder. Although, the present study posed a limitation that all other headache clinics and tertiary care hospitals in the state did not participate in this study and therefore, our results are not population-based and may be subject to referral bias. In regards to the headache frequency and disability experienced by the patients in our study sample, our study population likely represents the severity of the headache patient pool, comprising of patients who may have posed a treatment challenge to primary care physicians.
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 declared
Financial support: None declared
Englishhttp://ijcrr.com/abstract.php?article_id=3734http://ijcrr.com/article_html.php?did=3734
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareAbnormality Detection from X-Ray Bone Images using DenseNet Convolutional Neural Network
English101106Shukla AbhilashEnglish Patel AtulEnglishIntroduction: According to the survey of the World Health Organization and the International Agency for Research on Cancer; the death rate because of cancer is increasing day by day. It is preferable to detect cancer at its earlier stage or detect any kind of lesion which can cause cancer in the future. This paper shows how Artificial Intelligence especially the Convolutional Neural Network of Deep Learning can be used to detect abnormality from X-Ray bone images. Objective: To detect the abnormality in bone from X-Ray Images. Methods: MURA (Musculoskeletal Radiographs) dataset is used which was prepared by the Stanford ML group. Dataset is identified and categorized into training and validation dataset and after that data preprocessing techniques are used. This help in making the dataset convenient for the DenseNet (Densely Connected Convolutional Networks) Model. Tenserflow and Keras libraries are used to build DenseNet model. Results: Classification Table and Confusion Matrix methods are used to evaluate the performance of DenseNet (Densely Connected Convolutional Networks) Model for the detection of abnormality in bone from X-Ray Images. By using this proposed model more than 85% accuracy achieved. Conclusion: The result obtains from the proposed model will be helpful to the radiologist to make better decisions. This independent model can further be used to detect cancer of bone from X-Ray Images
English Bone Abnormality, Bone, Convolutional Neural Network, Deep Learning, DenseNet, X-Ray ImagesIntroduction
Deep Learning had a remarkable impact on the various field like agriculture, medical, education, weather, entertainment and many more in recent years. Deep Learning is the extension of machine learning methods. These methods are based on artificial neural network.1
Figure 1: Figure shows that Deep Learning is the subset of Machine Learning, which come under the umbrella of the Artificial Intelligence domain2
The main benefit of deep learning over machine learning is that deep learning automatically detects features, which may be 1000 times more than what human can think of. Deep Learning techniques used to train computers to learn through a huge amount of data. A computer program can be developed which can gain knowledge and analyze any data like a human does, through deep learning methods. Research in this field has broad-spectrum in the applications like Chatbots to improve Customer experience, Spelling and grammar correction for errorless text writing, detect objects from the satellite which help to aerospace and military, auto-generation of music as per human mood, service which senses the unusual things in industrial plant, cancer cell detection in medical research, self-driving car and many others. In many of the fields, we have to deal with images rather than data or information. In computer vision, this process is well known as image processing.3 This image processing can be done more effectively and efficiently with the help of Convolution Neural Network, which is modelled, based on the concept of deep learning. Convolution Neural Network has three layers called input, hidden and output. Various operations like convolution, activation, padding, pooling, normalization and Softmax performed to obtain the desired output in the hidden layer of CNN.CNN become a newly emerging field in deep learning through which image can be read and analyze to produce a significant result.4
Cancer, which considers as an abnormal growth of the cell, which harasses and spread into any human body organ. As per the record of ICMR-NICPR (Indian Council of Medical Research – National Institute of Cancer Prevention and Research), More than 2.5 million people live with this disease in India. On average 7 lakhs of new patients with cancer registered and around 6 lakhs of people lose their life because of cancer. According to World Health Organization (WHO), Worldwide 9.6 million people were estimated to have died from cancer in 2018.6 As per the survey of the International Agency for Research on Cancer (IARC), there will be 21.7 million cases and 13 million deaths in 2030 predicted because of cancer. In India, over 80% of cancer cases are detected late and patiently advised to go for advanced-stage treatment.7
This death rate can be reduced if cancer detected in its early stage or by finding any abnormality and rectify it before it converted into a tumour. A total of 75 types of cancer exists from which one type is bone cancer. In bone cancer, also there are 19 types of bone cancer. Osteosarcoma and Ewing are the most commonly seen bone cancer. The research objective is to detect any kind of abnormality or lesion on the bone from x-Ray images at its early stage so that patient gets the treatment at the earliest and can be saving from cancer.
The number and the table suggest the diversity and adversity in the disease like cancer. So, at the preliminary stage of the research, it has been found some thrust in the research of such disease prevention and prediction. Medical science is completely dependent upon the various images, which is generated or prepared because of some report testing. It is diagnosed only after the body is completely affected by that particular disease. The changes in the body when the body host the decease initially, the decease can be prevented or cured if the reports are tested and examined in early stage.
With this initial perception and state of mind, the research title was proposed where such decease prevention can be done in a much more efficient and effective manner where the chance of decease can be predicted in advance. The corrective steps can be taken to avoid it too completely. Moreover, Artificial Intelligence with Computer Vision and Image Processing was found most suitable to research the domain.3
Literature Survey
Substantial and remarkable work in the field found which is targeting disease detection and prevention with aids of Information Technology. Algorithm to calculate the mean intensity and tumour size from MRI images found useful in the prediction of various stages of cancers and bone cancer.8 It has been found that Region Growing Algorithm is the best-suited method to detect tumour size and bone cancer stage.9 Various other methods like texture-based region growing, cellular automata edge detection, K-Mean clustering algorithm and algorithm to calculate the sum of pixel intensities also gives the better result to detect cancer. Image segmentation is one of the important processes in image processing to detect bone cancer from radiography image.10-17 Especially biomedical image segmentation based on Entropy, Fuzzy Entropy and the Least Square Method used for it.18 Neuro-Fuzzy Classifier found useful to detect different types of brain cancer. In this various image processing techniques are used and the grey level Co-occurrence Matrix method used to extract texture features.19
The Computer Vision and Image Processing Feature Extraction and Pattern Classification (CVIP-FEPC) software found useful to detect bone cancer from thermography images. Thermography image gives better result than X-Ray, CT scans and MRI images in terms of diagnostic time and reduces the exposure of radiation.20 There are some advantage and disadvantage of using computer-aided diagnosis and it was found that it gives more accurate result.21 Osteosarcoma and Ewing’s sarcoma having similar early symptoms like fever and pain.22 Radiologist also remain in dilemma in the detection of these two types of bone cancer and this type of case, computer vision technology with artificial intelligence will be useful to the radiologist to draw a decision. Looking at the era and the current trends with futuristic technologies, the tasks related to image processing can be dominated by the use of Artificial intelligence especially Convolutional Neural Network techniques of Deep Learning.23-29
Research Rationale and Methodologies
Dataset
Dataset is one of the most crucial and important components for any deep learning algorithm. This dataset is divide into three categories called training dataset, validation and test dataset. The training dataset is the backbone for any deep learning project. The training dataset is used to train the neural network and it comprehends and memorizes such data, which help the network to predict the information in future. More amount of data in the training dataset result in accurate prediction. After having a dataset, the next important task is to label the data properly so that the neural network can be trained to answer Yes/No or can able to categories the data. Validation data set are used to identify the overfitting and under the fitting issue of neural network.
To trained the proposed CNN model, MURA (Musculoskeletal Radiographs) dataset is used which was prepared by the Stanford ML group and it also opens access. MURA is one of the largest datasets of bone X-Ray images. MURA contains around 60,000 images from 14,656 studies. All images are labelled as either normal or abnormal by the radiologist. To obtain a better result these images are classified into seven different classes Elbow, Finger, Forearm, hand, homers, shoulder and wrist.
Data Preprocessing and Augmentation
Data preprocessing is the important step by which data can be frame into proper input for the proposed model. In data preprocessing, we did the following three things. Data augmentation is the method in deep learning to increase the training dataset so that it results proposed model to provide an accurate result. Normally, Data Augmentation can be done by rotating image and flipping the images horizontally and/or vertically. For the research, we had to increase the dataset for training and validation. To achieve this, we had rotated the images to 30 degrees and flipped them horizontally. Because of this, we had 2 times more dataset than we started initially.
Image Normalization
Normalization of images is required so that the proposed neural network don’t face the issue of over or underfitting. To normalize all images, the mean and standard deviation are calculated. This mean value subtracted from each image mean intensity value and then subtracts the result value by standard deviation.
Resizing Images
All CNN model required a fixed size of images as input. The model, which we proposed, required all image in 224 x224 sizes.
Proposed Model
DenseNet Model used to detect any kind of lesion from bone X-Ray images. DenseNet is architecture is based on ResNet Architecture. The major difference between ResNet and DenseNet is that in ResNet each layer received a piece of knowledge from its immediate previous layer while in DenseNet each layer received collective knowledge from all its previous layer. Batch normalization, ReLU and 1x1 Convolution operations to reduce the model complexity and size. This layer considers a bottleneck layer in DenseNet.
Advantage of DenseNet
• Better Gradient Flow
• Efficiency gained in parameter and computation
• Diversified feature identified instead of co-related feature
With the help of TensorFlow and Keras library, DenseNet with 169 layer and Sigmoid activation function can build such that in each epoch model loss is decrease and accuracy increase.32
RESULTS
Confusion Matrix and classification table methods are used to evaluate the model for lesion detection of X-Ray bone images.
Conclusions
From the result, it can be concluding that the DenseNet Model can be used to detect abnormality from Bone X-Ray images. The same model can be used for cancer detection which can be detected from x-Ray images. These results will be helpful to the radiologist for the prediction of abnormality and presence of cancer in the X-Ray and MRI images.
Acknowledgement: The authors acknowledge the support received from the researcher whose articles are cited and included in references to this manuscript. The authors are also grateful to authors/ editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Conflict of Interest: NIL
Source of Funding: NIL
Authors’ contribution
Mr. Abhilash Shukla: Study Design, Literature Review, Dataset, Implementation
Dr. Atul Patel:: Data and Statistical analysis, Manuscript Review
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareDevelopment of Fenofibrate Solid Dispersions for the Plausible Aqueous Solubility Augmentation of this BCS Class-II Drug
English107116Purushottam S. GanganeEnglish Vaibhav M. MuleEnglish Debarshi Kar MahapatraEnglish Nilesh M. MahajanEnglish Harigopal S. SawarkarEnglishBackground: Fenofibrate is having a broad spectrum lipid-lowering activity that produces substantial reductions in the fatty components. The drug belongs to BCS Class-II and therefore in the majority of the cases, low pharmacodynamic potentials have been perceived and it requires serious improvement in the aqueous solubility. For the marked solubility enhancement of drugs, solid dispersions are an impressive approach. Objective: The current research emphasized on development of fenofibrate solid dispersions by employing the polymer PEG 6000 in the ratio of 1:1 w/w - 1:3 w/w using the fusion method/melting method/solvent evaporation method for enhancing the aqueous solubility that will directly affect the dissolution process and ultimately the therapeutic bioavailability. Methods: The fabricated solid dispersions were characterized for production yield, drug content, bulk density, tapped density, Carr’s index, Hausner’s ratio, angle of repose, and cumulative drug release. The transformation from crystalline nature to the amorphous form was characterized by DSC and XRD techniques. The optimized solid dispersion formulations were further loaded into the capsule and the content uniformity, drug content, disintegration time, and cumulative drug release in both the medium for 1 hr duration were investigated. Results: The physical mixtures exhibited the lowest drug release in the range 15%-26% at increasing polymeric ratios while the highest drug release was observed in solid dispersion batch prepared by fusion method (22.56%-34.89%). FT-IR studies indicated no incompatibilities between the drug and the polymer. Conclusion: This interesting investigation opened new avenues for the pharmacotherapeutic perspective of this drug in the upcoming future, both pharmacodynamically and pharmacokinetically by enhancing the aqueous solubility
English Fenofibrate, Solid dispersion, Solubility, Bioavailability, Dissolution, EnhancementINTRODUCTION
Fenofibrate is a fabric acid derivative having a broad spectrum lipid-lowering activity (lipid-modifying effects) that is primarily mediated by the activation of the therapeutic target - peroxisome proliferator-activated receptor-α (PPAR-α).1 This privileged drug produces substantial reductions in the plasma triglyceride level and low-density lipoprotein (LDL) level while increasing the levels of high-density lipoprotein (HDL).2 It acts to endorse the clearance of chylomicrons and very-low-density lipoproteins (VLDL) and can improvise the irregularities associated with the LDL subfractions with a transfer from dense LDL.3 The drug is principally recommended in improving the lipoprotein atherogenic phenotypes in patients suffering from coronary heart disease (CHD).4 Fenofibrate also possesses pleiotropic potentials such as reducing the levels of pro-inflammatory factors, C-reactive protein, fibrinogen, and simultaneously improves the microvascular outcomes as well as flow-mediated dilatation that results in clinical effectiveness.5 It is broadly absorbed exclusively in the presence of food and the presence of albumin, it is quickly transported through the human bloodstream.6 In normal persons, at a steady-state with customary doses of 100 mg t.i.d., it initiates a series of episodes that result in the lessening of apolipoprotein C-III formation in the human liver with a long plasma half-life of ~30 hrs.7 Fenofibrate is taken up by both the key organs of the human body; liver and kidney. Apart from a small percentage (~5%) reduction before the conjugation process at the ketone moiety, in the human urine, the majority of the drug is excreted as a conjugate. Englishhttp://ijcrr.com/abstract.php?article_id=3736http://ijcrr.com/article_html.php?did=3736[1] Mahapatra DK, Bharti SK. Handbook of Research on Medicinal Chemistry: Innovations and Methodologies. New Jersey: Apple Academic Press, 2017.
[2] Mahapatra DK, Bharti SK. Medicinal Chemistry with Pharmaceutical Product Development. New Jersey: Apple Academic Press, 2019.
[3] Borkar SS, Mahapatra DK, Wakodkar SB, Baheti JR. Pharmacology-III. Nagpur: ABD Publications Private Limited, 2020.
[4] Chhajed SS, Bastikar V, Bastikar AV, Mahapatra DK. Computer-Aided Drug Design. Pune: Everest Publishing House, 2019.
[5] Chhajed SS, Upasani CD, Wadher SJ, Mahapatra DK. Medicinal Chemistry. Nashik: Career Publications Private Limited, 2017.
[6] Mahapatra DK, Bharti SK. Drug Design. New Delhi: Tara Publications Private Limited, 2016.
[7] Shivhare RS, Mahapatra DK. Medicinal Chemistry-II. Nagpur: ABD Publications Private Limited, 2019.
[8] Puranik MP, Mahapatra DK. Medicinal Chemistry-III. Nagpur: ABD Publications Private Limited, 2020.
[9] Karen HD, Prajapti PH, Chaudhary JI. BCS Classification and Solubility Enhancement Techniques for BCS Class II and BCS Class IV drugs. Eur J Biomed 2019;6(1):663-670.
[10] Bhaskar R, Monika OL, Ghongade RM. Solid Dispersion Technique for Enhancement of Solubility of Poorly Soluble Drug. Indian J Pharm Biol Res 2018;6(2):43-52.
[11] Singh G, Kaur L, Gupta GD, Sharma S. Enhancement of the Solubility of Poorly Water-Soluble Drugs through Solid Dispersion: A Comprehensive Review. Indian J Pharm Sci 2017;79(5):674-687.
[12] Das PS, Verma S, Saha P. Fast dissolving tablet using solid dispersion technique: a review. Int J Curr Pharm Res 2017;9(6):1-4.
[13] Dhawale P, Mahajan NM, Mahapatra DK, Mahajan UN, Gangane PS. HPMC K15M and Carbopol 940 mediated fabrication of ondansetron hydrochloride intranasal mucoadhesive microspheres. J Appl Pharm Sci 2018;8(8):75-83.
[14] Dangre PV, Godbole MD, Ingle PV, Mahapatra DK. Improved Dissolution and Bioavailability of Eprosartan Mesylate Formulated as Solid Dispersions using Conventional Methods. Indian J Pharm Edu Res 2016;50(3): S209-S217.
[15] Kumar B. Solid Dispersion-A Review. PharmaTutor. 2017;5(2):24-29.
[16] Sharma DK. Solubility enhancement strategies for poorly water-soluble drugs in solid dispersions: A review. Asian J Pharm 2016;1(1):9-19.
[17] Khan S, Gangane PS, Mahapatra DK, Mahajan NM. Natural and Synthetic Polymers assisted Development of Lurasidone Hydrochloride Intranasal Mucoadhesive Microspheres. Indian J Pharm Edu Res 2020;54(1):213-222.
[18] Mahajan NM, Zode GH, Mahapatra DK, Thakre S, Dumore NG, Gangane PS. Formulation development and evaluation of transdermal patch of piroxicam for treating dysmenorrhoea. J Appl Pharm Sci. 2018;8(11):35-41.
[19] Mahajan NM, Wadhwane P, Mahapatra DK. Rational designing of sustained-release matrix formulation of Etodolac employing Hypromellose, Carbomer, Eudragit and Povidone. Int J Pharm Pharm Sci 2017;9(12):92-97.
[20] Gangane PS, Ghughuskar SH, Mahapatra DK, Mahajan NM. Evaluating the role of Celosia argentea powder and fenugreek seed mucilage as natural super-disintegrating agents in gliclazide fast disintegrating tablets. Int J Curr Res Rev 2020;12(17):101-108.
[21] Kazi FS, Mahajan RK, Mahapatra DK, Mahajan UN. Formulation development of innovator equivalent extended release tablets of gliclazide: A way ahead to Generic medicines. J Pharm Sci Pharmacol 2017;3:1-8.
[22] Patil MD, Mahapatra DK, Dangre PV. Formulation and in-vitro evaluation of once-daily sustained release matrix tablet of nifedipine using rate retardant polymers. Inventi Impact Pharm Tech 2016;4:190-196.
[23] Mahajan NM, Pardeshi A, Mahapatra DK, Darode A, Dumore NG. Hypromellose and Carbomer induce bioadhesion of Acyclovir tablet to vaginal mucosa. Indo Am J Pharm Res 2017;7(12):1108-1118.
[24] Godbole MD, Mahapatra DK, Khode PD. Fabrication and Characterization of Edible Jelly Formulation of Stevioside: A Nutraceutical or OTC Aid for the Diabetic Patients. Inventi Rapid: Nutraceut. 2017;2017(2):1-9.
[25] Umaredkar A, Dangre PV, Mahapatra DK, Dhabarde DM. Fabrication of chitosan-alginate polyelectrolyte complexed hydrogel for controlled release of cilnidipine: A statistical design approach. Mater Technol 2018;1:1-11.
[26] Pusala SV, Gangane PS, Mahapatra DK, Mahajan NM. Hydrophilic and Hydrophobic Matrix System Engineered Development of Extended Release Tablets of Oxybutynin Chloride. Int J Pharm Sci Res 2020;11(9):4603-4611.
[27] Gangane PS, Kadam MM, Mahapatra DK, Mahajan NM, Mahajan UN. Design and formulating gliclazide solid dispersion immediate release layer and metformin sustained release layer in bilayer tablet for the effective postprandial management of diabetes mellitus. Int J Pharm Sci Res 2018;9(9):3743-3756.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareIncidence, Clinical Features and Complications in Patients with Appendicolith Associated Acute Appendicitis
English117121Mishra TEnglish Patra GTEnglish Vardhan AEnglish Cheleng AGEnglish Samal DEnglishIntroduction: Acute appendicitis is one of the most frequent causes of abdominal pain in patients presenting to the emergency department (ED) who need surgical treatment with an incidence of 100 to 200 cases per 100,000 person-years. In this study, we have decided to see the incidence, clinical features and complications associated with appendicolith associated acute appendicitis in the patients which presented to us with clinical features of acute appendicitis in our tertiary care hospital setup Objective: To study the incidence, clinical features and complications associated with appendicolith associated acute appendicitis in the patients which presented to us with clinical features of acute appendicitis in our tertiary care hospital (IMS & SUM Hospital). Methods: This is a prospective study, carried out in IMS & SUM Hospital, a tertiary care hospital, Odisha during the period between April 2019 to October 2020. All the patients presenting to the Emergency Department (ED) with symptoms suggestive of Acute Appendicitis were included in this study. Results: Of the 200 patients who underwent appendectomy, 63 (31.5%) patients were ≤ 17 years of age. Following appendicectomy, appendicoliths were found in 66 (33%) appendicectomy specimens. The sensitivity of trans abdominal ultrasonography to detect appendicolith to be 53.03% with a positive predictive value and specificity to be 67.30% and 87.31% respectively. Overall, complicated appendicitis was more commonly seen in patients with appendicolith as compared to patients without appendicolith (69.7% vs 23.9%), and this value is significant (P < 0.001). Conclusion: Acute appendicitis is more common in the pediatric age group (0-17 years) as compared to the adult population. Ultrasonography has very low sensitivity and is a poor predictor of appendicoliths in patients presenting with acute appendicitis. Appendicitis with appendicolith results in higher incidences of complicated appendicitis. Thus, these patients should undergo appendicectomy rather than conservative management
English Acute Appendicitis, Appendicolith, Complicated Appendicitis, AppendectomINTRODUCTION
Acute appendicitis is one of the most frequent causes of abdominal pain in patients presenting to the emergency department (ED) who need surgical treatment with an incidence of 100 to 200 cases per 100,000 person-years.1 Acute appendicitis can present as uncomplicated or complicated variants. Complicated appendicitis is traditionally defined as appendicitis complicated by the presence of gangrene, perforation, peri appendicular abscess, generalized peritonitis. The most common cause of Appendicitis is luminal obstruction by appendicolith.2
Appendicolith, also known as faecolith/coproliths/stercoliths is composed of faecal concretions or pellets, calcium phosphates, bacteria and epithelial debris and can lead to luminal obstruction followed by appendicitis. They can be seen in around 10% of patients with acute appendicitis.3 Presence of appendicolith has been identified as an independent prognostic factor for failure of conservative management in cases of uncomplicated acute appendicitis and it has also been linked with increased incidence of complicated appendicitis.4-8 The detection of appendicoliths in cases of acute appendicitis have increased due to the better imaging modalities and are also being detected in patients without inflammatory changes in the appendix.
In this study, we have decided to see the incidence, clinical features and complications associated with appendicolith associated acute appendicitis in the patients who presented to us with clinical features of acute appendicitis in our tertiary care hospital setup (IMS & SUM Hospital).
MATERIALS AND METHODS
This is a prospective study, carried out in IMS & SUM Hospital, a tertiary care hospital, Odisha during the period between April 2019 to October 2020. All the patients presenting to the Emergency Department (ED) with symptoms suggestive of Acute Appendicitis were included in this study.
Demographic data collected included: age and sex. History of present illness data collected included duration of the symptoms and the presence/absence of nausea, vomiting, anorexia, diarrhoea, migration to the right lower quadrant (RLQ) and similar previous episodes. Duration of symptoms was defined as the time since the onset of symptoms to presentation to the ED. Physical examination data collected included the first recorded temperature (Fahrenheit), heart rate, systolic blood pressure (SBP), Alvarado score, and the presence/absence of RLQ tenderness, diffuse abdominal tenderness, RLQ rebound tenderness, diffuse abdominal rebound tenderness, Rovsing sign, Obturator sign, and Psoas sign, as documented by the surgeon or postgraduate resident.9 Laboratory data collected included the first recorded ED value for total WBC and percentage of polymorphonuclear cells. Radiological data collected included ultrasonography (USG). Appendicolith on USG along with uncomplicated or complicated appendicitis (gangrene, perforation, peri-appendicular abscess, generalized peritonitis) was noted.
Management data included Antibiotics and appendectomy (Open or Laparoscopic). Intraoperative findings were noted. After an appendectomy, the specimen was cut open to check for the presence of intraluminal appendicolith and sent for histopathological study.
RESULTS
Of the 200 patients who underwent appendectomy, 63 (31.5%) patients were ≤ 17 years of age and the rest 137 (68.5%) patients were of 18 years or more. Following appendicectomy, appendicoliths were found in 66 (33%) appendicectomy specimens. The incidence of appendicolith in paediatric age group was found to be 42.9% (27 patients) and 28.4% (39 patients) in adult population which was significant (P-value = 0.044) [Table 1 and 3].
Out of 66 patients with appendicolith, 34 patients (51.5%) presented with fever of more than 101°F whereas only 31 patients (23.1%) without appendicolith had fever more than 101°F [Table 2]. Vomiting was associated with 57.5% (38 patients) of patients with appendicolith as compared to only 36.5 % (49 patients) of patients without appendicolith [Table 2]. Generalized guarding was present in 12.1% (8 patients) of patients with appendicolith as compared to 2.2% (3 patients) without it [Table 2]. A history of a similar episode in the past was seen in 34.8% (23 patients) of patients with appendicolith and 14.9% (20 patients) in patients without [Table 2].
Preoperative transabdominal ultrasonography was done in all the 200 patients, revealing appendicolith in 52 patients. The results of the pre-operative ultrasonography were compared with the postoperative detection of appendicolith in the appendix specimen. This revealed the sensitivity of trans abdominal ultrasonography to detect appendicolith to be 53.03% with a positive predictive value and specificity to be 67.30% and 87.31% respectively [Table 3].
Intraoperatively, 22.7% of patients with appendicoliths had perforation as compared to 5.2% of patients without (P-value < 0.001) and 25.7% of patients had a gangrenous appendix with appendicolith vs 8.9% patients without appendicolith. Overall, complicated appendicitis was more commonly seen in patients with appendicolith as compared to patients without appendicolith (69.7% Vs 23.9%), and this value is significant (P-value < 0.001)[Table 4].
DISCUSSION
Acute appendicitis presents in the emergency department either as uncomplicated or complicated varieties. Most of the cases (70 – 80 %) are uncomplicated. In the past few years, the incidence of uncomplicated acute appendicitis is declining, whereas the incidence of complicated appendicitis remains unchanged.9,10 Early diagnosis and surgical resection of the appendix have been the mainstay for the treatment of acute appendicitis for many years. However, there is a paradigm shift in the approach and management of acute appendicitis with recent evidence showing that early surgical intervention is not always mandatory and acute appendicitis can be managed effectively with proper dosage of antibiotics.11,12 Many studies in the past concluded appendicolith as an independent prognostic risk factor for failure of non-surgical management of uncomplicated acute appendicitis and also showed its association with the increase in the incidences of appendiceal perforations.4-8
Older studies supported the theory of Appendicolith’s being the main cause of obstruction, leading to appendicitis. Collins described the prevalence of appendicolith as 44.25% in 71,000 specimens.13 Study of Collins included 12,119 prophylactic appendicectomies and 6,409 post-mortem specimens but only 11,961 cases of simple appendicitis. Since prevalence in each category was not calculated, conclusions about the association of appendicolith with appendicitis cannot be made.
Various other studies have also shown appendicolith prevalence of 33-44% in cases of appendicitis.14-16 However, larger series studies are done after 1970, show a decrease in the prevalence of appendicolith with the percentage ranging between 1.5% to 15%.17-23 A study by Jonas et all. (sample size < 100 cases) in the post-1970s era, showed the prevalence of appendicolith was 52%.24 In the present study, overall appendicolith prevalence was found to be 33%. Previous studies showed the prevalence of appendicolith in the paediatric age group (≤17 years) with acute appendicitis to be between 19-65%.6,25,26 Similar results were found in our study with 42.9% in the paediatric age group versus 28.4% in adults having appendicoliths in patients of acute appendicitis.
Historically, appendicolith has been associated with clinically severe appendicitis. In our study fever of more than 101°F was seen in 51.5% of patients with appendicolith as compared to only 23.1% of patients without appendicolith. Vomiting was more associated with acute appendicitis with appendicolith as compared to only appendicitis (57.5% vs 36.5%). Similarly, generalized guarding/ rigidity was seen in 12.1% of appendicolith positive patients as compared to 2.2% of patients without appendicolith. History of the similar episode of pain in the RIF was present in 34.8% of patients with appendicolith as compared to 14.9% of patients without appendicolith, suggesting, the attacks of appendicitis tend to recur in patients of an appendicolith, if not treated with appendicectomy in the first instance.
In our study, 22.7% of the patients with appendicolith presented with a perforated appendix as compared to only 5.2% of patients without appendicolith. These results are similar to the findings of Fitz and Wangensteen.27,28 Studies in the past show Transabdominal ultrasonography (USG) to have a sensitivity of 86%-95% and specificity (78%-84%) in diagnosing acute appendicitis.29 But computed tomography (CT) is more sensitive for diagnosing appendicolith in patients with appendicitis as compared to ultrasonography. CT scan is not done routinely for all the cases of acute appendicitis, so in our study, we have tried to find out the sensitivity, positive predictive value and specificity of ultrasonography in detecting appendicolith in a patient with acute appendicitis. In our study, the sensitivity, positive predictive value and specificity of USG in detecting appendicolith were found to be 53.03%, 67.30% and 87.31% respectively.
CONCLUSION
Based on the study findings, we can conclude that appendicolith in cases presenting with acute appendicitis is more common in the pediatric age group (0-17 years) as compared to the adult population. Acute appendicitis patients with appendicolith have a higher chance to develop a fever of more than 101°F and have episodes of vomiting as compared to patients without appendicolith. History of similar episodes of pain in the RLQ in the past, managed conservatively, is more common in patients of acute appendicitis with appendicolith. Appendicitis with appendicolith results in higher incidences of complicated appendicitis. Thus, these patients should undergo appendicectomy rather than conservative management. Ultrasonography has very low sensitivity and is a poor predictor of appendicoliths in patients presenting with acute appendicitis.
Conflict of Interest: There is no conflict of interest among the authors.
Author Contribution: Dr.Debasish Samal and Dr.Tejaswi Mishra have contributed in performing the surgeries, concept, study design, data analysis, statistical analysis and manuscript preparation, Dr.Godalu Trinath Patra contributed in performing the surgeries manuscript editing and manuscript review. Dr. Ayush Vardhan and Dr.Ankur Gogoi Cheleng have contributed towards literature search, data acquisition, manuscript editing.
Funding: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=3737http://ijcrr.com/article_html.php?did=37371. Ferris M, Quan S, Kaplan BS, Molodecky N, Ball CG, Chernoff GW, et al. The Global Incidence of Appendicitis. Ann Surg. 2017;266(2):237–241.
2. Prystowsky JB, Pugh CM, Nagle AP. Appendicitis. Curr Probl Surg. 2005;42(10):694–742.
3. Teke Z, Kabay B, Erbi? H, Tuncay ÖL. Appendicolithiasis causing diagnostic dilemma: A rare cause of acute appendicitis (report of a case). Ulus Travma ve Acil Cerrahi Derg 2008;14(4):323–325.
4. Mahida JB, Lodwick DL, Nacion KM, Sulkowski JP, Leonhart KL, Cooper JN, et al. High failure rate of nonoperative management of acute appendicitis with an appendicolith in children. J Pediatr Surg 2016;51(6):908–911.
5. Shindoh J, Niwa H, Kawai K, Ohata K, Ishihara Y, Takabayashi N, et al. Predictive factors for negative outcomes in initial non-operative management of suspected appendicitis. J Gastrointest Surg 2010;14(2):309–314.
6. Alaedeen DI, Cook M, Chwals WJ. Appendiceal fecalith is associated with early perforation in pediatric patients. J Pediatr Surg 2008;43(5):889–892.
7. Yoon HM, Kim JH, Lee JS, Ryu JM, Kim DY, Lee JY. Pediatric appendicitis with appendicolith often presents with prolonged abdominal pain and a high risk of perforation. World J Pediatr 2018;14(2):184–90.
8. Singh JP, Mariadason JG. Role of the faecolith in modern-day appendicitis. Ann R Coll Surg Engl 2013;95(1):48–51.
9. Bhangu A, Søreide K, Di Saverio S, Assarsson JH, Drake FT. Acute appendicitis: modern understanding of pathogenesis, diagnosis, and management. Lancet 2015;386(10000):1278–1287.
10. Cameron JL CA. Current Surgical Therapy. 10th edit. Philadelphia: Mosby; 2011. 219 p.
11. Styrud J, Eriksson S, Nilsson I, Ahlberg G, Haapaniemi S, Neovius G, et al. Appendectomy versus antibiotic treatment in acute appendicitis. A prospective multicenter randomized controlled trial. World J Surg 2006;30(6):1033–1037.
12. Oliak D, Yamini D, Udani VM, Lewis RJ, Vargas H, Arnell T, et al. Nonoperative management of perforated appendicitis without periappendiceal mass. Am J Surg 2000;179(3):177–181.
13. DC Collins. 71,000 Human appendix specimens. a final report, summarizing forty years’ study. Am J Proctol 1963;14(December):265–281.
14. Shaw RE. Appendix calculi and acute appendicitis. Br J Surg 1965;52(6):451–459.
15. Felson B. Appendical calculi; incidence and clinical significance. Surgery 1949;25(5)(May):734–737.
16. Steinert R, Hareide I, Christiansen T. Roentgenologic examination of acute appendicitis. Acta Radiol 1943;24(1):13–37.
17. Makaju R, Mohammad A, Shakya A. Acute appendicitis: Analysis of 518 histopathologically diagnosed cases at the Kathmandu University Hospital, Nepal. Kathmandu Univ Med J 2010;8(30):227–230.
18. Andreou P, Blain S DBC. A histopathological study of the appendix at autopsy and after surgical resection. Histopathology 1990;Nov(17(5)):427–431.
19. Marudanayagam R, Williams GT, Rees BI. Review of the pathological results of 2660 appendicectomy specimens. J Gastroenterol 2006;41(8):745–749.
20. Chang AR. An Analysis of the Pathology of 3003 Appendices. Aust NZ J Surg 1981;51(2):169–178.
21. Nitecki S, Karmeli R, Sarr MG. Appendiceal calculi and fecaliths as indications for appendectomy. Surg Gynecol Obstet 1990;171(3):185–188.
22. Forbes GB, Lloyd-Davies RW. The calculous disease of the vermiform appendix. Gut 1966;7(6):583–592.
23. Sgourakis G, Sotiropoulos GC, Molmenti EP, Eibl C, Bonticous S, Monge J, et al. Are acute exacerbations of chronic inflammatory appendicitis triggered by coprostasis and/or coproliths? World J Gastroenterol 2008;14(20):3179–3182.
24. Jones BA, Demetriades D, Segal I, Burkitt DP. The prevalence of appendiceal fecaliths in patients with and without appendicitis. A comparative study from Canada and South Africa. Ann Surg 1985;202(1):80–82.
25. Lowe LH, Penney MW, Scheker LE, Perez R. J, Stein SM, Heller RM, et al. Appendicolith revealed on CT in children with suspected appendicitis: How specific is it in the diagnosis of appendicitis? Am J Roentgenol 2000;175(4):981–984.
26. Fraser N, Gannon C, Stringer MD. Appendicular Colic and the Non-Inflamed Appendix: Fact or Fiction? Eur J Pediatr Surg 2004;14(1):21–24.
27. Fitz RH. Perforating inflammation of the vermiform appendix. Am J Med Sci. 1886;92:321–346.
28. Wangensteen O, Dennis C. experimental proof of the obstructive origin of appendicitis in man. Ann Surg 1939;110(665):629–647.
29. Terasawa T, Blackmore CC, Bent KR. Systematic review: computed tomography and ultrasonography to detect acute appendicitis in adults and adolescents. Ann Intern Med 2004;141(7):537–546.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareImportant of Upvas (Fasting) in Human Life to Maintain Mental and Physical Health
English122124Dhongdi Vivek VEnglish Kukde SnehalEnglish Ghogare AjinkyaEnglishAcharya Charaka Vaghbhat and Sushrut defined that the whole world runs toward food, as the individual’s complexion, happiness, friendly speech, life, talent, health and fulfilment, body maintenance, body strength and even intellectual abilities rely on food.1 They have given importance to food since the Vedic period. For the preservation of the health, well-being and vitality of the person, food is a material consumed other than water and narcotics. This essay will illustrate the Upvas i.e fasting, life for speculated time or a week without taking food or drink of any liquid to maintain mental, spiritual as well as physical health as specified in the health concept. We are all normal to excessive eating habits, but today this article focuses on controlling intake and preserving Gastrointestinal hygiene and maintaining or relaxing all GIT organs to rejuvenate fully by natural secretion in a natural way through daily practice. In our Life of Upvas. Ayurveda acknowledges the view that the assimilation of metabolic toxins that are not good for health is realised by fasting. In Ayurveda, it is also claimed that fasting promotes digestive fire with the exclusion of channel blockage, which helps to minimise the symptoms of any disease. In Ayurveda, there are ten remedies for consumption, and Upavasa is one of them. Ayurveda directs three wellness and wellbeing treatments, i.e. metaphysical, Rational/physical and psychological. Fasting is not recommended for very young, frail, gaunt, pregnant and immediately after intense exercise. The benefits of fasting include the clarity of the organs responsible for meaning. The beauty of the body and brain can be felt during fasting. In illnesses, it offers a better feeling. These factors collectively contribute to making individuals feel energised. Fasting is recommended as a precautionary methodology and remedial methodology in addition. This review is a genuine attempt to understand the concepts of fasting known in the Ayurveda classics.
EnglishAhara, Upvas, Nirahar, NirankarIntroduction
The effects of fasting in various forms are known by all therapeutic systems on the earth. Ayurveda has indexed and comprehensively explained this benefit as well. Fasting is a very important part of ensuring that Panchakarma medicines are adequate and effective (Ayurvedic detoxification treatment). In the Western medical system, it is claimed that fasting empowers the body to revive its self-mending capabilities.1 That is the In the Western medical system, it is claimed that fasting empowers the body to review its self-mending capabilities. Many Western healers quoted about fasting and according to them "fasting is the best cure as a doctor inside." In all religions, either short or long-term fasting is recommended as a tool for otherworldly purification. International Journal of the striking place known for its ancient human advances and cherished therapeutic legacy. Ayurveda, the checked, systematised knowledge. Life science, health and therapy system. The definitive discipline in systematic medicine is Ayurveda. Health is about acquiring four-fold bliss, according to Ayurveda, in which Dharma (nobility) is most important, followed by Artha (righteousness) and Kama (satisfaction of desires). Along with these three Moksha (salvation).2 The extremely essential bliss that can be achieved is the extreme. The signs and manifestations of happiness, excess and excess have been intricately and amazingly described by Ayurveda. In addition to the exemptions and safety guidelines in the execution of fasting, insufficient fasting help the physician direct adept and exact care and thus help the individual achieve ultimate well-being. Digestion, according to Ayurveda, is like acid. If you pour too much fuel all at once on the flames, you simply put the fire out. Fasting is a powerful method to igniting the digestive fire that contributes to all accumulated toxins that are saturated in the body and mind being burned away.3 It also wipes out gas by improving the mental clarity of fasting individuals, leading to improved health. Ayurveda recommends long-haul fasting over general and short-term fasting, which can hamper wellbeing.4 This may include fasting every week at about the same time, otherwise few days per month to quickly depending on body type and purifying Around 70-80% of the world's population rely on non-conventional medicines, primarily from herbal sources, in their healthcare, according to the World Health Organization. The public interest in the treatment of complementary and alternative medicinal products is primarily due to the increased side effects of synthetic medicinal products, the lack of curative treatment for many chronic diseases, the high cost of new medicines, Microbial resistance and emerging infections, etc. Thus, fasting is also developing a modern therapy for few illnesses in today's age, as well as GIT issues and geriatric disorder for young people.
Protocols for Upvas (Fasting)
Upvas is primarily of two forms that are SAJAL and Nirjala or NIRAHAR and FAL-AHAR Upvas. Upvas is preferably focused on human factors that are Age, Disease, Prakruti, Agni Bala of Individual and Lifestyle disorder medicine used daily.5
Types of Upvas
As per ancient text, there are 10 types upvas mentioned. Pratah Kalik Upvas, Ardhopvas, Raso Upvas, Falopvas, Dugdhopvas, Taropvas, Purnopvas, Saptahik Upvas, laghu Upvas, Dirgho Upvas. Dirghakalik Upvas is benifited to dharmik, Sadachari and Shudha Prakruti. For regular Health fitness advised doing Saptahik Upvas. Jwar, Pratishyay Kasa rugna need to do 2-3 days Fast for Upashay. Dirghakalik Upvas need vyajti Prikshan of Mutra and rakta. If there is ketone present in mutra and Urea present in rakta ( Blood) above 45 gm then that is a contraindication for Upvas. Dirghakalik upvas plan ideally Vasant and Grishma Ritu, because of good quality sunlight is present in these Ritu and that removes toxins from the body. In the meantime of Upvas advise drinking 8-10 litre water (Shudhha Jala). sdhudha jala during upvas is prepare sharer shudhi kriya.6
After specifically planned upvasa there is the protocol to withdraw. Firstly gradually eat some fruit and fruit juices or milk and then start slowly with Laghu ahar and Yartha Shakti Vihar and Vyayam. This means the number of days of Upvasa is followed by several days of rasahar and laghu ahar then start actual Yathashktio Samanya Ahar.7
"Chikitsatam vyadhikaram pathyam sadharanam aushadam prayshitam
prakritisthapanprashanam itaman."
"Deciphered, it states that individuals should "eliminate all that is not complete, Disappointing, by what is fair for the individual, using methodology together with Arrangements for re-establishing the individual, re-building Prakriti, and appeasing what is
Useful for well-being.8 Swearing off sustenance or water for well-being according to Ayurveda, Extended timeframes exhaust the tissues of the body, prompting a dosage discrepancy In Sanskrit, Panchakarma implies "five activities or actions." In Ayurveda, fasting is used. It is considered to be a preparatory therapy for Panchakarma and an appropriate technique for Detoxifying. Many experienced Vaidya (Ayurvedic medicinal experts) are advised that at particular periods, individuals can do safe fasting to maintain PPPrakriti, (Health) and Vikrititi Prevention (imbalance in a healthy body). As per Ayurveda, intermittent fasting is not only a diet, it's a pattern of feeding. Obtaining intake. It is a way of preparing meals to achieve the most beneficial health effect. Among them. Along with what to eat, intermittent fasting alters the timing of food intake. To lose weight, doctors prescribe intermittent fasting. Perhaps intermittent fasting, in particular, is one of the least difficult procedures recommended by Ayurveda to take away bad weight though Holding on with good weight because of the Long-haul fasting can occur occasionally, The balance of doshas in the body is disrupted, which can hamper the body's abilities. The Fasting type should be taken following the type of body and the number of toxins accumulated In your body. The most significant are digestive ability, body shape, and doshas vitiation, factors for the fasting process.9
Rajnitik Upvas is called as Anashan. It is useful to take some benefit from ruling government or any of the will of the particular person for good faith governance.
Upvas Yogya Vyakti
“Twagdoshanam Pramidhanam” particular rugna have Twak Vikar and Prameha can do short term upvas as per Charak rushi in the Samhita Sutrasthana. As well as all the swastha people can do short term upvasa in Shishir Ritu “Shishire Langhanam” according to jatharagni Bala and according to treating Vaidya.10
Upvas Ayogya Vyakti
If the person is Bramhachari, Pregnant, and Agnistimit is not able to do upvasa. These three categoric personality avoid upvasa for good health.
Upvasa Withdrawal Period
If a person is having spastha mala rahit Jivha, extensive hunger, sweetness in the mauth(Maukhik Madhurya), Spastha Mutra, Satvik Mana and feels pavitrya then only the person having long-lasting or short term Upvasa vidhi break with the help of some liquid fruit juice or with the butter milk.
Ati Upvasa Lakshana
If a person is in atiupvasa stage then that person may occur Parshvashool( Back Pain), Angamard, Kasa, Mukhashosh, aruchi, netradaurbalya, Bhrama( Dementia), dehabala Agni Nasha and Daurbalya (weakness).10
Conclusion
Individuals are constantly exposed to numerous toxic people in the current world situation. Substances alongside the rising way of life problem and tangible over-burden by water, air, food, and medicines. Which contributes to a greater accumulation in the body of different toxins. Because of this, the body's routine procedures to eliminate toxic things and purify Them remains insufficient to preserve the tone of individuals. This strengthens the importance of abstaining in the Context of precaution and remedy and depresses the GIT secretions and for that matter suppress the Immunity. It is the rejenuvating process for the body and GIT systeme to renew all the secretions for digestion and develope immunity. Upvasa is to maintain the Satvikta of Mana I,e. to maintain mental stability for good mental health. As per practitioners of Ayurveda, it helps in long term constipation that is Grahani and the other obstructive pathies regarding GIT upvasa is one of the treatment is used first. In Modern allopathic sciences, anything related to GIT obstructive pathy first treatment is Nil by Mouth that is also correlated with Upvasa that is Nirjala Upvasa and that helps in the treatment also.
Ayurveda gives the idea of fasting a great deal of significance since it is found thatThere are numerous books written by many Ayurvedic experts about fasting. Great The Ayurvedic Acharya concentrated on fasting, which can be seen very easily in the texts. Like Astanga Sangraha, Sushruta Samhitha, Astanga Hridaya adhya, Charaka Samhitha, 11,12. Bhaishajya Rathnavali and Bhavaprakasha are also observed to extravagantly describe the similar stuff about fasting at various locations. Ayurveda has done extensive work on this subject. Fasting and the primary importance assigned to it. Ayurveda's validity must be adopted, for life to be better. In today's period, as per ancient text and Ayurveda practitioner, Upvas recommended Jwara, Sangrahani, Atisar, Pravahika, Pratishyay, Kasa, Twak Vikar, bahumutrata, Swas, Ajirnsa, Malvshtambha, Sthaulya and also got Upashay.
Source of funding: Nil
Conflict of interest: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=3738http://ijcrr.com/article_html.php?did=3738[1] Kasture H. Ayurvediya panchakarma vijnana. Calcutta: Sri Baidyanatha. Ayurveda Bhavan Limited. 2006.
[2] Sharma R, Vaidya B. Agnivesha's Charaka Samhitha. seventh. Varanasi: Chowkahmba Sanskrit Series office, 2009;1:19.
[3] Adiga SH, Adiga RS. Concept and Canons of Fasting in Ayurveda. J Fasting Health
2013;1(1):3740.
[4] Nagashayana N. Association of L-DOPA with recovery following Ayurveda
medication in Parkinson’s disease. J Neur Sci 2000;176.2: 124-127.
[5] Patrikar V. Sampurna Swasthavritta Vigyan, Dhanvantari Prakshan Upvas Chikitsa. 325-327.
[6] Samgandi K. Swasthavritta Sudha. Adhyay 36. CCIM New Delhi.
[7] Deasi V. Ayurveda Kriya Shareera. Allahabad: Sri Baidyanath Ayurveda Bhavan
Limited; 1999: 18-21.
[8] Sumantran VN, Tillu G. Cancer, inflammation, and insights from Ayurveda. Evidence-Based Complem Altern Med 2012;2012: 306346
[9] Sharma R, Dash B. Charaka Samhita of Agnivesha. 8th ed. Varanasi: Vimana Sthana;
2004; 289-90.
[10] Charaka Samhita. Ayurveda Dipika Commentary of Chakrapanidatta. Ed Vaidya J, Acharya T. Chaukhamba Sanskrit Sansthana Varanasi. Charakasamhita Sutrasthana 22/21
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareCorrelation of HbA1c with Solid Organ Tumours in the Non-Diabetic Individuals - A Cross-Sectional Study
English125132Chodavarapu DheerajEnglish Girish MEnglishIntroduction: Diabetes is described by unending hyperglycemia and causes long haul difficulties like retinopathy, neuropathy, and nephropathy. Most of the cancers in diabetes are associated with high blood glucose levels. An increase in glucose uptake can activate oncogenic pathways in cells, so this provides information that another pathway by which hyperglycemia increases cancer incidence risk. Objective: To correlate HbA1c with solid organ tumours in non-diabetic individuals. Methods: A cross-sectional study with convenient sampling. An HbA1c test was done for all the patients who were diagnosed with solid organ tumour at the time of admission and values were noted and HbA1c test was done for age and sex-matched otherwise healthy individuals and the values were noted. We compared the HbA1c values of each case and control. Any case or control with an HbA1c level above 6.5 was excluded from the study. Results: The mean HbA1c among the cases was 5.578 whereas among the controls was 5.303 and the p value is Significant (EnglishHbA1c, Solid organ, Tumours, Non-diabetic, Correlation, HbA1cINTRODUCTION
Diabetes is described by unending hyperglycemia and causes long haul difficulties like retinopathy, neuropathy, and nephropathy.1,2 It for the most part quickens full scale and miniaturized scale vascular changes. Due to way of life changes (i.e., eating increasingly and practising less), diabetes has turned into a worldwide pestilence. Proficient and compelling aDiabetesinistration is required to deal with this pestilence.3-5 Convenient glucose meters encourage the fleeting a Diabetesinistration of diabetes.6 Long haul forthcoming investigations, prominently the Diabetes Control and Complications Trial (DCCT), the UK planned Diabetes Study Group (UKPDS), and the Epidemiology of Diabetes Interventions and Complications (EDIC) think about, have given clear proof that diabetic intricacies are specifically identified with mean glycemia esteem, as estimated by the HbA1c focus. It is, in any case, not clear whether hyperglycaemia, a sign of diabetes, connects with expanded malignancy hazard autonomous of diabetes.7-10 On the off chance that such affiliation exists, at that point the growth chance in people with glucose levels lower than that required to analyze diabetes may as of now be expanded. The relationship of most tumours and diabetes with constant aggravation and the immediate connection between expanded incendiary flagging and high blood glucose levels in disease models bolster the likelihood that incessant hyperglycaemia may have an essential part in growth chance in people. The expanded creation of endogenous hormones can likewise be by implication connected to hyperglycaemia using hyperinsulinaemia and weight, and, consequently, additionally to diabetes and malignancy hazard. Constant hyperglycaemia in diabetes patients is by all accounts specifically connected with the omnipresent dependence of most tumour cells on high glucose flux. It was discovered that an expansion in glucose take-up can enact oncogenic pathways in breast cells.11 This could conceivably give another pathway by which hyperglycaemia builds tumour frequency hazard. Constant hyperglycaemia might be assessed by estimating glycated haemoglobin (HbA1c) (American Diabetes Association, 2013), a biomarker of the normal blood glucose focus for a drawn-out timeframe. Vitally, HbA1c may likewise be a decent marker of metabolic procedures affecting levels of insulin or insulin-like development factors, essential for growth pathogenesis.12,13 Most investigations centre around the relationship between tumour hazard and diabetes. No meta-investigation has yet been distributed that unites the danger of various kinds of tumours with various HbA1c ranges, including glycaemic levels lower than that related to diabetes. If tumour hazard is brought down at low HbA1c levels, at that point the frequency of malignancy in the diabetic and non-diabetic populaces could be brought down by diminishing glucose levels.14 This could be accomplished by methods for a suitable way of life or helpful intercessions, and by forcing stricter proposals for glycaemic control. However even though Warburg had guessed that the metabolic move to glycolysis is "the source of disease cells", the showing of causative impacts of the expanded glucose take-up and digestion on oncogenesis has evaded the field up until now.
Conversely, the possibility that glucose level itself can trigger intra-and intercellular flagging is acknowledged and considered generally in the fields of endocrinology and diabetes. Glucose flagging is known to be connected to physiological and obsessive occasions, for example, control of hormone emission and insulin opposition. In the present we aimed to study the association of HbA1c levels with solid organ tumours in non-diabetic individuals. We have assessed the correlation between HbA1c levels and occurrence of solid organ tumours in non-diabetic individuals and compared the risk of solid organ tumours in Normal individuals versus Prediabetics with HbA1c levels.
MATERIALS AND METHODS
This is a Cross-sectional study done at Tertiary care hospitals attached to KASTURBA MEDICAL COLLEGE (Manipal Academy of Higher education), Mangalore has done between September 2016 to September 2018. Non-diabetic patients with solid organ tumours admitted to the hospital. Otherwise, Age and Sex matched healthy individuals from the community were taken as the control group for the study.
It was a Convenient sampling and the sample size was taken With a 95% confidence level and 90% power concerning the previous study6 by assuming the same proportion the sample size comes to be 160.By adding 10% error for the sample size and taking cases and controls as 1:1 ratio my sample size increases to 180 (cases: 90 and control: 90)
n = 2(Zα+Zβ) × σ2
d2
Zα =1.96 (95% confidence interval)
Zβ =1.28 (90% power)
σ =standard deviation
d = mean difference from the previous study
Ethical Clearance number: IEC KMC MLR 09-16/199
Procedure
All Solid-organ tumour patients admitted to hospitals attached to Kasturba Medical College, Mangalore who satisfied inclusion/exclusion criteria were included in the study. The data collection included demographic details, detailed medical history, history regarding the present event, the details of the medications received by the patients with the details of steroids and other hyperglycemia causing agents used, physical examination findings etc. The details regarding comorbid conditions were recorded and any change in the intervention and clinical status was recorded. An HbA1c test was done for all the patients who were diagnosed with solid organ tumour at the time of admission and values were noted and HbA1c test was done for age and sex-matched otherwise healthy individuals and the values were noted. We compared the HbA1c values of each case and control. Any case or control with an HbA1c level above 6.5 was excluded from the study. HbA1c test was done by High-Performance Liquid Chromatography (HPLC) method from the Kasturba Medical College (BIOCHEMISTRY DEPARTMENT)Collected data were coded and entered into SPSS 17.0. Categorical variables are described by frequencies and percentages, and continuous variables by mean±Standarddeviations. Chi-square test, ANOVA test and Paired t-test were used. Figures and tables are used to summarize the results. p Englishhttp://ijcrr.com/abstract.php?article_id=3739http://ijcrr.com/article_html.php?did=3739
Beer JC, Liebenberg L. Does cancer risk increase with HbA1c independent of diabetes. Br J Cancer 2014;110:2361-2368.
Coussens L, Zitvogel L, Palucka A. Neutralizing Tumor-Promoting Chronic Inflammation: A Magic Bullet. Science 2013;339(6117):286-291.
Giovannucci E, Harlan D, Archer M, Bergenstal R, Gapstur S, Habel L et al. Diabetes and Cancer: A consensus report. Science 2018;32:256-259.
Habib S, Rojna M. Diabetes and Risk of Cancer. Int J Oncol 2013;2013:1-16.
Donadon V, Balbi M, Casarin P, Vario A, Alberti A. Association between hepatocellular carcinoma and type 2 diabetes mellitus in Italy: potential role of insulin. World J Gastroenterol 2008;14(37):5695-700.
Centres for Disease Control and Prevention (CDC) Prevalence of overweight and obesity among adults with diagnosed diabetes the United States, 1988–1994 and 1999–2002. Morb Mort Weekly Rep 2004;53(45):1066–1068.
Calle EE, Thun MJ. Obesity and cancer. Oncogene 2004;23(38):6365–6378.
Calle EE, Kaaks R. Overweight, obesity and cancer: epidemiological evidence and proposed mechanisms. Nat Rev Can 2004;4(8):579–591.
Kulie T, Slattengren A, Redmer J, Counts H, Eglash A, Schrager S. Obesity and women’s health: an evidence-based review. J Am Board Fam Med 2011;24(1):75–85.
Eliassen AH, Colditz GA, Rosner B, Willett WC, Hankinson SE. Adult weight change and risk of postmenopausal breast cancer. J Ame Med Assoc 2006;296(2):193–201.
La Vecchia C, Giordano SH, Hortobagyi GN, Chabner B. Overweight, obesity, diabetes, and risk of breast cancer: interlocking pieces of the puzzle. Oncologist 2011;16(6):726–729.
Leroith D, Novosyadlyy R, Gallagher EJ, Obesity and Type 2 diabetes are associated with an increased risk of developing cancer and a worse prognosis; epidemiological and mechanistic evidence. Exp Clin Endocrinol Diab 2008;116(supplement 1):S4–S6.
Ma J, Li H, Giovannucci E, Prediagnostic body-mass index, plasma C-peptide concentration, and prostate cancer-specific mortality in men with prostate cancer: a long-term survival analysis. Lancet Oncol 2008;9(11):1039–1047.
Schienkiewitz A, Schulze MB, Hoffmann K, Kroke A, Boeing H. Body mass index history and risk of type 2 diabetes: results from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam Study. Am J Clin Nutr 2006;84(2):427–433.
Abdul-Ghani MA, Sabbah M, Muati B, et al. High frequency of pre-diabetes, undiagnosed diabetes and metabolic syndrome among overweight Arabs in Israel. Isr Med Assoc J 2005;7(3):143–147.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareA Cross-Sectional Evaluation Linked to Ear-Related Ailments Throughout Pregnancy
English133136Nayak MSEnglish Satpathy SEnglish Kala DEnglish Sahoo GEnglish Kar DEnglish Bhuyan REnglishBackground: Many changes occur in a woman’s physiology during pregnancy. These include all the major organ systems- cardiovascular, hematologic, respiratory, etc. Objective: We aim to study the effects of pregnancy on symptoms related to the Ear. Methods: 40 pregnant patients attending the Obstetric outpatient department (OPD) were selected and given a questionnaire listing various ear-related symptoms in pregnancy. Based on the response to the questionnaire, data were tabulated and evaluated. Results: Imbalance in gait was found to be the commonest symptom followed by dizziness. Altered smell perception and increased ear secretion were the next common symptoms. Conclusion: Based on our study, we conclude that feeling of loss of balance and dizziness is the most common ear-related symptoms in pregnancy
English Pregnancy, Trimester, Sensori-Neural Hearing Loss (SNHL)INTRODUCTION
The body of a female undergoes numerous changes during the menstrual cycle, at pregnancy and menopause. In pregnancy, there is increased demand for the rapidly growing fetus and placenta. To meet these demands the female physiology undergoes numerous alterations encompassing almost all major organ systems. These changes allow the growth of the baby and also protect both mother and fetus from certain risks associated with pregnancy and delivery. Weight gain is a highly noticeable change that occurs throughout pregnancy. Plasma volume expansion and hemodilution occurs in pregnancy with a fall of plasma osmolality and increased fluid in intercellular space.1 All this fluid retention that occurs can interfere with the sensorineural hearing system and changes in hearing may occur.2 The changed composition of the inner ear labyrinthine fluid may interfere with the sensitivity of the receptors in the inner ear and hence cause hearing-related symptoms in women- fullness in the ears, ringing in the ears, dizziness, hyperacusis or algiacusia.3 Symptoms like vertigo, tinnitus and sudden hearing loss are often associated with the action of estrogen and progesterone on the cochlea and semi-circular canals.4-6 We aim to study the occurrence of various auditory and vestibular complaints in pregnant women.
MATERIALS AND METHODS
The prospective cross-sectional non-randomised study was conducted on the patients attending Out Patient Department of Obstetrics and Gynecology (OPD O&G), and Ear Nose Throat (ENT) departments of Terna Medical College & Hospital. Forty (40) pregnant patients were included and given a questionnaire listing ENT symptoms after duly obtaining informed written consent. Patients had to fill up answers like ‘Yes’ or ‘No’. All participants were literate in English though Hindi and Marathi translations of the questionnaire were available. Institutional ethics committee approval was obtained before starting the study. Based upon the answers to the questionnaire, results were calculated after grouping women according to the three (3) trimesters of pregnancy:
GROUP 1(GTR1): 1st trimester: from confirmation of pregnancy till completion of 12 weeks.
GROUP 2(GTR2): 2nd trimester: from 13 weeks till completion of 28 weeks.
GROUP 3(GTR3): 3rd trimester: from 28 weeks till term.
Inclusion Criteria
All healthy pregnant females in the age group 20-35 years attending OPD. Patients in all three trimesters of pregnancy were enrolled after counselling.
Exclusion Criteria:
Patients having any ENT complaints before pregnancy.
Patients with hypertension, diabetes mellitus, any other chronic medical disorder like heart disease, renal disorder, epilepsy, etc.
Patients with alcoholism.
Any high-risk pregnancy
Results were analyzed using descriptive statistics.
RESULTS
In the current study, forty numbers of patients were enrolled and after meeting requisite inclusion and exclusion criteria they were asked to fill up a pre-prepared questionnaire. The questionnaire was based on eleven numbers symptoms that were studied during three trimesters of pregnancy [Table 1 and 2]. The symptoms that are observed during the studies are Imbalance in walking, Dizziness, Change in smell, Increased ear secretion, Increased nasal blocks, Headache, Earache, Tinnitus, Change in voice, Blackouts, Difficulty in hearing. The highest number of symptomatic patients were found at early pregnancy (GTR1) whereas fewer or rare symptoms were observed in second trimesters (GTR2) but maximum numbers of symptoms were studied at the late phase of pregnancy (GTR3).
Seven types of symptoms (Imbalance in walking, Dizziness, Change in smell, Increased ear secretion, Increased nasal blocks, Tinnitus, Difficulty in hearing) were common in all the phases of trimesters. Dizziness is regarded as the most common symptom with highest number of pregnant ladies (GTR1 = 23; GTR2 = 5; GTR 3 = 2). The lowest number of pregnant ladies were found with the symptom of low hearing (GTR 1 = 1; GTR 2 = 1; GTR 3 = 3), whereas the change in voice is the only symptom found in one pregnant lady of GT3 category [Table 2 and Figure 1].
DISCUSSION
The commonest symptom in our patients was a feeling of imbalance while walking (seen in 35 patients). This was seen maximum in the 3rd trimester (18 cases) followed by 15 cases in the 1st trimester. Instability in pregnancy could be due to weight gain and postural changes occurring as the pregnancy advances. Pregnancy is characterized by many changes–involving endocrine, cardiac, vascular and other systems along with oedema and weight gain which can affect the musculoskeletal system and posture.7 This reduction in postural stability is associated with the risk for falling, so much so that in pregnancy the risk of fall is comparable to that for elderly individuals.8
Dizziness and reeling of the head was the next most common complaint (seen in 30 patients), most of whom were in 1st trimester (23 cases). Similar findings are mentioned by Black FO.9 Attacks of vertigo can increase due to decreased serum osmolality seen in pregnancy and may be influence by the hormonal and fluid-volume changes in the vestibular system.9,10 Also, dizziness is more common in the 1st and 2nd trimester, which is in agreement with authors who reported that vestibular disorders normalize throughout the pregnancy duration, probably due to labyrinthine habituation.11
A change in the sense of smell was reported by 25 patients, and maximum cases were seen in 1st trimester (15). Patients frequently complained of increased sensitivity to oil, ghee and spices. Studies suggest that an increase in smell sensitivity is due to high levels of estriol and swelling of the olfactory membrane (12). According to National Geographic, Smell Survey conducted in the US including 13,610 pregnant and 277,228 non-pregnant women between 20-40 years of age, in comparison to non-pregnant women, pregnant women rated their sense of smell lower, rated the test odourless pleasant, more often classified the odours as inedible, were less likely to report odour evoked memories and used perfumeless.12
Increased secretions from the Ears were seen in 20 patients. A similar number of patients also complained of Nasal blocks. This is a very important thing to be kept in mind because many of the drugs used for these symptoms are available over the counter and carry a warning that these should not be used in pregnancy. Difficulty in hearing was described by 5 patients, three (3) of whom were in the 3rd trimester. Low-frequency sensorineural hearing loss (SNHL) in pregnancy has been described in the literature.13 This reduced hearing is again due to changes in estrogen and progesterone which cause alterations in the sensory nervous system and hearing mechanism.14
CONCLUSION
Based on our study, we conclude that feeling of loss of balance and dizziness are the most common ear-related symptoms in pregnancy. From a review of current literature, it can be safely concluded that pregnancy per-se, with its hormonal changes and resultant plasma volume alterations, affects the mechanism of the inner ear, but further research can be done in this field for a better understanding.
Conflict of interest: The authors declare there is no conflict of interest among them.
Funding: No funding or grant was availed by the authors during the study.
Author Contribution
Gangadhar Sahoo and Ruchi Bhuyan conceived, planned, designed and guided the study. Madhusmita Smrutibala Nayak, Deepa Kala and Shanta Satpathy, wrote the manuscript, screened the patient, and collected the data, performed the data to analysis statically. Final Modification editing and revising of the manuscript was carried out by Dattatreya Kar.
Englishhttp://ijcrr.com/abstract.php?article_id=3740http://ijcrr.com/article_html.php?did=3740
Heenan AP, Wolfe LA, Davies GAL, et al. Effects of human pregnancy on fluid regulation responses to short term exercise. J Appl Physiol 2003;95:2321-2327.
Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC, Hankins GD. Cesarean delivery and cesarean hysterectomy. Williams Obstetrics: Connecticut: Appleton Lange. 1997: 509-533.
Bittar RSM. As síndromes de equilíbrio na mulher. In: Formigoni LG, Gobbi AF. (coord.). Otoneurologia: fatos e experiências práticas. São Paulo: Editora Sarvier; 1999: 01-07.
Dengerink JE, Dengerink HA, Swanson S, Thompson P, Chermak GD. Gender and oral contraceptive effects on temporary auditory effects of noise. Audiology 1984;23:411-425.
Laws DW, Moon CE. Effects of the menstrual cycle on the human acoustic reflex threshold. J Audiol Res 1986;26:196-206.
Bittar RSM, Bottino MA, Bittar RE, Formigoni LG, Miniti A, Zugaib M. Estudo da função do ouvido interno na gestação normal. J Bras Ginecol 1991;101(9):381-383.
Ireland ML, Ott SM. The effects of pregnancy on the musculoskeletal system. Clin Orthop Relat Res 2000;372:169-179.
Dunning K, Lemarsters G, Bhattacharya A, Levin L, Alterman T, Lordo L. Falls in workers during pregnancy: risk factors, job hazards, and high risk occupations. Am J Ind Med 2003;44(6):664-672.
Black FO. Maternal susceptibility to nausea and vomiting of pregnancy: is the vestibular system involved? Am J Obstet Gynecol 2002;186(2):204-209.
Goodwin TM. Nausea and vomiting of pregnancy: an obstetric syndrome. Am J Obstet Gynecol 2002;186(5):S184-189.
Bittar RSM, Bottino MA, Bittar RE, Formigoni LG, Miniti A, Zugaib M. Estudo da função do ouvido interno na gestação normal. J Bras Ginecol 1991;101(9): 381-383.
Gilbert AN, Wysocki CJ. Quantitative assessment of olfactory experience during pregnancy. Psychosom Med 1991;53:693-700.
Bhagat DR, Chowdhary A, Verma S, Jyotsana. Physiological changes in ENT during pregnancy. Indian J Otolaryngol Head Neck Surg 2006;58: 269-270.
Baker MA, Weiler EM. Sex of listener and hormonal correlates of auditory thresholds. Br J Audiol 1977;11(3):65-68.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareAn Empirical Study on Changing Trends in Pharmaceutical Sector
English137141Arpita GhugeEnglish Vaishali RahateEnglish Sapan JoshiEnglish Roshan Kumar JhaEnglishIntroduction: Pharmaceutical industry in India is one of the important contributors to the economy of our country, the total industry size forecasted to reach the US $280 billion by 2021. One of the reasons for a high growth rate is attributed to more customer orientation of the promotional strategy of the pharmaceutical companies. Objective: This research deals with analysing the change in customer orientations. Methods: 300 Doctors in the Nagpur region were randomly selected and the survey questionnaire consisted of 44 items. Results: It was observed that the transformation in the pharmaceutical industry is taking place which was proved by applying various statistical techniques like t-test, regression analysis and factor analysis. Conclusion: The association with the physician is the key to the success of registering the brand with him. More the physician is associated with the company and more time he spends with the executives, the more are the chances of him remembering the brand and prescribing it.
EnglishPharmaceutical sector, Promotion, Customer orientationIntroduction
The pharmaceutical industry, like any other industry, is very dynamic. There had been many changes and in many forms of its operations. In terms of size, India's pharmaceutical sector accounts for about 2.4 % of the global pharmaceutical industry and 10 % in terms of production. India accounts for 20% of global generics exports.1 The various aspects of the industry can be studied for the change, but this research consists of two main perspectives that are the “role of marketing of product” and “the approach of pharmaceutical professionals”.
In the “role of marketing of product”, we try to understand the new approach of industry towards their customer i.e. the doctor. The role of corporate is studied and their contribution is analyzed in generating sales for the company. The preference of doctor is studied how they think about a company when a pharmaceutical executive approaches the doctor.1,2
From the point of view of “pharmaceutical professionals”, we have tried to understand various factors affecting doctor’s prescription. Here some interpersonal attributes are studied to understand the reason for a doctor’s prescription for a brand, how technology is playing its part and is the customer-specific segmentation is affecting the prescription pattern.
MATERIALS AND METHODS
Study design
The type of research design followed for the study is Exploratory Research. The study was conducted on doctors by snowball method sampling technique. The sample size was 300 doctors of Nagpur city. The main criteria were to select those doctors who get a regular visit from the medical representatives of various companies. Primary data was collected through questionnaires and Interview methods. Secondary data was collected through various websites and literature review.
Objectives:
1. To understand the current behavioural trend of the pharmaceutical companies towards their customers (Doctors/Physicians).
2. To understand the preference of physicians/Doctors to recommend the local pharmaceutical company or multinational company
3. To study the various factors affecting the intention of a doctor to prescribe a drug.
Statistical analysis
The analysis was done in SPSS. The test was conducted using Statistical Package for Social Sciences 21 on 303 responses received after gathering primary data (Table 1). The score obtained is 0.959 which is more than 0.9. As per the table above we can say that there is excellent internal consistency among all the 44 variables.
RESULT AND DISCUSSION
Total 43.6% of total respondents agreed to the fact that they are experiencing a transformation in the pharmaceutical sector. 76.5% of total respondents agreed that they discuss a new molecule with MR during launch.72% of the respondents agreed that Company image influences their prescription.79% of the respondents agreed that innovative drug delivery system and packaging influences their prescription.3
Only 11% of the respondents agreed that the Size of the tablet and the taste of the products influence their prescription.69.7 % of the respondents think communication of field staff with retailer/chemist plays an important role in the successful promotion of brands. 73.9% of total respondents agreed that the companies conduct different campaigns in your clinic/hospital. 77.2 % of the respondents agreed that companies send mailer or samples or updates to you regularly. 81.5% of the respondents agreed that personalized communication from corporate affects their prescriptions. 72% of the respondents agree that companies have increased their communication with you in the last 2 to 3 years.
68% of the respondents opine that companies are reducing their dependence on MR for regular communication and inputs. 79% of the respondents agree that information exposure to internet / TV/ print media has made the patient more aware and do you think this has influenced patients to comply with the dosage and duration of medicine prescribed.
72% of the doctors think that brand recollection is simplified because of division wise Therapeutic segmentation of products by companies. Amongst the various attributes of MR such as Product knowledge of MR, Communication skills of MR, New information with MR, relations with MR, Punctuality and regularity of MR, Visit with a senior manager from the head office of the company, Product knowledge and visit of senior manager has an impact to influence the prescription of the drug.4,5
Hypothesis Testing
The “Model Summary” indicates an R2 value of 0.466, which means that the linear regression explains 46.6% of the variance in the data. The Durbin-Watson d = 1.950, which is between the two critical values of 1.5 < d < 2.5 and therefore we can assume that there is no first-order linear auto-correlation in the data (Table 2).
H01: There is no changed attitude of the Pharmaceutical companies towards their customers.
Ha1: There is a changed attitude of the Pharmaceutical companies towards their customers.
Each variable from V1 to V12 show a significant difference between each variable’s mean and test value. This difference is statistically significant as indicated by the p-value of each variable which is less than 0.05 at a 95% significance level. This indicates that the null hypothesis is rejected and the alternate hypothesis is accepted (Table 3).
The above discussion proves that there is a changed attitude of the Pharmaceutical companies towards their customers.3
HO2: Physicians have a preference for the local pharmaceutical company over a multinational company
Ha2: Physicians are unbiased towards the local pharmaceutical company or multinational company.
From the t-test conducted we see p values less than 0.05 at a 95% confidence level. This suggests that there is a difference between the mean and the test value which is significant. Hence we can conclude that the null hypothesis is rejected and the alternate hypothesis is accepted (Table 4).
This indicates that the physicians are unbiased towards the local pharmaceutical company or multinational company. The last variable number 44 shows a p-value less than 0.05 and thus the difference is statistically significant as compared to the test value. This suggests that there is no much difference in the marketing strategy of local and multinational companies. The above analysis concludes that the physicians are unbiased towards local or multinational companies and there is no much difference in marketing strategy between them.
Factor analysis was conducted on V 24 to V 34 to analyze if there are any more factors
KMO and Bartlett’s value for Q24 to Q34 is 0.882, which is near to 1. This indicates sample adequacy and factor analysis can be conducted on these variables. The number is significant as indicated by p values which are less than 0.05 as indicated in Table 5-7.
From the variables of component 1, we can say that “Professional” MR influences the prescription pattern of the physician. From the variables of component 2, we can say that “Experienced and matured” field staff of any gender influences the prescription equally of a physician. Two new factors are found out from the above factor analysis. One is “Professional” and the second is “Experienced and Matured” field staff of any gender.6
CONCLUSION
This study was undertaken to be useful to those who want to launch a new molecule by any pharmaceutical company, or launch a new molecule in the market or want to study the dynamics of the industry. The association with the physician is the key to the success of registering the brand with him. More the physician is associated with the company and more time he spends with the executives, the more are the chances of him remembering the brand and prescribing it. The physicians are therefore invited to attend various programs like CME (Continues Medical Education) workshops, seminars etc. by which they are associated with the company and spend more time with the company executive. This activity registers the brand and increases business for the company. Therapy wise segmentation of the products or brands increases the chances of registration of brand with the physician. It becomes difficult for the physician to remember brands if not associated with any segment.
Conflict of Interest: Nil
Source of Funding: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=3741http://ijcrr.com/article_html.php?did=3741
Erdinc O, Vayvay O. Ergonomics interventions improve quality in manufacturing: a case study. Int J Ind Syst Engg 2008;3:727-745.
Kim Y, Kang D, Koh S. Risk factors of work-related musculoskeletal symptoms among motor engine assembly plant workers. Korean J Occup Environ Med 2004;16(4):488-498.
Gentzler M, Stader S. Posture stress on fire-fighters and emergency medical technicians (EMTs) associated with repetitive reaching, bending, lifting, and pulling tasks. Work 2010;37(3): 227-239.
Jones T, Kumar S. Comparison of ergonomic risk assessments in a repetitive high-risk sawmill occupation: Saw-filer. Int J Ind Ergon 2007;37(9-10):744-753.
Janowitz I, Gillen M, Ryan G. Measuring the physical demands of work in hospital settings: Design and implementation of an ergonomics assessment. Appl Ergon 2006;37(5):641-658.
Choobineh A, Tabatabaee S, Behzadi M. Musculoskeletal problems among workers of an Iranian sugar-producing factory. Int J Occup Saf Ergon 2009;15(4):419-24.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareEffect of Motor Dual-Task Training Over Progressive Resisted Exercises on Balance and Mobility in Elderly People
English142146Sarulatha HaridassEnglish M. ManikumarEnglish Vasanthan RajagopalanEnglish R. VijayaraghavanEnglish Ramesh Kumar JeyaramanEnglishBackground: The older adults’ population is rapidly growing and projected to be 198 million in 2030, which means greater demand on the health care system to sustain and improve the quality of life. The international report of the World Health Organization declared that the elderly above 65 years have 28% to 35% of falls every year and this rate rises with growing age and associated risk factors. Falls cause reduced confidence, mobility, major injuries, decreased functional status and increased dependency in older adults. Hence the need to explore an effective exercise program for the elderly to improve their functional abilities. Objective: To analyse the effects of motor dual-task training over progressive strength training in older adults with impaired balance. Methods: This is Randomized pilot study. The elderly participants aged between 60 to 75 years from residential care facilities were randomly allocated to 2 groups, (12 in each). One group received motor dual-task exercise (MDT) and the other group received progressive resisted exercises (PRE), for a total of 24 sessions. The effects of MDT and PRE on balance and mobility were analysed using Performance-oriented mobility assessment (POMA) scale. Results: It was observed that the motor dual-task training group showed better improvement in balance and mobility measures. (pEnglishStrength training, Falls, Gait, Older adultsINTRODUCTION
Ageing progressively declines movements and functions, thereby impacting muscle strength, endurance and power. By 2025, the geriatric population is expected to be 840 million in developing countries.1 The distribution of elderly aged 60 and above is projected to increase from 7.5% in 2010 to 11.1% in 2025. The elderly population in India is expected to reach 158.7 million in 2025 eventually increasing the burden on the resources of the country.2
Elderly people are vulnerable to functional impairments. Common activities like rising from the chair, reaching top shelves, activities requiring postural responses, functional activities like walking, climbing stairs becomes challenging and risky. The impaired mobility and muscle strength gradually lead to loss of balance, body instability and increases the risk of falls. The reductions in the important physical components due to ageing have to be identified at the earliest to prevent & control essential physical losses. The uses of various physical exercises in enhancing functional activity in older adults have been the focus of recent research. The exercise protocol requires the inclusion of the best possible combination of training parameters to improve musculoskeletal, neurological & cardiovascular adaptations which can help cope with the functional activity.
Strength training was found to be one of the important exercise components recommended in kinds of literature. But the use of strength training as the stand-alone protocol for elderly subjects is still debated and is an area of interest for many researchers. Moreover, the exercise protocol needs to address the root cause of functional limitation and the important factors like muscle strength, balance, postural control, cognition etc,.3 Falls in the older age group has a debilitating effect on mobility, confidence in performing activities of daily living (ADL), resulting in institutionalization and escalation of economic costs4 and hence it’s imperative to develop an effective exercise protocol for a better quality of life in the elderly.
Most of the functional activities and ADL require performance of a motor task, postural control & cognitive function simultaneously, probably with the role of recognition and concentration as a part of motor learning.5 It has been reported that older subjects have difficulty in performing the dual task at the same time like walking and balancing activities.6 Few studies highlighted the importance & benefits of dual-task balance training, in the prevention of falls in elderly people.7
Due to the dearth of studies within the context of literature searched, the contribution and the effectiveness of strength training and dual-task exercises in improving balance and mobility which are the cardinal element of functional activity in the elderly population eventually resulted in the scope of the present study. We aimed to study the feasibility to analyse the effect of motor dual-task exercises and progressive resisted exercises on balance & mobility improvements in the elderly.
MATERIALS AND METHODS
This was a randomized pilot study conducted in elderly from residential care homes. Ethical clearance was obtained from the institutional human research & ethical committee(001/03/2016//IEC/SU). The participants were recruited from residential elderly care centres, who volunteered and were willing to take part in the study. Written informed consent was obtained from all the participants. Nearly 12 participants were recruited in each group.
Inclusion criteria
Elderly aged between 60 to 75 years of both genders, who were able to ambulate at least 5m with/without aide and able to stand independently for 1 min without support, POMA score of 24 and less were included. The cognitive status was assessed to ensure that the subjects were mentally competent to perform the exercises safely, understand and respond appropriately to the tests and questionnaires used as outcome measures.
Exclusion criteria
Participants with unstable medical conditions and with significant visual or auditory impairments, vestibular disorders, severe pain on weight-bearing during activity with musculoskeletal disorders of the lower extremity, who underwent regular exercises for lower limb strength and/or balance training in the past 3 months and conditions like stroke, Parkinson’s disease, cancer were excluded.
The baseline data on age, sex, BMI, no of falls, presence of physical discomfort were recorded and preserved for data analysis before randomly allotting them into the groups. The pre-test data on balance and gait using POMA were collected before beginning the intervention and post-treatment (at the end of 8 weeks of intervention). The participants were allotted using block randomization, each containing 4 sealed envelopes (2 PRE, 2MDT). The allocation concealment was done using sealed opaque envelopes which were sequentially arranged. The sealed envelopes were opened by the investigator who was blinded to the intervention.
Participants in both groups underwent 8 weeks of supervised exercise training. Each exercise program consisted of 3 sessions per week and hence underwent a total of 24 sessions. Each session consisted of warm-up exercises for 10 mins (Stretching of major lower limb muscles), followed by main exercises (respective to their allotted groups) for 40 mins and cool-down exercises for 10min similar to warm-up exercises.
Motor dual-task exercises included challenging the balance tasks with upper limb manipulation, change in the base of support, activities on complaint surface and progressed from standing to walking. The participants started the exercises by normal standing, standing with a narrow base of support like standing with feet together side to side, semi tandem standing, tandem standing, weight shifts with active ankle rolling in normal stance and tandem stance, one leg standing with palm supported on the wall and later off the wall. The above exercises were performed in normal stance and tandem stance with arm movements to the lateral side (shoulder joint abducted to 90 degrees) and anterior side (shoulder flexion in 90 degrees) and with closed eyes. The participants then progressed to standing on the foam. The next sets of exercises were walking, semi tandem and tandem walking with their comfortable speed for a 4 m distance, walking with changing the directions, varying the speed and with alternating hand motions. The participants performed normal walking and progressed to tandem walking on the foam, combined with alternating hand movement 7. Further during walking the participants were trained to do secondary task performance like holding a cup of water and walking, receiving and returning the cup of water, walking while talking to a person, walking with tossing and catching the ball 5. Transferring from one chair to another on the side and in front was also practised by the participants with and without the use of the arms. The participants were able to effectively perform the challenging dual-task exercises after 8-12 sessions. So, they were made to focus and practice with the difficult level of dual-task exercises. A rest period of 2-3 mins was given after 15-20 mins of exercises.
The PRT group received resisted exercise for the key muscles of both the lower limb. The targeted muscles for strengthening were Hip flexors, extensors, abductors, knee flexors and extensors, ankle dorsi -flexors and plantar flexors 8. The external load was given through weight cuffs tied above the ankle joint, except for the ankle plantar and dorsi flexors it was secured around the foot. In the first week of training, participants were trained at 30 % of their 1RM and gradually increased to reach 80 % of the 1RM by the final week, as tolerated by the participants. 1RM was reassessed every 2 weeks. The PRE program consisted of 1 set of 8-10 repetitions for each muscle group during each session, with 3 sessions per week for a total of 8 weeks 9. A rest period of 1min was allowed between each set of training. The participants were instructed to not hold the breath while performing exercises. The lifting and lowering of the weight during every repetition facilitated concentric and eccentric muscle action. The participants of the PRT group had slight muscle discomfort and soreness during the initial sessions and they were treated symptomatically.
Statistical analysis
The statistical analysis was done using SPSS statistics version 26. Baseline homogeneity for outcome measures was established by an independent t-test. POMA scale was analyzed using a non-parametric test. Independent t-test was used for between-group analysis and paired t-test used for between-group analysis with 95% confidence level with a significance level of pEnglishhttp://ijcrr.com/abstract.php?article_id=3742http://ijcrr.com/article_html.php?did=37421. Mane A. Ageing in India: Some Social Challenges to Elderly Care. J Gerontol Geriatr Res 2016;05(02).
2. Dey S, Nambiar D, Lakshmi JK, Sheikh K.The health of the Elderly in India: Challenges of Access and Affordability. National Research Council. 2012. Ageing in Asia: Findings from New and Emerging Data Initiatives. Washington, DC: The National Academies Press.
3. Liu C-J, Latham NK. Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev 2009;2009(3):CD002759.4.
4. Soriano TA, DeCherrie L V., Thomas DC. Falls in the community-dwelling older adult: a review for primary care providers. Clin Interv Aging 2007;2(4):545-554.
5. An HJ, Kim JI, Kim YR, Lee KB, Kim DJ, Yoo KT, et al. The Effect of Various Dual-Task Training Methods with Gait on the Balance and Gait of Patients with Chronic Stroke. J Phys Ther Sci 2014;(26):1287–1291.
6. Shin SS. The Effect of Motor Dual-task Balance Training on Balance and Gait of Elderly Women. J Phys Ther Sci 2014;12:2-4.
7. Wollesen B, Schulz S, Seydel L, Delbaere K. Does dual task training improve walking performance of older adults with concern of falling? BMC Geriatr 2017;17(1):1-9.
8. Trudelle-Jackson EJ, Jackson AW, Morrow JR. Muscle Strength and Postural Stability in Healthy, Older Women: Implications for Fall Prevention. J Phys Act Health 2016;3(3):292-303.
9. Heyn PC, Johnsons AFK. Endurance and Strength Training Outcomes on Cognitively Impaired and cognitively intact older adults: A Meta-Analysis. J Nutr Heal Aging 2008;12(6):401-409.
10. Hess JA, Woollacott M. Effect of high-intensity strength-training on functional measures of balance ability in balance-impaired older adults. J Manipulative Physiol Ther 2005;28(8):582-590.
11. Lang T, Streeper T, Cawthon P, Baldwin K, Taaffe DR, Harris TB. Sarcopenia: Etiology, clinical consequences, intervention, and assessment. Osteoporos Int 2010;21(4):543-559.
12. Bunout D, Barrera G, Avendaño M, de la Maza P, Gattas V, Leiva L, et al. Results of a community-based weight-bearing resistance training programme for healthy Chilean elderly subjects. Age Ageing 2005;34(1):80-3.
13. Vogler CM, Sherrington C, Ogle SJ, Lord SR. Reducing Risk of Falling in Older People Discharged From Hospital: A Randomized Controlled Trial Comparing Seated Exercises, Weight-Bearing Exercises, and Social Visits. Arch Phys Med Rehabil 2009;90(8):1317-1324.
14. Peterson CR. Acute neural adaptations to resistance training performed with low and high rates of muscle activation. Diss Abstr Int Sect B Sci Eng 2009;70(5-B):2746.
15. Hall CD, Echt K V., Wolf SL, Rogers WA. Cognitive and motor mechanisms underlying older adults’ ability to divide attention while walking. Phys Ther 2011;91(7):1039-1050.
16. Perry J, Judith M. Burnfield. Gait Analysis: Normal and Pathological Function. Slack Incorporated, New Jersey, 2010.ISBN: 978- 1556427664,
17. Hyndman D, Ashburn A, Yardley L, Stack E. Interference between balance, gait and cognitive task performance among people with stroke living in the community. Disabil Rehabil 2006;28(13-14):849-856.
18. Gabriele W, Prinz W. Directing Attention to Movement Effects Enhances Learning: A Review. Psychon Bull Rev 2001;8(4):648–60.
19. Yang YR, Wang RY, Chen YC, Kao MJ. Dual-Task Exercise Improves Walking Ability in Chronic Stroke: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2007;88(10):1236-1240.
20. Doumas M, Rapp MA, Krampe RT. Working memory and postural control: Adult age differences in potential for improvement, task priority, and dual tasking. J Gerontol Ser B Psychol Sci Soc Sci 2009;64(2):193-201.
21. Silsupadol P, Shumway-Cook A, Lugade V. Effects of Single-Task Versus Dual-Task Training on Balance Performance in Older Adults: A Double-Blind, Randomized Controlled Trial. Arch Phys Med Rehabil 2009;90(3):381-387.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareRevisiting Organ Donation – Voyage from Death, Donation, Transportation to Organ Transplantation
English147150Nikita ChhablaniEnglish Sonali G. ChoudhariEnglish Abhay M. GaidhaneEnglish Syed Quazi ZahiruddinEnglishThe gap between the huge demand for organs and their inadequate supply is the issue of concern. Organ shortage is a global issue and deceased organ donation is the major sustainable way out. There are stringent criteria instituted for the retrieval, preservation, and transportation of donor organs. India slips to the 40th rank in the study of 69 countries in terms of the number of organ transplants per million population. However, the country has significant potential for deceased organ donation due to a higher proportion of fatal road traffic accidents. There are various programs, policy, legislation, organizations including observation of ‘Organ Donation day’ addressing organ donation. From the Transplantation of Human Organ Act to National Organ and Tissue Transplant Organization, each modality promotes organ donation &transplantation. There are various determinants of organ donation especially influencing the decision making for donation. It is the need of the hour to address wherein the process, and for what reason, potential donors fail to become actual donors. This article reviews and revisits the evolution of organ donation, the magnitude of the problem of inadequate organ donation, measures and services available to promote organ donation.
EnglishOrgan donation, Organ transplantation, Legislation, Transportation, Determinants, DeceasedBackground
Organ donation has evolved significantly from an experimental procedure to acceptable medical treatment for terminal illnesses. Despite these contemporary advances, globally there has been relatively slow progress in the supply of organs for transplantation.1 In many countries, increasing the number of donors and thereby decreasing the waiting list for donor organs is an important subject on the health policy agenda as organ transplantation is an important, and sometimes even the only option to treat organ failures.2 There are various determinants of organ donation especially influencing the decision making for donation. It is the need of the hour to address wherein the process, and for what reason, potential donors fail to become actual donors. This article reviews and revisits the evolution of organ donation, the magnitude of the problem of the shortage of organ donation, measures, and services available to promote organ donation.
Data extraction
The data is extracted from PubMed, Web of Science, Google Scholar, and websites of WHO, Ministry of Health & Family Welfare, Government of India and other websites related to organ donation, transplantation. The extracted information included statistics from various countries including India, the magnitude of the problem of inadequate organ donation, various programs, policy, legislation & organizations for the promotion of organ donation and transplantation.
Problem burden
Global silhouette
The WHO’s global observatory on donation and transplantation data suggests that less than 10% of the world transplantation need is met. Organ donation can only result from around 1% to 2% of all deaths. Even these potential donors might not be willing to donate because of false perceptions, superstitions, and other factors. Fewer than 2000 of the 420,000 kidney transplants in the US since 1988 have been from altruistic living donors who didn’t know the person getting their organ. About one third have been living donors who did. The rest of these transplants were from deceased organ donors. Among all the countries, Spain has the highest rate of organ donation. The rate of donation in the US is about midway among nations that are tracked.3
Indian Scenario
India's organ donation rate in 2016 stood at an abysmal 0.8 persons/million population whereas other western countries like Spain, Croatia, US at 36, 32 and 26 per million, respectively.4 In India, every year nearly 5 lakh people die because of the non-availability of organs. Two lakh and 50,000 people die of liver and heart disease respectively. 1.5 lakh people require kidney transplantation, but it gets available to only 5000. Ten lakh people suffer from corneal blindness yet, less than a thousand transplantations from deceased donors are performed each year - an insignificant number compared to the statistics.5
There is a paucity of skilled manpower and facilities too in the country for transplantation. There are less than 100 kidney transplantation centres, less than 350 clinicians involved in transplantation. Thus, India slips to the 40th rank in the study of 69 countries in terms of the number of transplants per million population, with only three in a million getting the kidney in case of renal failure. The country’s number has now come near to one, after revolving around 0.5 for many years. For India, the country with the second-largest population (over 1.3 billion) across the globe, the number of organ donations taking place is remarkably low.
Organ donation in India has a relatively short history compared to the developed world. A closer look at donation patterns across the country reveals that deceased donation is largely driven by hospitals with active transplant programmes. This could be an area for India to explore to increase the donor pool. Whilst we must continuously strive towards increasing donation rates, we must not lose sight of this big picture. In India, there is significant potential for deceased donation due to the large proportion of fatal road traffic accidents. Over 50% of brain death involves young people with head injury due to road traffic accidents. With adequate systems in place, people succumbing to accident-prone injuries could meet a major portion of the demand.6
Relation between brain death and donation
Brain death is characterised by an irreversible loss of consciousness and the absence of brain stem reflexes. Using artificial technology, the body organs can be kept alive, even after brain death. Vital organs can be donated only if death occurs in the hospital. In case of cardiac death, organs that can be donated are cornea, bones, ligaments, veins, heart valves, blood, platelets and stem cells.
Deceased organ donation
For patients who have not registered to donate, the organization educates families about the donation process and seeks their consent on the patient’s behalf.
Living organ donor program
Live donations impose risks to donors which include infection, bleeding, pain and even death. It also affects their quality of life and daily day to day activities. Organ donation after death if suffices the need for organs then the need for living beings to donate will be minimal and they will not be compelled to donate. There are a lot of ethical issues related to living organ donation.
Determinants of organ donation
In a systematic review by Irving et al.7 out of the qualitative literature on ‘Factors that influence the decision to be an organ donor’, studies that explored community attitudes towards living and deceased solid organ donation (heart, liver, kidney, and lung) using qualitative data through focus groups or interviews were included. The review highlighted that seemingly intractable factors, such as religion and culture, are often tied in with more complex issues such as a distrust of the medical system, misunderstandings about religious stances and ignorance about the donation process. Similarly, various community based studies8,9 showed opposition from family, fear and concern as some of the key barriers for organ donation.
The foremost necessary facilitators were the thought that organ donation would save someone’s life and a sense of improved immunity. Education, occupation, marital status, socio-economic status were also found to be determinants of intention to gift organ.
Programs, Policy, Legislation & Organizations addressing Organ Donation
National Organ Transplant Program10
The various activities under the program are preventive, health education, curative, surveillance and research, training, etc. It also includes the initiatives required to enhance the role of organ retrieval banking organization. The programs stated that there are improved facilities for organ transplantation throughout India, establish a network for equitable distribution of retrieved deceased organs, increase organ availability through a change in attitude and facilitating the retrieval of deceased organs, building up human resource like training required manpower.
Legislation11
Transplantation of Human Organ Bill was introduced in the Lok Sabha on 20th August 1992. Transplantation of Human Organ Act (THOA) was passed in 1994. This is the primary legislation related to organ donation and transplantation in India. Before the introduction of this act, the regulations for organ donation and transplantation in India were non-existent and malpractices were rampant. The amendment to the act was passed by the parliament in 2011, and the rules were notified in 2014 as the Transplantation of Human Organs and Tissue Rules – 2014.
National Organ and Tissue Transplant Organization (NOTTO)12
It is a national level organization set up under the Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. It has the following two divisions:
National human organ and tissue removal and storage network- This has been mandated as per the THOA 2011. The division of the NOTTO is the nodal networking agency and network for procurement allocation and distribution of organs and tissues in Delhi.
The national network division of NOTTO would function as the apex centre for all Indian activities of coordination and networking for procurement and distribution and registry of organs and tissues donation and transplantation in the country.
National biomaterial centre / National tissue bank- The THOA act 2011 has included the component of tissue donation and registration of tissue banks. The objective of the centre is to fill up the gap between ‘Demand’ and ‘Supply’ as well as promote ‘Quality Assurance’ in the availability of various tissues so that demands of tissue transplantation including activities for procurement, storage and distribution of biomaterials can be fulfilled.
Policy for organ donation
Opt-in or Opt-out policy
Several countries, including the Republic of Ireland & Germany, have plumped for an ‘Opt in’ policy. According to this kind of scheme, people are placed in an organ donor register if they take active steps to have their name added to the list.
In contrast, the other countries like Singapore, Spain, have adopted a slightly more radical ‘Opt out’ policy. As per the scheme, mandatorily every eligible adult is auto-registered in an organ donation register. If any individual does not wish his/her organs to be donated after death, then he/she has to complete official formalities for removal of his/her names from the registry.
Mandated choice policy
Several states in the USA, most notably Texas and California have experimented with another kind of policy termed as ‘Mandated Choice policy’, which tries to seek every adult citizen for declaring their views about organ donation. Often newly qualified drivers are asked to declare their preference as a condition of being giving their driving license.
World Organ Donation Day
August 13th is observed as ‘World Organ Donation Day every year with the purpose to remove the taboo and promote organ donation for those who require them as lakhs of people die each year because of organ failure. These precious lives can be saved only if healthy volunteers could go ahead with donating their organs. Donation of organs like liver, kidney, heart, intestine, lungs, pancreas, bones, veins, skin, etc. can be life-changing for thousands of people in need, all across the world.
Zonal transplant coordination committee(ZTCC)13
ZTCC is a not-for-profit, government organization that started to promote organ donation. It works with the objectives like promoting cadaver transplant and fair distribution of organs, reaching out to every needy waiting recipient as per government guidelines, creation of transplant registry and maintaining an organ-specific waiting list of recipients, improving awareness about organ donation.
Transplant Coordinator is a person appointed by the hospital for coordinating all the matters related to removal or transplantation of human organ or tissues or both and for assisting the authority for removal of human organs following the provision of section 3.
Transplant coordinators play a crucial role in the achievement of any organ donation and transplantation. The THOA has made transplant coordinators nomination mandatory before a hospital is registered as a transplant centre. Hence, such a training programme on transplant coordinator is required which will enable to enhance the counselling and coordination skill & other needed competency of the coordinators.
MOHAN Foundation- Key NGO working in the field of organ donation
Mohan foundation i.e. Multi-Organ Harvesting and aid Network is a not for profit non-governmental organization that started to promote organ donation in 1997 in Chennai. It has branches in several cities of India. It is started by the like-minded and concerned medical and non-medical professionals committed to increasing the reach of transplantation of human organs act. Its mission is to ensure that every Indian who is suffering from end-stage organ failure be provided with the ‘gift of life through a lifesaving organ.
Green corridors
It refers to a special road route that facilitates the transportation of harvested organs meant for transplantation to the desired hospitals. The street signals are manually operated to avoid stoppage at red lights and to divert the traffic to ensure rapid transportation of the desired organ. There are many recent instances in India where organs were transported in time using this facility.15
Tissue banks
Tissue banking is the process in which biomedical tissue is stored under cryogenic conditions to be used later when the need arises. Several tissue banks have been established in India in recent times, which help in storing tissues such as the cornea, skin, heart valves, bones and tendons for later use. These centres help in preventing tissue wastage to a great extent.15
Green Ribbon
It symbolizes hope for those who are waiting for a second chance at life through organ transplantation. It reminds of the individuals who have died waiting for a life-saving transplant. It also takes into cognizance the contribution of donors and their families for bestowing the greatest gift, the gift of life to the needy.
Conclusion
Thus, globally and nationally, there is a need to strengthen the promotion of organ donation since there is an acute mismatch between the organs donated and people in the queue for transplantation. It points towards the need to assess the awareness and willingness of the community for organ donation. Because if people will be aware of when and how they can donate organs, will donations happen.
Efforts must be undertaken to motivate the people of the community by large scale information dissemination. In addition, eradication of the misconceptions that continue to overshadow reason and hamper the spread of an action saving many lives is also crucial.
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– Declared none
Funding – The article is from the research project work sponsored by the Indian Council of Medical Research, Delhi.
Authors’ Contribution: NC: Conception of the work, design of the work, manuscript drafting. SGC: Screened and reviewed studies and literature., involved in data acquisition and manuscript drafting. AMG and SQZ: Critical review of the manuscript with final approval of the version to be published.
Englishhttp://ijcrr.com/abstract.php?article_id=3743http://ijcrr.com/article_html.php?did=3743
Morgan SE, Miller JK. Beyond the organ donor card: the effect of knowledge, attitudes, and values on willingness to communicate about organ donation to family members. Health Commun. 2002;14(1):121-34.
Cameron S, Forsythe J. How can we improve organ donation rates? Research into the identification of factors that may influence the variation. Nefrologia 2001;21 Suppl 5:68-77.
WHO’S a global observatory on donation and transplantation. 2016http://www.transplant-observatory.org/
Pal S. Donate life: What you need to know about organ donation in India. Nov 2016. https://www.thebetterindia.com/75687/organ-donation-india/
Organ donation up 4-fold in India, but still a long way to go. TOI, August 2017. https://m.timesofindia.com/india/organ-donation-up-4-fold-in-india-but-still-a-long-way-to-go/articleshow/59855757.cms
Barcellos FC, Araujo CL, da Costa JD. Organ donation: a population-based study. Clin Transplant 2005;19(1):33-7.
Irving MJ, Tong A, Jan S, Cass A, Rose J, Chadban S, et al. Factors that influence the decision to be an organ donor: a systematic review of the qualitative literature. Nephrol Daily Transpl 2012;27(6):2526–2533.
Arunachalam D, Bose SC. Barriers and facilitators of intention to organ donation among general people in the state of Puducherry: a cross-sectional study. Int J Community Med Public Health 2017;5(1):134-139.
Josephine GR. Little Flower and Balamurugan E. A study on public intention to donate organ: Perceived barriers and facilitators. BJMP 2013;6(4):a636.
Kishore J. National Organ Transplant Program. In : National health programs of India- National policies & legislations related to health, 19thed., Century Publications, New Delhi; 2019 .
Transplantation of Human Organs and Tissues Rules. The Gazette of India: Extraordinary Part II Section 3 Subsection (i) March 27,2014.
National Organ and Tissue Transplant Organization (NOTTO), Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India. http://www.notto.gov.in/
Zonal Transplant Coordination Centre, Mumbai: Government of Maharashtra. http://www.ztccmumbai.org/
Shroff S, Navin S. INOS and the essence of organ sharing. Editorial. Indian Transplant Newsletter Vol 3 (10): Oct 2001. https://www.itnnews.co.in/indian-transplant-newsletter/issue10/Editorial Desk-189.htm
Srivastava A, Mani A. Deceased organ donation and transplantation in India: Promises and challenges. Neurol India 2018;66:316-22.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareAnalysis of Electro-Mechanical Window of Heart in The Healthy Young Adults of Bengal
English155160Suranjana Sur MukherjeeEnglish Sharmishtha GhoshalEnglish Aditya ChowdhuryEnglishBackground: Measurement of Systolic Time Intervals (STIs) is a non-invasive and convenient way of assessing left ventricular electro-mechanical activity in health and disease. In this study, we assessed some of the parameters of STIs in a group of healthy young adults from the first-year students of a government medical college in West Bengal, India. Objectives: To assess QT, QS2 and their ratio and compare them between the girls and boys and to create a regional database in comparison to the international values. Methods: IX-TA-220 multichannel recorder was used to record Electrocardiogram (ECG), Heart sound (Phonocardiogram) and Carotid pulse tracing in lying down position at noon and in the postabsorptive stage after the last meal. Results: Mean values of the proposed parameters were analysed by Microsoft Excel software and compared between the boys and girls and also with available international reference values. QS2-Index (QS2-I) was calculated using Wandermann equation6. There were significant differences in the mean values of QT, QS2-I and QT/QS2 between the two sexes. Also, the observed values of QS2-I were slightly longer than international standards. Conclusion: Observed deviation in the duration of systolic intervals from the available international data might be due to geographical and genetic differences. The difference was observed even between the two sexes. Hence the diagnosis of probable cardiac complications should be done based on regional as well as age & sex-specific references.
English Systolic Time Intervals (STIs), QT, QS2, QT/QS2, QS2-IBACKGROUND
Electro-Mechanical Window (EMW) is the temporal difference between electrical and mechanical events in the beating heart. Time intervals that indicate systolic cardiac functions are together known as Systolic Time Intervals (STI). It has been suggested that these intervals can be useful parameters to assess the contractile state of the LV myocardium.1-3 The intervals are measured in milliseconds (ms).
Major components of STIs are QT, QS2, LVET and PEP [Fig.1].
QT = Electrical systole as per electrocardiogram; the interval between the beginning of Q wave (septal depolarization) to the end of T wave (ventricular repolarisation)
QS2 = Electromechanical systole = the interval between the beginning of Q wave of ECG to the appearance of the first high-frequency vibration of S2 i.e closure of Aortic valves. It represents the electrical plus mechanical activity of the entire period of systole which includes: Electro-mechanical Lag (EML), QS1, Isovolumetric Contraction Time (ICT) and LVET.
LVET = Left Ventricular Ejection Time = appearance of carotid pulse to dicrotic notch on pulse transducer recording
PEP = Pre-Ejection Period = (QS2 - LVET). It is the interval from the onset of ventricular depolarization to the beginning of the left ventricular ejection.
PEP/LVET - most sensitive index of ventricular function - normally about 0.35
QT/QS2 - Electrical systole/Electro-Mechanical systole - a useful pro-arrhythmic biomarker. In this study, we have measured three parameters viz. QT, QS2 and ratio of QT & QS2 in 180 healthy First Professional MBBS students of both sexes in a government medical college of West Bengal.
In the present study we aimed to determine the mean value of QT, QS2, QS2I and the value of QT/QS2 in sympathetically naive healthy young adults under identical environmental and metabolic conditions. We have also decided prepare a database of these STI parameters in healthy young populations of West Bengal which can be used as a future reference for subsequent research in this region.
MATERIALS AND METHOD
An analytical clinical study of the cross-sectional design was done in the department of physiology of a tertiary care hospital from 20th March 2019 to 15th February 2020. 180 1st year MBBS students aged between 17 to 19 years of both sexes participated voluntarily after being fully explained about the procedure. Criteria for inclusion were: a) body weight in the range of 50-65 kg and b) height in the range of 150cm to 175 cm. Students falling beyond the two extremes were not included in the study to remove compounding factors that might affect the autonomic nervous system. Students with a history of hypertension, congenital or acquired cardiovascular diseases, respiratory and renal diseases which might affect cardiac parameters were excluded from the study. The recording was scheduled at noon every day and 3 hours after breakfast. The institutional ethical clearance was duly obtained before starting the research [copy attached]. For the recording of STIs, we used IX-TA-220
Recorder which is a multichannel recorder of which the following three channels were used for the purpose:
1. Electrocardiograph: iwire - B3G Bipotential module with A-GC-7165 electrodes to record electrical activities of heart
2. Phonocardiograph: a microphone HSM-220 to transduce heart sound to the electrical signal
3. Carotid Pulse transducer: PT-104 to pick up the pulse wave from the carotid artery. Subjects were allowed to lie down comfortably on a bed. ECG electrodes were placed in such a manner on the subject that Lead II is recorded where a definite 'q' wave is formed. The microphone (phonocardiograph) was placed on the Pulmonary Area of the chest to record the second heart sound (S2). The pulse transducer was placed on the neck over the carotid pulse to record the left ventricular ejection during ventricular systole.
After a short pre-run, the recording was done for about 30 seconds. For calculation of the STIs, good polygraph tracings of at least 10 cardiac cycles were chosen. Variables for analysis were QT interval, QS2 interval and QT/QS2. Duration of QT and QS2 intervals were automatically produced by Kubios software after manually marking the q wave on ECG and dicrotic notch on the pulse tracing. The obtained data were compiled on Microsoft excel and compared between the two sexes. p values were calculated by Student's T-test using SPSS software at 460ms in women it will be called prolonged. There will be an increased risk of torsades de pointes if QTc >500. QTc is termed abnormally short if it is < 350ms. Conventionally, a normal QT should be less than half of the preceding RR interval.4 Causes of a prolonged QTc (>440ms) are Hypokalaemia, Hypomagnesaemia, Hypocalcaemia, Hypothermia, Myocardial ischemia, Raised intracranial pressure, Congenital long QT syndrome and drugs.4 With the invention of modern electronic equipment which can transform various signals of our body to both analogue and digital data, we can get values of every phase of a cardiac cycle upto three decimal places or more. Hence measurement of Electro Mechanical window (EMW) has been proposed as a better predictor of arrhythmia than QTc.16
QS2 is variably affected by acute changes in stroke volume (SV) brought about by changes in preload.17 QS2 best reflects the presence of inotropic stimulation. The shortening of QS2 can be reversed towards normal by administering intravenous propranolol.18 As STIs increases with age and are affected by heart rate some regression equations had to be developed to create age and heart rate specific indices. Different corrections are required for children until puberty 1. Weissler's regression equations for QS2 at 19-65 years is as follows:
For Male QS2I = QS2 + 2.1 x HR ( mean 546 ± 14ms) and for Female QS2I = QS2 + 2.0 x HR ( mean 549 ± 14ms).10 Here the study group comprises of the age group of around 17 to 19 years; so we have used the Wanderman Eqn6,10 for estimating QS2-Index which is calculated for Adolescents of 13-19 years as follows:
Male QS2I= QS2 + 1.6 x HR and Female QS21 = QS2 + 1.7 x HR which gives a predictive male QS2I value of 498 +/- 16 ms and female QS2I as 522 +/- 14 ms. Observed QS2-I in our study for both male and female were higher than the predicted upper limit for the corresponding sex which may be due to racial and ethnic variation.
QT/QS2: QT/QS2 ratio might represent a reliable index of sympathetic cardiac tone.19 QT should always be less than QS2 at rest and the ratio should be QS2 Syndrome” which occurs in high catecholamine levels (as in exercise), mitral leaflet prolapse, CAD or Diabetes. It is a more sensitive & reliable index of pro-arrhythmic danger than traditional QT prolongation.
In basal conditions, the QT/QS2 ratio was less than 1, whereas it increased progressively during the physical exercise (bicycle ergometry) and became greater than 1 at peak exercise.19 These results demonstrate that those stimuli which induce a rise in adrenergic activity may increase the QT/QS2 ratio. In contrast, the reflex inhibition of the adrenergic activity induced by phenylephrine is accompanied by a reduction in QT/QS2 ratio. Therefore, the QT/QS2 ratio might represent a reliable index of sympathetic cardiac tone.
Both QT & QS2 had a significant correlation with HR and mean QT remained shorter than QS2 during exercise though both decreased in parallel, but in patients with coronary artery disease QT was longer than QS2 even at rest and this could be considered a risk factor in CAD patients for ventricular arrhythmia & sudden death.20 An immediate and significant rise in QS2 though HR dropped and QS2 remained prolonged even after 10 sec of the tilt.21
Linde et al22 induced Torsades de pointes (TdP) on 8 beagle dogs and then studied for STIs putting them on the sling. All dogs were treated with a potent potassium channel (IKs ) blocker (JNJ 303; 0.1 mg/kg/min, IV) and after 15 minutes the dogs were triggered with a bolus injection of isoproterenol (0.5 μg/kg, IV) or a mere “natural” stimulus (“fright” with an airbrush) to induce a beta-adrenergic stimulation and possible induction of TdP. They concluded that in slung dogs JNJ 303 prolonged QT, did not affect QS2, resulting in an enhanced QT/QS2 ratio. A high QT/QS2 ratio predicted the induction of TdP after beta-adrenergic stimulation, as observed after isoproterenol, and also after a more “natural” stimulus (“fright” with an airbrush). This observation proves the importance of the QT/QS2 parameter to unearth a hidden probability of cardiac arrhythmia in a healthy individual when under stress.
4. Sexual variations in the cardiovascular parameters:
Virginia Huxley23 has proved in detail that sexual dimorphism is a reality concerning cardiovascular functions. Not only the size of a woman's heart is smaller than a man's heart24, but they also maintain homeostasis differently too. Geelen G et al25 have shown that women of all ages have enhanced para-sympathetic activity (reflected by low Total Peripheral Resistance or TPR and low Mean Arterial Pressure or MAP) and men are found to have relatively higher plasma norepinephrine levels. Under stressful situation men and women use the two arms of baroreceptor reflex differently; men respond by increasing TPR thereby raising MAP whereas, women increase HR and cardiac output (CO). In both cases, there is an appropriate cardiovascular response, but there are potentially different outcomes.23 Cardiac myocytes of the two sexes also differ in their electrical activity.26 Normally ECG of a woman's heart demonstrates a longer QT interval than that of men (which is just the reverse in our study). QT interval does not show much difference in boys and girls before sexual maturity but it shortens in males after attaining puberty.23 Anthony M27 has stated that the density of repolarizing potassium currents (Kr and Ks) in cardiac myocytes are less in females and L-type calcium currents are also of many varieties; hence there is difference in the patterns of cardiac repolarisation between the two sexes. Thus the incidence of cardiac arrhythmias and their response to drugs turn out to be sex-specific which should be taken care of during treatment.
According to Virginia Huxley23, there is a sex-specific difference even in the composition of circulating blood. As the formed elements are less, women usually show lower hematocrit level than men. Both lipid and plasma protein compositions demonstrate sexual dimorphism and the blood flow into the superior mesenteric artery is also higher in females. The significant difference in some of the STI parameters between the male and female population in our study justifies the aforesaid explanation of sexual dimorphism of cardiovascular physiology. Therefore, a single approach to the diagnosis and treatment of cardiac dysfunction will not be optimal for both men and women. To cater to this problem we need separate data for the male and female population. But the study of cardiovascular parameters is difficult in female because of the “women’s cycle”- the sex hormone status of females, changes in a cyclical fashion over the lunar month posing a problem in the interpretation of the findings. The level of testosterone hormone remains relatively constant in males; therefore, males are accepted as a “cleaner model” for the study of cardiovascular function.23
5. Genetic and ethnic influence on cardiovascular parameters:
Predisposition to cardiovascular diseases may be due to racial characteristics but the outcome may be influenced by the environmental factors which are togetherly termed as ethnicity. Ethnicity refers to a group of people who share a geographic area, religion, culture, or language whereas race refers to common characteristics passed down through the genes.
There is diversity even within a racial or ethnic group; genetic traits common to some groups may not be present in others of the same race. The higher heart disease rates seen among some groups like the Afro-American population in the USA may be due to many intertwined factors. Their lower average incomes affect where they live, which in turn affects their access to healthy food, safe places to exercise, and quality health care.28 So the interpretation of cardiovascular parameters encompasses all the aforementioned factors taken care of for which we need a separate database for different race and ethnicity.
Estimation of Systolic time intervals like QT, QS2 and their ratio yields a rich source of information about the conductivity and contractility of the heart and can predict hemodynamic and autonomic modulation of the heart when subjected to stress. Hence Urbaszek29 has aptly said Left ventricular (LV) systolic time intervals (STI) should be considered the integral components of LV performance. Unlike echocardiography or electrocardiography, the risk of arrhythmia can be anticipated only through the estimation of STIs; hence it should be checked before prescribing any drugs which may have a chance to cause arrhythmia in both normal and diseased. The values of STIs in these sympathetically naïve young adults at resting state can be taken as a standard reference for healthy adults in this region.
CONCLUSION
Systolic Time Intervals (STI) are influenced by several anthropometric, hemodynamic, and pharmacologic factors which can limit the usefulness of STI for the evaluation of cardiac function in individual patients. That's why a normative database has to be prepared under similar hemodynamic conditions for different ethnic groups and different age groups in both the sexes.
CONFLICT OF INTEREST: Nil
SOURCE OF FUNDING: Nil
ACKNOWLEDGEMENT: We would like to express our heartfelt gratitude to Prof. Dr. Ananda Kumar Mukhopadhyay, Head of the Department, Department of Physiology, Nil Ratan Sircar Medical College and Hospital, Kolkata for providing the laboratory facilities and other logistic support. We authors are very thankful to each other as we have done this work collaboratively from the very first day. We would like to thank all of the participants without whom the research work could not be completed. Weissler, Peeler & Roehll’s 7 work inspired us to work on this very important and interesting topic. Research paper of S. Hassan10 helped us to understand the topic meticulously. Wanderman’s equation 6 helped us to measure the QS2 index for which we are very grateful to the inventor of the equation. We are grateful to all of the scholars whose articles are used for review of the literature and mentioned in the reference.
Englishhttp://ijcrr.com/abstract.php?article_id=3745http://ijcrr.com/article_html.php?did=37451. Lewis RP, Stanley ER, Forester WF, Boudoulas H. A critical review of systolic time intervals. Circulation 1977; 56: 146–158.
2. Metzger CC, Chough CB, Kroetz EW, Leonard JJ. True isovolumic contraction time and its correlation with easily measured external indices of ventricular contractility. Circulation 1967; 36 (suppl II): II-187p.
3. Talley R, Meyer J, McNay J. Effect of diastolic pressure on relationships between an external contractile state and two internal indices of myocardial dysfunction. Clin Res 1969;7(20).
4. Burns ED. QT Interval. ECG Library-ECG Basics. Life in the Fast lane (LITFL). 2019.
5. Pal GK, Pal P. Ch 35. Systolic Time Intervals. In: A textbook of Practical Physiology. 4th ed. Hyderabad, Telangana, India: University Press. 2016; 231-33.
6. Wanderman KI, Hayek Z, Ovsyshcher I, Loutaty G, Cantor A. Systolic time intervals in adolescents. Normal standards for clinical use and comparison with children and adults. Circulation 1981; 63: 204.
7. Weissler AM, Peeler RG , Roehll WH. Relationships between left ventricular ejection time, stroke volume, and heart rate in normal individuals and patients with cardiovascular disease. Am Heart J 1961;62:367-78.
8. Slodki SJ, Hussain AT, Luisada AA: The Q-II interval. III. Study of the second heart sound in old age. J Am Geriatr Soc 1969;17(7):673-9.
9. Willems JL, Roelandt J, DeGeest H, Kesteloot H, Joosens JF. Left ventricular ejection time in elderly subjects. Circ. 1970, 42(1): 37-42.
10. Hassan S, Turner P. Systolic time intervals: a review of the method in the non-invasive investigation of cardiac function in health, disease and clinical pharmacology. Postgraduate Medical J 1983;59:423-34.
11. Golde D, Burstin L. Systolic Phases of the Cardiac Cycle in Children. Med Circul 1970; 42:1029–1036.
12. Slodki SJ, Hussain AT, Luisada AA. The Q-II interval; III Study of the second heart sound in old age. J Am Geriatr Soc 1969;17:673.
13.Weissler AM, Kamem AR, Bornstein RS, Shoenfeld CD & Cohen S. Effect of deslanoside on the duration of the phases of ventricular systole in man. Am J Cardiol 1965;15:153.
14. Weissler AM, Lewis RP, Leighton RF. The systolic time intervals as a measure of left ventricular performance in man. In: PN Yu, JF Goodwin (Eds.) Progress in cardiology, Lea & Febiger, Philadelphia (1972); pp.155-83.
15. Weissler AM, Harris WS, Schoenfeld CD. Systolic time intervals in heart failure in man. Circulation 1968;37:149-159.
16. Charisopoulou D, Koulaouzidis G, Rydberg A, Henein MY. Exercise worsening of electromechanical disturbances: A predictor of arrhythmia in long QT syndrome. Clin Cardiol 2019; 42(7): 235-40.
17. Martin CE, Shaver JA, Thompson ME, Reddy PS, Leonard JJ. Direct correlation of external systolic time intervals with internal indices of left ventricular function in man. Circulation 1971;44:419-31.
18. Lewis RP, Boudoulas H, Welch TG, Forester WF. The usefulness of systolic time intervals in coronary artery disease. Am J Cardiol 1976;37(5):787-96.
19. Caprio LDe, Ferro G, S Cuomo, Volpe M, Artiaco D. QT/QS2 ratio as an index of autonomic tone changes. Am J Cardiol 1984;53(6):818-22.
20. Ferro G, Romano M, Carella G, Cotecchia MR, Maro TD. Relation between QT &QS2 intervals during exercise & recovery; Response in a patient with coronary artery disease & age-matched control subjects. Chest. 1986 Oct; 90(4): 558-61.
21. Singh K. Effect of Orthostatic Stress on Systolic Time Intervals in rabbits. IJPP 2004: 48(3):361-64.
22. van der Linde H, van Deuren B, Somers Y, Teisman A, Towart R. The QT/QS2 ratio: a risk-marker for torsades de pointes in conscious dogs after Iks-blockade and beta-adrenergic triggers. Janssen pharmaceutical companies of Johnson & Johnson Center of Excellence for Cardiovascular Safety Research, B-2340 Beerse, Belgium. Proceedings of the British Pharmacological Society at http://www.pA2online.org/abstracts/Vol8Issue1abst045P.pdf.
23. Virginia H. Huxley. Sex and the cardiovascular system: the intriguing tale of how women and men regulate cardiovascular function differently. Adv Physiol Educ 2007;31(1):17–22.
24. Rabbia F, Grosso T, Cat Genova G, Conterno AA, De Vito B et al. Assessing resting rate in adolescents: determinants and correlates. J Hum Hypertens 2002;16(5):327–32.
25. Geelen G, Laitinen T, Hartikainen J, Bergstrom K, Niskanen L. Gender influence on vasoactive hormones at rest and during a 70-degree head-up tilt in healthy humans. J Appl Physiol 2002;92:1401–08.
26. Surawicz B, Parikh SR. Differences between ventricular repolarization in men and women: description, mechanism and implications. Ann Noninvasive Electrocardiol 2003;8(4):333–40.
27. Anthony M. Male/female differences in pharmacology: safety issues with QT-prolonging drugs. J Women's Health (Larchmt) 2005;14(1):47–52.
28. Race and ethnicity: Clues to your heart disease risk? Published: July 2015; Updated: July 17, 2015. [Harvard Health Publishing. Harvard Medical School]
29. Urbaszek W. (1980) Noninvasive Evaluation of the Cardiovascular Function using the Pre-ejection Index. In: List W., Gravenstein J.S., Spodick D.H. (eds) Systolic Time Intervals. International Boehringer Mannheim Symposia. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-46418-8_23.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareA Case Report of a Left-Sided Cerebrovascular Accident with Systemic Hypertension in Elderly Women
English161164Swapna G. MoreyEnglish Seema SinghEnglish Ranjana SharmaEnglish Ruchira AnkarEnglishEnglishCerebrovascular accident, Elderly women, Hemiplegia, Hypertension, neuromuscular, Therapeutic exercise??????INTRODUCTION
Worldwide, 13.7 million people will experience a hemorrhagic stroke each year. In India, 1.8 million people suffering from a stroke. The incidence of stroke in the general population varies from 154 per 100,000 in India.1,2 Stroke is the fifth leading cause of death, behind cancer and cardiac disease.3 Approximately, twelve % of all strokes occur below the age of forty-year and slightly more common in males. It is a major cause of mortality and morbidity in the elderly.4 Three main vessels supply blood to the brain. These vessels are the anterior cerebral artery, middle cerebral artery and posterior cerebral artery. In this common long time disabilities add in paralysis, inability to talk, inability to walk and depression.5
Alcohol intake reduction, avoidance of cigarette smoking and exercise of these basic strategies and improvements in lifestyle have a higher potential for prevention of stroke.6 In cases of acute stroke, the study of the cerebral vasculature is very important for vasculature management. To assess the utility of MRA, Vascular occlusion, flow and severity of collateral stenosis.7
CASE HISTORY
Patient information
A case of 66-year-old women admitted in the medical intensive care unit on date 3 January 2020 with complaints about the inability to talk and weakness over the right half of the body since 2 days after examining right-side hemiplegia and blood pressure is high 160/100mmof Hg. She had these complaints about 2 days.
Medical/Surgical History
The patient has developed the problem of hypertension before 5 yr. After some investigation did the cerebrovascular accident (CVA) presented initially with the inability to talk, right side hemiplegia. She has a history of hypertension, obesity, anaemia, lower extremity oedema. But the patient underwent coronary angiography done before a few days. She has a double vessel coronary artery disease. No past and present surgical history of the patient. A significant medical problem in the timeline refers to in table 1.
Psychosocial history: She maintains good interpersonal relationships between family member, neighbours, friends and relatives.
Environmental history: Patient home surrounding environment is good. There is a facility of a closed drainage system and proper disposal of waste.
Physical examination
General parameter:
Height : 160 cm , weight : 92 kg , body mass index (BMI) : 35.93
Vital sign : temperature : 99.2 0F , pulse : 60 beat / min , respiration : 16 breath/min , blood pressure: 160/100mmof Hg
Mental status: She was semi-conscious and she had a Glasgow Coma Scale of 11.given the response after the stimulation.
Pulmonary/cardiovascular: Slow pulse rate and sound .respiration also abnormal and blood pressure is high. murmur sound is present.
Integumentary: no skin lesions .dry skin
Musculoskeletal system: She was obese and body mass index (BMI) of 35.93 .slow range of motion (ROM). Muscle weakness is present and a reduction in muscle strength. Periphery oedema in lower extremities.
Speech: inability to talk. sound is present
DIAGNOSIS ASSESSMENT
Blood investigation: In complete blood count (CBC):
Hemoglobin is 10.6 mg/dl(11-13mg/dl) , mean corpuscular hemoglobin concentration is 33.6 g/dl , Mean corpuscular volume (MCV) is 90 fl (78-98 fl ), total RBC count is 3.52 m/ul, WBC is 9200 (4500-11,500 k/ul) ,platelet count is 139,000/ml (150,000 to 450,000 ), Hematocrit (Hct) Levels is 31.7 % (37 %-47 %), monocytes is 03 %(00-15%) , Granulocytes is 74 % ()Lymphocytes is 20 %(20%-40%) , red cell distribution width (RDW) is 10.9 (11.6-14.8) , Eosinophils is 03 % (1-5 %) basophils is 00 % (0-1 % ).
In kidney fuction test (KFT): urea is 36 (9.81 – 20.1 mg/dl) , creatinine is 0.8 mg/dl (0.7-1.4 mg/dl ) ,sodium is 133meq/ l (135-145meq/l) , potassium 4.5(3.5-5.5 meq /l ).
In liver fuction test (LFT): alkaline phosphates is 86 (32-45g/l), Alanine transaminase (ALT) is 34 IU/L (0-50IU/L), aspartate aminotransferase,( AST) is 70 IU/L (10-40 IU/L) ,total protein ia 6.5 (23-38 g/dl) ,total bilirubin is 1.0 g/dl (1-1 g/dl ) ,conjugated bilirubin is 0.2 mg/dl (0-0.25 mg/dl ) ,unconjugated bilirubin is 0.8 mg/dl (0.2-0.7mg/dl) , globulin is 2.8.
In Lipid profile total cholesterol is 159 (200-239 mg/dl ) , triglycerides is 102 mg/dl(150-199 mg/dl) , low –density lipoprotein (LDL) Cholesterol is 94 mg/dl (130-159 mg/dl), high-density lipoprotein (HDL) cholesterol is 45 (35=45 mg/dl).
Calcium is 8.8 mg/dl (8.6-10.2 mg/dl )
Urine examination: Urine albumin is nil, urine sugar is nil, an epithelial cell is 1 cell /hpf.
In peripheral smear, red blood cell (RBC’s) - normocytic normochromic platelets are adequate on smear, seen in clumps no hemiparasite seen.
An electrocardiogram (ECG): An ECG may reveal abnormalities in heart rhythm seen in the ECG.
Brain magnetic resonance imaging (MRI) finding: MRI brain was done. MRI brain showed the suggestive of haemorrhage transformation of acute infarct in left corona radiate and parietal- temporal region corresponding to left middle cerebral artery (MCA).
Fundas examination: In fundus examination was done, which was suggestive of grade II hypertensive retinopathy in both eyes, no evidence of papilla oedema was noted
Therapeutic intervention
General measures: To check the vital sign (Temperature pulse respiration and BP. ) airway, fluid and electrolyte balance and prevention of complications like seizures, pulmonary aspiration, pressure source, thrombophlebitis are mandatory. Health management includes physiotherapy, healthy diet.
Pharmacological management
Antiplatelet agents: Tab aspirin 75mg/day is a non-steroidal anti-inflammatory drug (NSAID) with anti-platelet action, which is used to inhibit platelet aggregation and useful in stroke. To give a low dose in the long term help to irreversible blocks the formation of thromboxane A2 in platelets.
Osmotic diuretic: I nj. Mannitol 100 ml IV. Mannitol is an osmotic diuretic. To reduce of cerebral edema and increased intracranial pressure. To reduce vasogenic cerebral edema.
Antibacterial drug: Inj. Ceftriaxone – 1 gm IV. Ceftriaxone is the third-generation antibiotic from the family of the antibiotic.
Calcium channel blockers: Tab Amlodipin – 5 mg orally, Amlodipineis the calcium channel blocker.
Tab atorin 40mg orally. It is the works by blocking an enzyme (HMG-CoA-reductase) that is required in the body to make cholesterol. It helps for decreased the level of bad cholesterol and increases the level of good cholesterol.
Anticonvulsant drug: InjLevepril 500mg IV , levepril is the anticonvulsant drug. levepril is the help for modulation of the synaptic neurotransmitter release with the help of binding to the synaptic vesicle protein SV2A in the brain.
Proton pump inhibitors (PPIs): Inj. pantoprazole 40 mg IV. Pantoprazole is more effective than H2receptor blockers in reducing gastric acid secretion.
Antiemetic agent:- Inj emeset 4 mg IV . Decreases nausea and vomiting.
Oxygen therapy:- oxygen administration 4 litres/min through a nasal catheter.
Nursing management
First of all makes nursing assessment with the help of observation to check the consciousness, weakness, speech, vital sign, the reaction of a pupil, size of a pupil. To make the client lie comfortably in bed. After checking vital signs ensure patient airway and to given O2 therapy .elevate head end of the bed to 30o and railing bed is provided. To monitor BP.
Nursing diagnosis
1. Impaired physical mobility related to hemiparesis and loss of balance
Goal: to improve and maintain the increased strength and function of affected parts.
Intervention: - to given the proper position and the prone one or twice a day.
2. Impaired airway clearance related to disturbed breathing pattern.
Goal: To improve the breathing pattern
Intervention: assess the respiratory function and implement measures to maintain a patent airway and to improve breathing pattern. To give the prop up position.
3. Impaired nutrition due to less intake.
Therapeutic diet plan
Required the low sodium diet provides 2-3 gm sodium 1600- 1800 calories which give adequate nutrition given. carbohydrate 200gm, protein 60gm fat 40 gm.
Physiotherapy and rehabilitation
Physiotherapy and rehabilitation are useful in the first few months after stroke. exercise, re-education, the provided of walking aids, where appropriate, toe springs adaptation to home.
Communication
Assess the difficulty in using language to communicate or question answer. Encourage the patient's effort to communicate. Speak slowly in simple and also provided consult speech therapists.
DISCUSSION
So many studies indicated that the recovery period within six weeks. If the patient is normal recovery within thirteen weeks. In severe strokes may take twenty weeks. Both cognitive and physical function improved with to help of exercise.8 She has a diagnosis of cerebral vascular accident .systemic hypertension is the secondary diagnosis. the patient gives the respondent well to treatment but the patient relative takes discharge against medical advice (DAMA). As a report of the MRI showing the suggestive of haemorrhage transformation of acute infarct in left corona radiate and parietal- temporal region corresponding to left MCA, the patient had further investigations to find out the cause of hemorrhagic shock.
The patient reacted well to therapy, but more approaches may be used in the future to help in further changes. The rehabilitation and recovery of the patient will mostly depend on the phase of the disease condition. To make improvements and recovery expect the team also requires. In the stroke phase and rehabilitation is dependent on the stage, in stroke management to involves the interprofessional staff and team to manage the patient.
Prognosis
Cerebrovascular accident is a major cause of disability and death. The majority (66%) of stroke that requires hospitalization occur in adults over 65. If the patient has an elderly spousal caregiver who also has health concerns, home maintenance can be a particular challenge. Restricted family members may be living nearby to provide assistance.9,10
Improvement time after a cerebrovascular accident is different for all people it can take weeks, months, or even years. But few people recover fully, but others have long-term. she takes a long period to recover.
CONCLUSION
Hypertension related stroke is a common incident; It is a major cause of mortality and morbidity in the elderly. She fully depends on her family. So health talk taught them the importance of Physiotherapy and its implementation at home after discharge and its usefulness in rehabilitation. Being a health worker it’s an opportunity and responsibility to assist the patient and caregiver in the transition through acute hospitalization, long –term care, rehabilitation, and family requires continuous nursing evaluation and intervention adaptation in response to evolving needs to maximise.
Acknowledgement: The author thanks Dr.Seema Singh, Professor cum Principal, Smt.Radhikabai Meghe Memorial College of Nursing. Datta Meghe Institute of Medical Sciences, Sawangi (M) Wardha for her timely support and valuable suggestions.Mrs. Jaya Gawai, Asso. professor cum academic dean.Mrs.Vaishali Taksande, Professor Dept. of OBGY, The author also thanks Mrs. Archana Maurya, Professor, Dept. of Child Health Nursing. Smt.Radhikabai Meghe Memorial College of Nursing, Datta Meghe Institute of Medical Sciences, (Deemed to be University), Sawangi (M) Wardha, for their continuous support and valuable suggestions. 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. The authors are grateful to the IJCRR editorial board members and the IJCRR team of reviewers who have helped to bring quality to this manuscript.
Ethical approval: Not applicable
Patient Inform consent: While preparing the case report and for publication patient’s informed consent has been taken.
Conflict of Interest: The author declares that there are no conflicts of interest.
Funding: Not applicable
Englishhttp://ijcrr.com/abstract.php?article_id=3746http://ijcrr.com/article_html.php?did=3746
Kamalakannan S, Gudlavalleti AS, Gudlavalleti VS, Goenka S, Kuper H. Incidence & prevalence of stroke in India: A systematic review. Indian J Med Res 2017;146(2):175.
The stroke disease burden in India has increased nearly 100%?: Indian Stroke Association. 2019 Dec 20; https://health.economictimes.indiatimes.com/news/industry/the-stroke-disease-burden-in-india-has-increased-nearly-100-indian-stroke-association/72895241
Becheva M, Georgiev D. Functional Recovery of Patient Whit Ischemic Stroke: Case Report. Iranian J Public Health 2017;46(11):1579-7.
Kayla A. A Case Report: Cerebrovascular Accident. Phys Ther Scholarly Projects 2016;576.
Brenner I. Effects of Passive Exercise Training in Hemiplegic Stroke Patients: A Mini-Review. Sports Med Rehabil J 2018;3(3):1036.
Agrawal A, Joharapurkar SR, Gharde P. Ischemic stroke in a child mistaken as a functional disorder. Clin Neurol Neurosurg 2007;109(10):876-9.
Kumar RJ. Ischemic stroke: relevance of magnetic resonance angiography (mra) findings and correlating the changes with various conventional and nonconventional risk factors. Int J Curr Res Rev 2014;06(01):72–8.
Sunderland A, Tinson DJ, Bradley EL, Fletcher D, Hewer RL, Wade DT. Enhanced physical therapy improves recovery of arm function after stroke. A randomised controlled trial. J Neurol Neurosurg Psychiatry. 1992 Jul 1;55(7):530-5,
Lewis SM. Lewis's Medical-surgical Nursing: Assessment and Management of Clinical Problems. Elsevier Australia; 2009.
Black JM, Hawks JH, Keene AM. Medical-surgical nursing: Clinical management for positive outcomes. WB Saunders Co; 2001.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareAn Intuitive Framework to Segment the Fetal Brain Abnormalities using Improved Semantic Blend Segmentation Algorithm
English165169N. Suresh KumarEnglish Amit Kumar GoelEnglish Tapas KumarEnglishIntroduction: In this day and age, Machine Learning in clinical imaging introduces an energizing time with reengineered and rethought clinical abilities. Deep Learning aids deep further to make physicians feel like a walk in the park with a handful of more desirable resources. Aim and Objective: The Research focuses to classify and segment the abnormalities in the fetal brain MRI images. The normal and lesion tissue are identified with their location from the given raw images. Method: The model will perform localization, Segmentation, and Enhancement of the Fetal Brain and able to address the two significant abnormalities such as Encephalocele and Arteriovenous Malformation using the Improved Semantic Blend Segmentation Algorithm. Results: The model has been trained with the capability to segment the Region of Interest (ROI) on an average of 7.2 Seconds per input. Conclusion: The raw fetal brain images are segmented and enhanced with various classes of input and the results are analyzed which outperforms the existing techniques by saving time and achieving better accuracy.
EnglishFetal Brain Segmentation, Improved SBS Algorithm, Semantic Segmentation, U-Net Architecture
INTRODUCTION
The radiologists deal with expanding and the outstanding task at hand with more information from patients concerning electronic health care records. A definitive task is to play out the manual segmentation of the variations from the norm in the pictures from the information gathered will be more time-consuming. The qualities of the computational framework help the pathologist in a critical decrease by large mistake rate. Automatic segmentation is the best solution to address this issue with the help of evolving technology. The Machine Learning (ML) has been very staggering over the past few which conquered all the place where time consumption need be reduced and accuracy need to be increased. ML will empower clinicians to work better more precisely which will downstream lead to better outcomes for patient care.1 ML has the potential to be an excellent contributor to the entire image interpretation lifecycle beginning from image acquisition to the interpretation and communication of those results. A push is recognized in building new techniques and tools to all the more viably analyze the illness and fix the ailment can majorly affect a huge extent of the population. ML protection medical services applications can be utilized to distinguish different conditions, or any lesion which is driving vital innovation in the health care industry in this decade. On leveraging ML and advanced IT tools in the medical field will achieve data-driven or evidence-driven machines for a human optimized workflow.
Machine Learning plays an eminent role in assisting the medical field with improved early prediction of diseases and abnormalities. Medical imaging segmentation is a significant process in diagnosing abnormalities.1 When the human manually analyzes the images one by one for the abnormal lesion it will be more tedious, exceptionally mind-boggling, and inclined to high mistake rates delays in conclusion. Perhaps, the treatment can be dangerous and can have basic ramifications for a patient's wellbeing. Automatic Segmentation is a precise way to find abnormalities using Machine Learning Algorithms.
The woman of 3 out of 1000 patients have fetal abnormalities.2 The main aim is to locate, segment, and enhance the Fetal Brain Abnormalities from the Fetal MRI images, which is taken as a Region of Interest (ROI) in this work.3,4 With the advancement of profound learning, various deep learning strategies have been proposed to improve MRI image enhancement and highlighting abnormalities.5
Magnetic Resonance Imaging in short it is termed MRI, which is the peculiar modality that provides a beneficial interpretation of the fetal brain scanned images.
The MRI images are taken as the input to our model input. The image enters the room in the .nii format which is the direct output of the scanned machine. The .nii images are loaded in the model and processed into machine learning algorithms. The inference generated will assist the physician to ensure the lesion shape, size, intensity, and significantly the abnormalities of the fetal brain. This model forestalls human-based indicative mistakes and simplifies exertion during an assessment.1,6
K.Somasundaram et al.stated to localize the fetal brain using the centre of gravity (COG) technique, which is a time-consuming but efficient way to achieve the best results.6 He has achieved with less computational methods which are highly handy. The total time taken to perform the localization of the fetal brain takes less than one minute after depicting the algorithm with the input. The area-based segmentation technique was adopted by Omneya Attallah et al., results applied all the three planes of sagittal, coronal, and axial of brain images. The obtained segmented fetal brain images are classified into two categories, a) Healthy class and b) Unhealthy class. The classification accuracy was 95.6%.7
The Superpixel graphs technique was adopted to obtain fetal brain segmentation by Amir Alansary et al., which extracts the features from the segmented pixels and produces a Superpixel graph. Using the superpixel graph, the classifier will categorize whether the given fetal brain is brain or non-brain and localize the fetal brain from the given input.5,8
MATERIALS AND METHODS
Data Collection
The Fetal MRI images of 117 Dicom volumes are obtained from the Beth Israel Deaconess Medical Center, Boston associated with Harvard Medical School. The images were collected with Philips (1.5 Tesla) of T-2 weighted images.
Architecture
The deep convolutional network for the segmentation of biomedical images significantly uses U-Net Architecture. The U-Net is specifically configured for the Biomedical Images.4 In Figure 2.2.1 The U-Net architecture will resemble all other convolutional networks it comprises of countless various tasks showed by these small arrows, the input image is feed into the network in the initial phase then the data is engendered through every conceivable way till the end, the segmentation map will be received at the end of the process. Each blue box corresponds to a multi-channel feature and the number of featured channels with the scale of x and y size.
The majority of the tasks are convolutions trailed by a nonlinear activation function. It is a standard 3x3 convolution followed by a nonlinear activation function an important design choice is that it uses the valid part of the convolution which means that for a 3 by 3 convolution a 1-pixel border is lost this allows later to process large images in individual tiles. The following activity in the U-Net is max-pooling it diminishes the XY size of the element map which was represented as a downward arrow.
The max-pooling follows up on each channel independently it just engenders the maximum activation from each 2x2 window to the following feature map.
After every max-pooling operation, it expands the number of featured channels by a factor of 2 all things considered the arrangement of convolutions and max-pooling operations brings about a spatial contraction where it gradually increases the bot and at the same time decreased the wear. The standard classification ends with this step. Presently, for all features to change a single yield vector the unit has an extra extension way to make a high-resolution segmentation map. This expansion path comprises an arrangement of up convolutions and connection with the relating high-resolution features from the contracting path. This convolution utilizes a learned kernel to map every feature vector to the 2 x 2-pixel output window, trailed by a nonlinear activation function. The output segmentation map contains two distinct channels, foreground and background class. Due to the haphazard convolutions, the map is smaller than the input image. The Softmax Output layer is given by,
Where S denotes the input vector.
Procedure
The fetal brain MRI image is taken as input to the system, where the images will be in the .nii or .nii.gz format of the T2 imaging standard. In this Research, The 94 volume of Healthy and 23 Unhealthy fetal brains was used. The Proposed steps are illustrated in figure 3.1 to perform the Improved Semantic Blend Segmentation (SBS) Algorithm followed by the Optimal Slice Enhancement (OSE) Algorithm.
i) The pre-processing step includes the dataset preparation for the localization and segmentation. Initially, the images are converted into .nii format into .jpg format using the python library named med2image. This library will take all the .nii files from the source folder as input and converts them into the JPG files and store them in the destination folder.
Each slice from the input volume is converted into a jpg image additionally comprises the Sagittal, axial and coronal views are divided separately. The next step is to analyze whether the images all the images in the folder are of the same size. This step is performed using a python library, PIL. This module will take all the images from the Source folder and convert into the same size of 256 x 256 pixel.
Now, the images are split into two sets of folders, called train and testing. The train folder carries 80% of the images and the rest of the images were placed in the test folder. The U-Net model generated image label will be in the .xml file which is to be converted into .csv for further process. The generated .csv file will contain detailed data regarding file_name, width, and height. In addition to that, .csv will have a labelling column, xmin, ymin, xmax, and ymax with its associated class.
ii) In the Processing Step, The Tensor Flow record (TF Record) file needs to be generated, using the classes declared. In this Research, the classes will be Fetal Brain (Region of Interest) and Unhealthy Fetal brain with various abnormalities. The TF Record will be generated using the .csv files with the associated training images and the same will be performed for the testing images with test.csv in parallel the label map (LM) file will be created. The U-Net architecture will be used to localize the ROI.
The model is configured with the training and testing record directory and set ready for training. The MRI scans of the fetal brain images are divided into two different categories, First Folder contains the Healthy Fetal MRI images (Normal) and Unhealthy Fetal images (Abnormal) which is used for the training phase. The training will be started to learn the ROI image features and the model is trained with NVIDIA GPU 1050. The fetal brain images are trained using obtained image features using Machine Learning. The training will be started to learn the ROI image features and the model is trained with NVIDIA GPU 1050. The fetal brain images are trained using obtained image features using Machine Learning.
The trained model is used for predicting the abnormalities from the given input. The test image is passed to the model to detect whether the given image is healthy or unhealthy. If Unhealthy, which type of abnormalities are identified. The model was trained with 3 different classes. Class 1, depicts the healthy fetal brain, Class 2 and 3 which address the abnormality of Encephalocele and Arteriovenous Malformation respectively. In all these classes, the model will spotlight the physician with, what type of abnormality is found, and what is the impact o Post-Processing Step, the segmentation of the fetal brain is initiated by feeding the input image to the Improved Semantic Blend Segmentation Algorithm. The algorithm will blend the processed image into the designated LM file to obtain the segmented image as the output.3 The resultant output will be enhanced.
RESULTS AND DISCUSSION
The raw input image is taken as the input to the algorithm, which processes the segmented enhanced image as the output. Figure 1 illustrates, the complete incremental process of the system output. In Figure 1(a), a slice of the MRI fetal brain is chosen using the algorithm with the best view for analysis, which is initially in the format .nii. Figure 1(b), the label of the fetal brain is extracted from the input image.
The Figure 1(c-f), the enhanced image of the fetal brain is processed to make better visualization analysis for the physician to detect the abnormalities. Figure 1(g,h), leads to the segmentation of the fetal brain and its enhancement representation.
The interpretative representation of the Class 1 category of the fetal brain which is normally free from abnormalities is exhibited in Figure 1. Class 2 and 3 of Encephalocele and Arteriovenous Malformation respectively are processed in Figure 2, which provides the broad resource and perception for the physicians to analyze the patient’s disease progress and take the decision, incrementally better than the previous methods.
All the images were generated automatically after getting the input from the local disk, which is ultimately faster than the manual handling of the MRI images. The significant aspect of the system is to reduce the time of segmenting the fetal MRI images.
A batch of 17 MRI cases are passed to the model in Table 1 the abnormalities are localized and segmented in 318 Seconds. The model process on an average of 18.74 Sec/per case, which is highly efficient when compared to all existing models.
The bar chart and graph in Figure 4 and 5 respectively interprets the individual case time taken and compared with the other volume passed in the batch. The total time taken to complete the total batch of 17 MRI volume of images is 5 minutes and 18 seconds.
CONCLUSION
The classification, localization, and segmentation are performed by this model. The classification informs whether the given input is the normal or abnormal fetal brain. This is the first milestone that delivers significant data about the given input. The localization is performed on the next step to depict the ROI position, with its meticulous shape and size. If the brain is abnormal the lesion tissue is emphasized in the phase. In the final phase, Segmentation of the fetal brain is performed by using the Improved Semantic Blend Segmentation Algorithm, which provides the fetal brain and its abnormalities. This model was a tower of strength to physicians, who work with fetal brain segmentation.
Acknowledgement: Authors acknowledgement the enormous assistance received from the scholars whose articles are cited and included in references of this manuscript. The author is thankful 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
Authors' Contribution: The first author involved in conceptualization, conducted the study, collected data, perform implementation, wrote manuscript, reviewed. The second and third author guided the research work in making necessary amendments in the write-up and final review.
Englishhttp://ijcrr.com/abstract.php?article_id=3747http://ijcrr.com/article_html.php?did=3747
Wiljer D. Developing an Artificial Intelligence–Enabled Health Care Practice: Rewiring Health Care Professions for Better Care. J Med Imaging Radia Sci 2019;50(4):8-14.
Sharma KN, Kamra A. A Model for Mammogram Image Segmentation based on Hybrid Enhancement. Int J Curr Res Rev 2020;12(16): 34-39.
Bhide P, Gund P, Kar A. Prevalence of Congenital Anomalies in an Indian Maternal Cohort: Healthcare, Prevention, and Surveillance Implications. PLoS One. 2016;11(11):1-13.
Vijayalakshmi, Kumar NS. A Review on Fetal Brain Structure Extraction Techniques from Human MRI Images. Int J Comp Sci Engi 2018; 6(4): 239-24.
Alansary A, Lee M, Keraudren K, Kainz B, Malamateniou C, Rutherford M, et al., Automatic Brain Localization in Fetal MRI Using Superpixel Graphs. In Revised Selected Papers of the First International Workshop on Machine Learning Meets Medical Imaging (LNCS). 2015; 9487(1):13–22.
Somasundaram K, Gayathri SP, Shankar RS, and Rajeswaran R. Fetal head localization and fetal brain segmentation from MRI using the center of gravity. International Computer Science and Engineering Conference (ICSEC), Chiang Mai. 2016; 1-6.
Attallah O, Sharkas, Maha. A Gadelkarim H. Fetal Brain Abnormality Classification from MRI Images of Different Gestational Age. Brain Sci 2019;9(9): 231-252.
Tourbier S, Automated template-based brain localization and extraction for fetal brain MRI reconstruction. Neuroimage 2017; 155(1):460-472.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareA Systematic Review of Relation between COVID-19 and Diabetes
English170172Vikrant MankarEnglish Archana DhengareEnglish Ranjana SharmaEnglish Swarupa ChakoleEnglishEnglishCOVID-19, Inflammation, Diabetes, SARS-CoV-2Introduction
Although most human coronavirus infections are mild, major two beta-coronavirus outbreaks, severe SARS-CoV in the 2002–2003 period, and Middle East Coronavirus Respiratory Syndrome (MERS-CoV) in 2012 have caused fatal pneumonia, with increasing mortality. Multilateral pneumonia Coronaviruses have enveloped positive RNA viruses that are widely spread to humans and animals all over the world.1 To include a brief overview of the general characteristics of COVID-19, as well as a more detailed explanation and critical assessment of the relationship between this emerging infectious disease and diabetes, we performed a scope analysis. We hope this analysis will provide useful knowledge for future studies and eventually lead to improved clinical management of COVID-19 and diabetes patients.1
The COVID-19 pandemic poses a health threat to humanity like never before. And people with diabetes, as in many other cases, are paying a very high price. Unfortunately, statistics indicate that people with diabetes are at greater risk for COVID-19 and the prognosis is very low. Due to the constraints imposed by many governments, they also have to face tough challenges in the daily management of their disease in having required treatments as well as the requisite help from specialists and other healthcare professionals, all completely engaged in the COVID-19. Around the same time, they are not getting the most effective care while treated in such a challenging health crisis.
Rates of Diabetes and Obesity in Subjects with Coronavirus Infections
Diabetes is associated with an elevated risk of serious bacterial and viral infections in the respiratory tract including influenza H1N1. A study of more than 500 individuals hospitalized with SARS-CoV in China showed that increased death levels were associated with elevations in fasting glucose; however, hyperglycemia was mostly transient and generally resolved after discharge from hospital in the majority of subjects.3
Diabetes, Infection, and Immune Responses
Acute respiratory virus infection has been linked to the rapid development of transient insulin resistance, whether in otherwise stable individuals with normal euglycemic weight or overweight. In addition, cancer, serious disease, and drugs such as glucocorticoids impair insulin sensitivity and therefore need hospital modification of glucose-lowering medications and insulin dosage. Infectious diseases worldwide contribute to excess mortality in diabetes sufferers.3
Use of Glucose-Lowering Therapies in Subjects with Coronavirus Infections
In preclinical studies, metformin exerts anti-inflammatory action and decreases circulating inflammatory biomarkers in people with T2D.4 Metformin has also been widely used in non-hospitalized subjects with stable hepatitis or HIV infections; however, information on metformin's immunomodulatory activities in the sense of coronavirus infection is scarce. Several studies investigating antibody titers in a limited number of individuals have indicated that immune responses to influenza vaccination in metformin-treated subjects are modestly impaired; however, the clinical relevance of these findings, if any, is unclear. Metformin should be used with caution in depressed hospitalized patients and stopped in persons with chronic sepsis.5
Type 1 Diabetes and SARS-CoV-2
The knowledge available does not suggest that children or adults with T1D are more vulnerable to coronavirus infections. People with T1D can find that interrupting regular daily activities, changing exercise form and duration, and changing dietary habits can alter glucose regulation, requiring re-examination of the insulin requirements.6 The available evidence does not suggest that children or adults with T1D are more vulnerable to coronavirus infections. People with T1D may find that interrupting regular daily activities, changing exercise form and duration, and altering dietary habits will alter glucose regulation requiring re-examination of the insulin requirements.7
Implications on diabetes management
We have assembled a simple flowchart for the metabolic testing and care of COVID-19 patients or those with a risk of metabolic disease. The clinical significance of the above mechanisms is currently not clear, but the effects on patients living with diabetes should be known to health care providers. These include guidelines both for the prevention of primary diabetes and the prevention of serious diabetes-related sequelae (figure). Further, the panel provides detailed guidance on anti-diabetes drugs commonly used in COVID-19 patients with type 2 diabetes.8
To stop the coronavirus that triggers COVID-19 everybody must be alert. I have diabetes type 1 or type 2 then can be even more vigilant. Your chance of contracting the virus is no greater than that of anyone else. But if do get sick, might have worse complications. That's especially true if diabetes isn't regulated properly.
To lower the risk of being infected:
• Hold distance from others
• Provide good hygiene
• Keep blood sugar in order9
Diabetes and Coronavirus
Approximately 25% of people with grave COVID-19 infections have been hospitalized with diabetes in recent studies. Patients with diabetes were more likely to suffer serious complications and die from the infection. One explanation is that high blood sugar weakens the immune system and reduces its ability to prevent infections. If another disease, such as heart and lung diseases, is present, the risk of serious coronavirus infection is much higher. The risk of diabetes complications like diabetic ketoacidosis ( DKA) from infection may be increased if get the COVID-19. DKA occurs when blood builds up at elevated levels of acids known as ketones. This can be very dangerous.9
Tips to Avoid Infection
Staying home as soon as can, is the safest way to stop getting sick. According to the American Disability Act, persons with diabetes have the right to "reasonable workplace accommodation," which includes the right to work at home or to leave when required. When out and when get home or using a hand sanitiser, wash your hands regularly. Position self at least 6 feet from other people when have to leave and wear a face mask of textile. Wash hands until a finger stick or insulin shot is given. First, clean any place with water and soap or rub alcohol.9
COVID-19 Diabetes Plan
Social distancing and shelter-in-place regulations can make it more difficult to get the supplies to need. Stock up enough supplies to last for a few weeks, in the case are quarantined.
Make sure you have:
Simple carbs like honey, sugar-sweetened soda, fruit juice, or hard candies in case your blood sugar dips.
A maximum number of refills from insulin and other medicines you can get.
Extra glucagon and strips of the ketone.
Your phone and health insurance company telephone numbers.9
Medicare and other private insurance providers also cover expenses relating to telehealth visit
• How often to check for sugar and ketones in your blood.
• How to change the medications for your diabetes if you are sick.
• Every cold and flu treatments you can take are free.
To Do is Get Sick
I begin to feel sick, then stay home. Check the sugar in the blood more often than usual. COVID-19 may lower appetite and may cause to eat less, which may affect levels. If are sick will need more fluids than normal. Hold water close by, and sometimes drink it.9 Diabetes is a chronic disease that occurs when the insulin is no longer produced by the pancreas, or when the body can not make good use of the insulin it produces. Insulin is a pancreatic hormone that acts as a gateway to enable glucose from the food we consume to pass from the bloodstream into the body's cells to generate energy. All foods made with carbohydrates are broken down into blood glucose. The epidemiology of diabetes is evident from many GBD studies.10 Effects of diabetes on various body systems and proneness to infections have been reported in several studies.11 Subhadarsanee et al compared Coronavirus Disease and Diabetes as the interplay of two pandemics.12
CONCLUSION
The rapid flow of clinical news from the SARS-CoV-2 epidemic requires ongoing monitoring to understand the conservative uses, risks and benefits of individual glucose-related agents and medicines commonly used in high-risk individuals, or those hospitalized with coronavirus-relevant diabetes. The pandemic emphasises that wearables and portable monitors and the regular communication among diabetes and their health care practitioners must continue and expand innovative diabetes treatments.
Source of funding: Nil
Conflict of interest: Nil
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Mohanty SK, Satapathy A, Naidu MM, Mukhopadhyay S, Sharma S, Barton LM, et al. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and coronavirus disease 19 (COVID-19) – anatomic pathology perspective on current knowledge. Diagn Pathol 2020; 15:103.
Antonio C. COVID-19 and Diabetes: A Call To Action: International Diabetes Federation. 2020;161: 218.
Drucker DJ. Coronavirus Infections and Type 2 Diabetes—Shared Pathways with Therapeutic Implications. Endocr Rev 2020;41(3):011.
Cameron A. Anti-inflammatory effects of metformin irrespective of diabetes status. Circulation Res 2016;119(5):652-665.
Frydrych LM, Fattahi F, He K, Ward PA, Delano MJ. Diabetes and Sepsis: Risk, Recurrence, and Ruination. Front Endocrinol (Lausanne) 2017;8:271.
Basu A. Direct evidence of acetaminophen interference with subcutaneous glucose sensing in humans: a pilot study. Diabetes Tech Therapy 2016;18(S2):S2-43.
Yamamoto JM, Donovan LE, Feig DS, Berger H. Urgent update – temporary alternative screening strategy for gestational diabetes screening during the COVID-19 pandemic. Diabetes Tech Therap 2020;2(5):122-126.
Bornstein S. Practical recommendations for the management of diabetes in patients with COVID-19. Lancet Diabetes Endocrinol 2020; 8:546–50
Lim S, Bae JH, Kwon HS, Nauck MA. COVID-19 and diabetes mellitus: from pathophysiology to clinical management. Nat Rev Endocrinol 2020:1–20.
James S, Castle CD, Dingels ZV, Fox JT, Hamilton EB, Liu Z, et al. Global Injury Morbidity and Mortality from 1990 to 2017: Results from the Global Burden of Disease Study 2017. Injury Prevention 2020;26(1): i96–114.
Gupte Y. Assessment of Endothelial Function by Fmd (Flow Mediated Dilatation) in Prediabetes. Int. J Pharm Res 2019;11(2):1808–1812.
Subhadarsanee C. Coronavirus Disease and Diabetes – Interplay of Two Pandemics. Int. J Pharm Res. 2019; 11(1): 1243–46.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411310EnglishN2021May19HealthcareCorrelates of Happiness Among Older Adults: A Systematic Review
English173179Chaudhary RichaEnglish Pandey NeelamEnglish Dubey AnubhutiEnglishEnglishHappiness, Older Adults, Factors of Happiness, Systematic Review, Ageing Population, Healthhttp://ijcrr.com/abstract.php?article_id=3941http://ijcrr.com/article_html.php?did=3941