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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareToxic Effects of Nanoparticles from Environment and Indoor / Outdoor Workplaces
English0102Tomy M. JosephEnglishEnglishIntroduction to NP toxicity
The environment is constantly in touch with human skin, lungs, and gastrointestinal system. While the skin serves as a good barrier against external chemicals, the lungs and gastrointestinal system are more susceptible. Natural or manmade NPs are most likely to enter via these three routes. Other methods of exposure include injections and implants, which are mostly restricted to engineered materials. NPs may translocate from these entrance sites into the circulatory and lymphatic systems, and then into human tissues and organs, due to their tiny size. Depending on their composition and size, certain NPs may cause irreversible oxidative stress and/or organelle injury in cells. These negative health consequences aren't caused by all NPs. Size, aggregation, composition, crystallinity, surface functionalization, and other variables all influence NP toxicity. Furthermore, the toxicity of any NP to an organism is governed by the genetic complement of the person, which supplies the biochemical toolbox via which it may adapt to and combat hazardous compounds.
Nervous system uptake, oxidative stress, inflammation, and genotoxicity
The brain, spinal cord, and nerves that link the brain and spinal cord to the rest of the body make up the nervous system. In addition to breathing, NP may be taken into the nervous system via additional routes, such as the dermis. The most researched routes are the olfactory nerves and the blood-brain barrier. While the precise method by which NPs have proinflammatory effects is unknown, it is thought that they produce reactive oxygen species, which alter intracellular calcium concentrations, activate transcription factors, and cause cytokine production.
Interactions among organisms, NPs, and contaminants
When NPs interact with hazardous materials and organic molecules, they may either enhance or decrease their toxicity. As a result, although NPs may have negative consequences for the environment, they can also be beneficial. Contaminants may be absorbed by NPs, lowering the quantities of free pollutant molecules in the vicinity of cells and decreasing the pollutants' harmful effects. However, no toxic effects may be seen if the NP or its combination with the pollutant is not hazardous.
Environmental risk assessment of NPs
The effects of nanoparticles on the environment are determined by how they are utilised in the workplace, how they are divided into various media (e.g., water and air), their mobility in each of these media, and their stability. To assess NPs' risks, such basic information about their behavior and toxicity is required; however, a realistic assessment cannot be made solely on the basis of this information; rather, some data on the expected concentration of NPs in environmental systems is required, and there is no accurate data on such concentrations to date. The resources, environmental routes, and uses of NPs, as well as the plants and animals that are sensitive to NPs, must be identified as a starting point for the environmental risk assessment of NPs.
Indoor pollution and health effects
According to the Environmental Protection Agency, indoor air may be 10 times more contaminated than outside air. Indoors, humans and their activities produce a significant quantity of particulate matter. Cooking, smoking, cleaning, and combustion (e.g., candles and fireplaces) are all typical indoor activities that produce NPs. Textile fibres, skin particles, spores, dust mite droppings, chemicals, and smoke from candles, cooking, and cigarettes are examples of indoor NPs. Particles have also been shown to infiltrate buildings via ventilation systems from the outside. Because people spend more than 80% of their time inside, indoor pollution has a direct impact on our health. Indoor smoke from solid fuels causes significant mortality in many parts of the globe, particularly in Africa and Asia. Poorly ventilated stoves utilising biomass fuels such as wood, agricultural waste, dung, and coal are the primary cause of mortality, with more than half of the victims being children under the age of five. According to the World Health Organization, more than half of the world's population cooks and heats using solid fuels, including biomass fuels. Because wood is a renewable resource, it is often overlooked as a source of NPs and thought to be environmentally friendly.
NPs in outdoor spaces
NPs are released in both indoor and outdoor areas as a result of a variety of natural and artificial activities. Some construction workers, gas and petroleum transmission pipeline workers, police officers, farmers, and employees in a variety of other occupations work outside. Few studies have been done on the consequences of such employees' exposure to NPs; nevertheless, the minimal research that has been completed indicates that such workers are at an elevated risk of unfavorable health effects as a result of their exposure to NPs. The penetration of NPs from indoor locations into the outside environment is possible in certain circumstances. For example, NPs that pass past a filtering system may reach outdoor areas through ventilation ducts and have an impact on employees. NPs easily penetrate and are disseminated across indoor and outdoor workplaces due to their unique physical and chemical characteristics. They may harm the human body's biochemistry by causing certain responses in the cells. Many studies are now monitoring the concentrations of different NPs in indoor and outdoor workplaces to establish worker exposure limits. To evaluate the interactions of NPs with biological systems, further study is required. Studies on the absorption routes for NPs, the processes through which they interact with cells, their bio-distribution, and their excretion pathways in the human body should also be addressed. Researchers have recently performed studies on detecting NPs in various settings and monitoring these chemicals in both indoor and outdoor work situations. They've created methods and equipment for measuring NP concentrations in a range of work settings, making it easier to keep track of employees' exposures.
Inhaled NPs associated diseases
Asthma, bronchitis, emphysema, lung cancer, and neurological disorders like Parkinson's and Alzheimer's are all linked to inhaled NPs. Crohn's disease and colon cancer have been related to NPs in the gastrointestinal system. Arteriosclerosis, blood clots, arrhythmia, heart disorders, and eventually cardiac mortality are all linked to NPs that enter the circulatory system. Translocation to other organs, including as the liver, spleen, and kidneys, may result in illness in those organs as well. Some NPs have been linked to the development of autoimmune disorders including systemic lupus erythematosus, scleroderma, and rheumatoid arthritis.
Englishhttp://ijcrr.com/abstract.php?article_id=4013http://ijcrr.com/article_html.php?did=4013Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareEvaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria
English0309Ese AniborEnglish Yvonne O. MabiakuEnglish John C. OyemEnglish Vivian I. UgbechieEnglishBackground and Aim of the Work: Population studies on the prevalence of Temporomandibular Disorders (TMD) and its symptoms amongst Nigerians overlap. Hence, this cross-sectional survey study assessed TMD prevalence, its symptoms, and causes among students attending Delta State University in Abraka, Nigeria. Methods: Three hundred and eighty-four students from Delta State University Abraka, Nigeria, were enrolled in this study and completed a self-administered questionnaire consisting of students’ socio-demographic data and TMD symptoms. Data obtained from the survey were subjected to SPSS. A Chi-square test was used to test sex differences and the relationship between socio-demographic variables and TMD symptoms. Data were presented using pie charts and tables. Results: We recorded a TMD prevalence of 44%. Male had a higher TMD prevalence of 52.4% than females, who had a prevalence of 47.6%. Our findings demonstrated no significant relationship between sex and TMD prevalence, with significant associations between age and TMD symptoms. Pain on chewing was most common and closely followed by limitations in opening the mouth in subjects between 21 and 26 years. Our study demonstrated that TMD is caused by injury to the head and neck and stressful conditions in both sexes. Conclusion: TMD is highly prevalent among students attending Delta State University in Nigeria; its prevalence is higher in males than females, and most subjects experienced pain on chewing. Considering the high prevalence value of TMD recorded in this study, screenings should be recommended for its diagnosis and management.
EnglishTemporomandibular, Disorders, Prevalence, Pain, Chewing, MandibleIntroduction
Temporomandibular joint disorders (TMD) represent common health disorders that encompass dysfunction of the temporomandibular joint (TMJ) and mastication muscles. This health problem is characterized by severe pain, followed by limited mandibular movements, and TMJ noise during jaw movement, mandibular deviation, and chewing disability.1, 2 Although the symptom associated with TMJ disorders is not life-threatening, it has been confirmed to pose adverse effects on an individual's health.3
The pathophysiology of this disorder is described to be multifactorial, resulting from several dental dysfunctions, including parafunctional habits, trauma, restorative procedures or orthodontic treatment, occlusion, emotional stress, trauma, the anatomy of the disc, pathophysiology of the muscles, psychosocial factors, genetics, age and gender. 4
The most prominent TMD symptom reported by patients and clinicians is pain; it is often the main reason patients seek medical help. 5 TMD pains result from mandibular movement; these pains cause restrictions in mandible movement and thus protect it from further damages. 6 TMD may also result from the pain associated with non-dental origin in the orofacial musculature, including the head, face, and related structure. 6] Although restriction in mouth opening is linked to painful mandibular movement, it may or may not be accompanied by pain. 7
Other common TMD symptoms include joint sounds (clicking or noise) and headaches. 8 In TMJ disorders, the joint sound is not often seen as a challenge but more as a possible cause. 9 Displacement of TMJ disc, condyle abnormalities, and mechanical disc distortion may cause joint noise without malfunction or pain. 9 Magnusson et al. (2005) showed an increase in TMJ sound incidence among patients between 15 and 25 years of age. 10
Susanna and Anders in 2007 carried out a cross-sectional survey aimed at investigating TMD prevalence during a one-year period and to investigate confounders linked with TMD manifestations. 11 The clinical manifestations examined in their study-included mobility, pain and TMJ sounds, morphological and dental functional occlusion. Their findings revealed that the prevalence of TMJ manifestations was 12%, with no gender difference. Other findings, such as reported TMJ sounds, accounted for 10%, while clinically registered TMJ pain accounted for 8%. However, the 1-year prevalence of TMJ pain and dysfunction was highest among 1st-year university students.
Another cross-sectional survey study aimed at evaluating the relationship between nutritional and parafunctional habits and the TMD incidence in children with primary dentition demonstrated that atypical swallowing and feeding methods were not determinants for TMD occurrence in the studied population. 12
Soukaina and colleagues in 2009 carried out a study on the incidence of TMD amongst Jordan University students. 13 They reported earaches or pain around the cheek as the most frequent symptom faced by TMD patients, followed by joint clicking (sound). Bora et al. (2012) investigated TMD incidence and manifestations among patients referred to the Prosthodontics unit. 14 Temporal muscle pain was the most prominent, followed by pain during TMJ movement (89%) in males and females. TMJ and masseter muscle pains, grinding, clicking, and anti-depressant use was reported in females compared to males. Age had a significant association with the incidence of TMD. They concluded that girls had more TMD compared to boys in their study population. The most frequent classical sign reported in both genders was pain.
Ahmed and Abuaffan (2016), in their special issue on TMD prevalence among University of Sudan students, showed 77.8% of the participants experienced TMD symptoms while 22.8% of the participants were negative. 15 They recorded a very high prevalence (77.8%), with 43.5% clicking (highest recorded symptom), which was followed by joint tenderness 123 (31.6%).
The incidence of TMD in different study populations reported in different cross-sectional studies varies widely across different populations because of variations of examining practitioners and racial differences, different criteria for diagnosis, and different examination methods. 16
A large body of work had successfully investigated the prevalence of the temporomandibular joint disorder in different populations globally. 10 - 16 Nevertheless, there is an overlap in TMD prevalence in some study populations in Nigeria; therefore the current study investigated the incidence of TMD and its manifestations among Delta State University Students in Abraka, Nigeria.
Materials and Methods
Study Design and Area: This study adopted a descriptive cross-sectional survey and was carried out among Delta State University (DELSU) students, in Abraka. Initially, the institution was a Government Teachers Training College. From 1971 – to 1985, It became a College of Education that issued the Nigerian Certificate of Education (NCE). In 1981 – 1985, the Faculty of Education of the former Bendel State University was affiliated to the University of Benin, Benin City. The establishment of the Edo and Delta States in August 1991 and the conversion of the then Bendel State University's main campus, Ekpoma, to Edo State University in December 1991, mandated the establishment of an autonomous Delta State University, Abraka, on 30th April 1992. Its main campus is in Abraka, Delta State, and other campuses are situated in Anwai and Oleh. Delta State University, Abraka comprises ten faculties, including the Faculty of Basic Medical Sciences.
Sample and Sampling Techniques and Sample size: Authors adopted the multistage/cluster sampling technique for this research work, while the sample size constituted 384 participants, made up of 196 males and 188 females.
Subject Selection Criteria: Students of DELSU, Nigeria, who gave their consent to participate and were between the age range of 15 – 32 years were included in this study. Incomplete questionnaires were excluded. Also, participants with occlusal splints, dental prosthesis, facial and dental anomalies, and extensive dental destruction were excluded from the present study.
Ethical consideration: Approval for this study was obtained from the Research and Ethics Committee of the Department of Human Anatomy and Cell Biology, Faculty of Basic Medical Sciences, DELSU, with IEC number DELSU/CHS/ANA/2017/118. Informed consent was also obtained from all participants. The study adopted the ethical guidelines of Helsinki's Declaration.
Procedure and Protocol for Data Collection
A well-structured self-administered questionnaire was used for data collection. The survey questions contained the following details; age, sex, marital status, joint sound, limitations in opening the mouth, earache, joint locking, pains associated with chewing, head and neck injury, and stressful conditions . Each participant was examined based on the features listed above.
Data Analysis: Data obtained was subjected to Statistical Package for the Social Sciences (SPSS version 22). Results were presented in frequency distribution, pie charts, and cross-tabulation. Chi-square test was used to test for significant gender differences at a confidence level of 95%, while P ≤ .05 was considered as statistically significant.
RESULTS
The pie chart above (figure 1) shows that out of the 384 subjects who responded to the questionnaire and were considered fit for this study, 49.0% were female while 51.0% were male participants.
TMD prevalence was found in 44% of the studied population. Asymptomatic subjects or subjects who had no form of TMD accounted for 56%.
Table 1 shows that out of the 168 subjects who had TMD, 55 and 54 participants respectively who were aged between 21 – 26 years who experiences pain on chewing and limitation of mouth opening have the highest frequency of occurrence. Symptoms like presence of joint sound seen in 31 participants and limitations of mouth openings also seen in 31participants recorded the highest frequency in females aged between 21 – 26 years while pain on chewing seen in 29 participants recorded the highest frequency in males of the same age group.
Table 2 showed the comparison between the prevalence of TMD and gender. Males were reported to have a higher percentage of TMD (52.4%) compared to females who had a lower percentage of TMD prevalence ( 47.6%).
From the Chi square table (table 3) above the P value is eequals 0.643. This implies a no significant association between TMD occurrence and gender (P=0.643).
In examining the association of these symptoms with age using chi-square test, there was a significant association (PEnglishhttp://ijcrr.com/abstract.php?article_id=4014http://ijcrr.com/article_html.php?did=4014
Cooper BC, Kleinberg I. Examination of a Large Patient Population for the Presence of Symptoms &Signs of Temporomandibular Disorders. J Craniomand Sleep Prac. 2007; 25(2): 114-126
Mujakperuo HR, Watson M, Morrison R, Macfarlane. "Pharmacological interventions for pain in patients with temporomandibular disorders". The Cochrane Database of Sys Rev. 2010;(10): CD004715.
Shi Z, Guo C, Awad M. "Hyaluronate for temporomandibular joint disorders". Cochrane Database Syst Rev 2003(1): CD002970.
Jensen R. Pathophysiological mechanisms of tension-type headache: a review of epidemiological and experimental studies. Cephalalgia. 1999;(19):602-621.
Dao TT, LeResche L. Gender differences in pain. J Orofac Pain. 2000;(14): 169-84.
Farsi NM. Symptoms and signs of temporomandibular disorders and oral para functions among Saudi children. J Oral Rehabil. 2003;(30): 1200-1208.
Cairns BE. Pathophysiology of TMD pain – basic mechanisms and their implications for pharmacotherapy. J Oral Rehabil. 2010;(37):391 - 410.
Schmitter M, Rammelsberg P, Hassel A. The prevalence of signs and symptoms of temporomandibular disorders in very old subjects. J Oral Rehabil. 2005;(32):467-473.
Tanaka E, Detamore MS, Mercuri LG. (2008). Degenerative disorders of the temporomandibular joint: etiology, diagnosis, and treatment. J Dent Res. 2008;(87):296-307.
Magnusson T, Egermarki I, Carlsson GE. A prospective investigation over two decades on signs and symptoms of temporomandibular dis-orders and associated variables. A final summary. Acta Odontol Scand. 2005;(63):99-109.
Sussana M. Anders W. Incidence and prevalence of temporomandibular joint pain and dysfunction. A one-year prospective study of university students. Acta Odontol. Scand 2007;65(2):119-27.
Castelo PM, Gavião MBD, Pereira LJ, Bonjardim LR. Relationship between oral parafunctional/nutritive sucking habits and temporomandibular joint dysfunction in primary dentition. Int J Paediatr Dent. 2005;15(1):29-36.
Soukaina R, Zaid HB, Wala MA, Faleh S, Osama S, Darwish HB. Prevalence of Temporomandibular Joint Disorders Among Students of the University of Jordan. J Clin Med. 2009;1(3): 158-164.
Bora B, Elif AA, Sedanur T, Rukiye D, Mutlu O. Gender difference in Prevalence of Signs and Symptoms of Temporomandibular Joint Disorders. a Retrospective Study on 243 Consecutive Patients. Int J Med Sci. 2012; 9(7): 539-544.
Ahmed LI, Abuaffan AH. Prevalence of Temporomandibular Joint Disorders Among Sudanese University Students. J Oral Hygiene Health. 2016; (4): 200.
Sena MF, Mesquita KS, Santos FR, Silva FW, Serrano KV. Prevalence of temporomandibular dysfunction in children and adolescents. Rev Paul Pediatr. 2013; 31(4):538-45.
Fernandes G, van Selms MK, Goncalves DA, Lobbezoo F, Camparis CM. Factors associated with temporomandibular disorders pain in adolescents. J Oral Rehabil. 2015; (42): 113 -119.
Al Zarea BK. Prevalence of temporomandibular dysfunction in edentulous patients of Saudi Arabia. J Int Oral Health. 2017;(9):1-5.
Ahmed MR, Khalid B, Orakzai GS, Khan RS, Mahmood A, Hassan R.: DentistryIncidence of Temporomandibular Disorders Among Dental Students. Int J Contemp Med Res. 2018;5(4): 23.
Deepak G, Amar SR, Varun KV. Treatment of recurrent TMJ dislocation in geriatric patient by autologous blood – A technique revisited. J Oral Biol Craniofac Res. 2013;(1):39–41.
Al-Khotani A, Naimi-Akbar A, Albadawi E, Ernberg M, Hedenberg-Magnusson B, Christidis N. Prevalence of diagnosed temporomandibular disorders among Saudi Arabian children and adolescents. J Headache Pain. 2016;(17): 41.
Franco AL, Fernandes G, Goncalves DA, Bonafe FS, Camparis CM. Headache associated with temporomandibular disorders among young Brazilian adolescents. Clin J Pain. 2014;(30): 340-345.
Nazih I, Naser B, Maria M. Prevalence of Symptoms of Temporomandibular Joint Disorder in Lattakida, Syria. Int J Biomed Eng Clin Sci. 2015;1(2): 23-28
Torii K. Longitudinal course of temporomandibular joint sounds in Japanese children and adolescents. Head Face Med. 2011;(7): 17.
Christensen LV. Facial pain and internal pressure of masseter muscle in experimental bruxism in man. Arch Oral Biol. 1975;(16):1021-31.
Ferrando M, Andreu Y, Galdón MJ, Durá E, Poveda R, Bagán JV. Psychological variables and temporomandibular disorders: distress, coping, and personality. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2004;98(2):153-60.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareBizygomatic Distance and Maxillary Sinus Dimensions as Predictors for Sex Determination: A Morphometric Analysis using Cone Beam Computed Tomography
English1016Aishwarya REnglish Patil KEnglish Mahima VGEnglish Jaishankar HPEnglish CJ SanjayEnglish Nagabhushana DEnglishIntroduction: Many researchers have described the progression of genetically based differences in personality among sex groups and components of the genetics of individual differences in their masculinity and femininity within each sex group. This has made the basis, for both legal and humanitarian purposes. Aims and objectives: The study was aimed to measure, compare and distinguish the sexual dimorphism in the bizygomatic distance and dimensions of maxillary sinuses on Cone Beam Computed Tomography (CBCT) images and to evaluate their reliability in sex determination that might serve as evidence in forensics. Methodology: Bilateral maxillary sinus CBCT images were obtained for 30 patients, 15 males and 15 females. Bizygomatic distance and maxillary sinus dimensions such as length, height, width, area, perimeter and volume were measured and evaluated. The data obtained was then subjected to descriptive statistical analysis followed by an Independent t-test and One-way ANOVA test to arrive at the results. Results: Comparison between CBCT images of male and female groups showed statistically significant differences in bizygoMatic distance and means of both the right and left maxillary sinus length, height, area, volume and left perimeter with P0.05. Conclusion: Sex determination with few linear measurements of bizygomatic distance and maxillary sinus dimensions was possible among the study population. It was found that males had wider bizygomatic distance and larger sized maxillary sinus when compared to females. Hence this study positively recommends the use of bizygomatic distance and maxillary sinus dimensions for sex determination in the field of forensics.
EnglishBizygomatic distance, Cone Beam Computed Tomography, Maxillary sinus, Sex determination, Forensic Odontology, Zygomatic archIntroduction:
Evolution of human life began millions of years ago, probably when some ape-like creatures began to walk habitually on two legs. Eventually, by the end most of the millennium, the perspective of minds as empty slate was rigorously disconfirmed by the temperament and behaviour genetics research.1 Many researchers have described the progression of genetically based differences in personality among sex groups and components of the genetics of individual differences in their masculinity and femininity within each sex group.2 This has made the basis, for both legal and humanitarian purposes. Establishment of one's individuality is important for unknown deceased person in homicide, accident, suicide, mass disasters and for culprits those who are hiding their identity. 3,4
As there are tremendous advancements in field of science, medicine and technology natural catastrophe, misdeed and unfortunate events persist till the date. At such instances, there is a need to collect all possible information to identify the victim. There are many features which differentiate the sex groups, among which the skeletal structures play a major role as they are strongest and are often the sole remnants of a fossil.5Presently identifying these executioners has become slightly trouble-free as a result of evolution in various fields of forensics.6
This ideology could be implicated in radiological identification as no two radiographs are alike. Many studies have shown that the skeletal remains especially the pelvis and skull bones show the greatest sexual dimorphism of around 98%. Skull consists of bones, teeth and air-filled spaces.
Air-filled spaces present within bones surrounding the nasal cavities are known as paranasal sinuses. Paranasal sinuses include frontal, ethmoidal, sphenoidal and maxillary sinus. All of these show minor changes among the sex groups radiographically. Among the paranasal sinuses, maxillary sinuses are first to undergo development and are the largest occupying the maxillary bone bilaterally.7 It is been reported in few studies that maxillary sinus and zygomatic bone will remain intact even though skull and other different bones are badly disfigured among victims.8 Both maxillary sinuses and bizygomatic arches show greatest sexual dimorphism. Maxillary sinus often tends to appear towards the end of second embryonic month and forms completely by 18 to 20 years of age.9
Earlier two-dimensional imaging modality was used for study purposes. Recently, Cone Beam Computed Tomography (CBCT), is being used as the standard imaging modality for visualizing both soft tissues and skeletal structures in multiple views with thin sections and is widely accepted because of its accuracy in three-dimensional imaging, high-quality tissue contrast, better resolution by eliminating overlapping of adjacent structures and also because of its low cost. It can produce images with significantly less radiation exposure.10
Worldwide in few studies, it has been proven that the bizygomatic distance and maxillary sinus dimensions help in sex determination. The bizygomatic distance and all the dimensions of maxillary sinuses are well appreciated in the CBCT images, which varies from one individual to another. This study was undertaken to ascertain if any sexual dimorphism exists in the bizygomatic distance and maxillary sinus dimensions.11
Materials and Method:
Study was a prospective observational study conducted on 30 apparently healthy subjects of age group 20 - 60 years selected by simple purposive sampling for whom CBCT had been advised for assessment/treatment of any oro dentofacial conditions without any developmental defects or trauma to head and neck region with no evidence of midfacial fracture, for which ethical clearance was obtained from institutional ethical committee No- 27/2018.
Eligibility criteria:
Inclusion criteria:
Subjects with the full complement of completely erupted maxillary teeth with or without the third molars.
Ideal CBCT images with optimum diagnostic quality, clearly showing the maxillae including maxillary sinuses.
Exclusion criteria:
Subjects with malocclusion and have undergone orthodontic treatment.
Radiographic evidence of the developmental anomalies, pathology and malunion of fractures affecting the bones of the maxillofacial region and/artefacts.
Method
The clinical examination was carried out after obtaining the written consent from the selected cases and the clinical findings were recorded in individual proforma specially designed for the study. Individuals satisfying the eligibility criteria were subjected to CBCT examination at fixed operating parameters based on the built of the subject by adopting requisite radiation protection measures. Linear measurements were performed on axial and coronal sections for both right and left maxillary sinuses using Planmeca Romexis 5.3 (3D Software). (Figure 1) (Figure 2) (Figure 3) (Figure 4)
Each of these measurements was made twice by the same observer at 15 days interval and the average was considered to avoid intra examiner variability. With the help of these measurement’s other parameters like area, perimeter and volume were calculated using the following formulae.
“Area = Length x Width (cm2)
Perimeter = 2 x Length + 2 x Width (cm)
Volume = Length x Width x Height x ½ (cm3)”
Bizygomatic distance
The bizygomatic width: Maximum distance between the most prominent points on both right side and left side zygomatic arches on axial sections.
Maxillary sinus dimensions
Length of the maxillary sinus
The length of the maxillary sinus: Longest anteroposterior distance from the point most anteriorly to the point most posteriorly on axial sections.
Height of the maxillary sinus
The height of the maxillary sinus: Longest distance from the point most inferiorly on the sinus floor to the point most superiorly on the sinus roof in the coronal sections.
(c) Width of the maxillary sinus
All the obtained data were tabulated and analysed statistically and compared between the right and the left maxillary sinuses of the same individual and between the sex groups respectively using SPSS software version 22.0. The data was then subjected to descriptive statistics, Independent t-test and One-way ANOVA test to arrive at the results.The width of the maxillary sinus: Longest distance perpendicularly from the medial wall of the maxillary sinus to the outermost point on the lateral wall of the lateral process on axial sections.
RESULTS
Of the 30 subjects, 15 (50%) were females and 15 (50%) were males. Each age group comprised of 05 (25%) males and 05 (25%) females with a mean age of 43.1333 for males and 41.8667 for females with a Std. Deviation 14.53993 for males and 13.64795 for females.
On comparing the mean value of BIZYGOMATIC DISTANCE among 15 males and 15 females, a significant difference was noted with males depicting comparatively higher values than females, which was statistically significant. This was further confirmed by independent sample t-test. (Table 1)
The right and left maxillary sinus parameters were measured and compared between males and females. (Table 2)
The difference in the mean value obtained for length, height, area, volume between males and females was statistically significant and was non-significant for width and perimeter. (Table 3)
To summarize the male group revealed statistically significant higher values than the female group for the following dimensions.
Bizygomatic distance
Maxillary Sinus dimensions –
Length – Right side and Left side & Mean length,
Height – Right side and Left side & Mean height,
Area - Right side and Left side & Mean area,
Volume – Right side and Left side & Mean volume,
Perimeter – Left side"
Following parameters revealed no significant difference statistically between both the sex groups.
“Maxillary Sinus dimensions –
Width – Right and left side & Mean width,
Perimeter – Right side & Mean perimeter”
DISCUSSION
From ancient times it is believed that "everybody is unique" in their own way. This uniqueness helps in individual’s identity where identification of an individual becomes difficult. During the due course, forensic science has progressed enormously. In the field of forensic sciences, identity is defined as the recognition of the individuality of a person, alive or dead. An individual can be identified based on age, sex, ethnicity, and appearance which includes weight, height, skin, cornea, hair colour, face contour etc.6
Sex determination is considered to be the classic procedure in the field of forensics as they form a major inceptive step in pragmatic identification of the dead person and building a post-mortem profile which aids in narrowing down the prediction of an unknown cadaver towards a correct probability.12,13
According to many works of literature, it has been stated that the precision rate of sex determination from the skeleton is 100%12,13 because it anatomically withstands heavy injuries. All the structures of the craniofacial region have their own advantages of being composed greatly of the hard tissues, that are comparatively non-breakable, due to which the probability of getting intact maxillary sinus and zygomatic complex without deformity is high. This can be worth using for the purpose of sex determination.
Hence the present study was framed based on the above background to determine the reliability of the bizygomatic distance and maxillary sinus dimensions as a method for sex determination using Cone Beam Computed Tomographic (CBCT) images of 30 subjects, comprised of 15 males and 15 females.
A study by Akhiland Chaurasia14 evaluated sexual dimorphism in the bizygomatic distance and paranasal sinus of 202 subjects using CBCT images. No significant difference was obtained between both the males and females for paranasal sinuses parameters. It was found that the bizygomatic distance was significantly higher in males than in females with a statistical significance of 0.01.
A study conducted by Jehan M et. al.,15 in 2014 on the Sexual Dimorphism of Bizygomatic distance and the Maxillary sinus using CT images and a study by Vidya C.S et.al.,16 on the anthropometric predictors for the sexual dimorphism of skulls of the South Indian population, has been proved that sexual dimorphism exists in the bizygomatic distance. In our study, measurements were made on CBCT images for its advantages over other imaging techniques. Results obtained are in consistent with these studies and showed significant sexual dimorphism in the bizygomatic distance with statistical significancepEnglishhttp://ijcrr.com/abstract.php?article_id=4015http://ijcrr.com/article_html.php?did=4015
Dr Rick Potts. Introduction to Human Evolution, National Museum of National History. Jan.16, 2019. Page no. 1.
Ngun TC, Ghahramani N, Sánchez FJ, Bocklandt S, Vilain E. The genetics of sex differences in brain and behavior. Front Neuroendocrinol. 2011;32(2):227-246. doi: 10.1016/j.yfrne.2010.10.001.Page no. 227-246.
Weisberg YJ, Deyoung CG, Hirsh JB. Gender Differences in Personality across the Ten Aspects of the Big Five. Front Psychol. 2011; 2:178. Published 2011 Aug 1. doi:10.3389/fpsyg.2011.00178. Article 178. Page no. 1-11.
Maloth AK, Dorankula SP, Pasupula AP. Lip outline: A new paradigm in forensic sciences. J Forensic Dent Sci. 2016;8(3). doi:10.4103/0975-1475.195109. Page no. 178-9.
Sidhu R, Chandra S, Devi P, Taneja N, Sah K, Kaur N. Forensic importance of maxillary sinus in gender determination: A morphometric analysis from Western Uttar Pradesh, India. Eur J Gen Dent. 2014; 3 Page no. 53-56.
Rao NG. Text book of Forensic Medicine and Toxicology. 2nd ed. New Delhi: Jaypee Brothers; 2010. Page no. 1-6.
UroogeAyeesha, Patil B.A. Sexual Dimorphism of Maxillary Sinus: A Morphometric Analysis using Cone Beam Computed Tomography, Journal of Clinical and Diagnostic Research. 2017 Mar, Vol-11(3).Page no. ZC67-ZC70.
Uthman AT, Al-Rawi NH, Al-Timimi JF. Evaluation of foramen magnum in gender determination using helical CT scanning. Dentomaxillofac Radiol 2012;41(3). Page no. 197–202.
Masri AA, Yusof A, Hassan R. A Three-dimensional computed tomography (3DCT): A study of maxillary sinus in Malays. CJBAS. 2013;01(02). Page no. 125-34.
Tambawala S.S, Karjodkar F.R, Sansare Kanstubh, Prakash Nimish. Sexual dimorphism of maxillary sinus using Cone Beam Computed Tomography, Egyptian Journal of Forensic Sciences (2016)6. Page no. 120-125.
Azhar A, Ibrahim G, Salah F. Ct scan images analysis of maxillary sinus dimensions as a forensic tool for sexual and racial detection in a sample of kurdish population. ESJ. 2015;11(18). Page no.271-81.
M. SACCUCCI et.al., Gender assessment through three-dimensional analysis of maxillary sinuses by means of Cone Beam Computed Tomography. European Review for Medical and Pharmacological Sciences. 2015; 19. Page no. 185-193.
Teke HY, Duran S, Canturk N, Canturk G. Determination of gender by measuring the size of the maxillary sinuses in computerized tomography scans. SurgRadiolAnat 2007;29(1). Page no. 9–13.
ChaurasiaAkhilanand, Katheriya Gaurav. Morphometric evaluation of Bizygomatic distance and maxillary sinus width as dimorphic tool- A CBCT study. International Journal of Maxillofacial Imaging, October-December, 2016;2(4). Page no. 123-128.
Jehan M, Bhadkaria V, Trivedi A, Sharma SK. sexual dimorphism of bizygomatic distance & maxillary sinus using CT Scan. IOSR-J Dent Med Sci 2014;13(3). Page no. 91–5.
Vidya CS, Shamasundar N, Manjunatha B, Raichurkar K. Evaluation of size and volume of maxillary sinus to determine gender by 3D computerized tomography scan method using dry skulls of south Indian origin. Int J Cur. 2013;05(03). Page no. 97- 100.
Amin MF, Hassan EI. Sex identification in Egyptian population using multidetector computed tomography of the maxillary sinus. J Forensic Leg Med. 2012;19(2). Page no. 65– 69.
Baweja S, Dixit A, Baweja S. Study of age related changes of maxillary air sinus from its anteroposterior, transverse and vertical dimensions using Computerized Tomographic (CT) scan. IJBR 2013;04 (01). Page no. 22-25.
Jehan M, Bhadkaria V, Trivedi A, Sharma SK. sexual dimorphism of bizygomatic distance & maxillary sinus using CT Scan. IOSR-J Dent Med Sci 2014;13(3). Page no. 91–5.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareKnowledge and Awareness on Dental Implants Among Dentate and Partially / Completely Edentulous Adults - A Comparative Assessment in Chennai, India
English1723Tadepalli AEnglish Appukuttan DEnglish Subramanian SEnglish Jenefa JEnglishIntroduction: Dental implants (DI) are being widely used for replacing missing teeth and literature reports showed successful results of DI supported prostheses in partial and complete edentulous rehabilitations. However, knowledge and awareness pertaining to these treatment modalities among patients with and without missing teeth need to be evaluated. Objective: This Cross-sectional observational research aimed to assess and compare the knowledge and awareness on prosthetic rehabilitation with dental implants among dentate and partially / completely edentulous adults. Methods: Self-administeredstructured questionnaire was used to collect the information pertaining to the knowledge and awareness of DI from 500 adults (Group 1: Partially / completely edentulous subjects n=250, Group 2: Dentulous subjects n=250). Further their attitude towards replacement and restoration of missing teeth were also assessed. Responses were tabulated and data was analysed using Chi-Square test and Fisher’s exact test. Result: 53.2 % of group 1subjects and 47.6% of group 2 were aware of dental implants (p>0.05). Nevertheless, the latter group had better knowledge and information on DI (surgical placement, DI failure) than the former group (PEnglishAwareness, Adults, Dental implants, Edentulous, Partially, KnowledgeIntroduction
Newer biomaterials and technologies have radically altered the way dental treatment has been delivered for the past several decades. In this context, dental implants have taken a leading edge over conventional complete, fixed and removable partial dentures for replacement of missing teeth. Despite the fact that these treatment modalities serve the purpose, the advantage rendered by dental implants in terms of enhanced stability, retention, aesthetics, social and psychological comfort, better quality of life and improved self-confidence accentuate them as an excellent alternative treatment for missing teeth.1,2,3,4
Scientific adoption of a novel technology in any area of medicine requires evidence to convince the practitioner and substantial impartation of awareness and knowledge to the general public in order to clarify the benefits and misconceptions associated with that as well. Emerging systematic reviews and meta-analysis suggested excellent success and survival rates with reduced biological and technical complications associated with dental implant therapy.5,6 The cumulative survival rate of dental implants up to 16 years was projected at 82.94% and the prevalence of biological and technical complications was 16.94% and 31.09% respectively according to Simonis P et al.7 Similarly, Mark-Steven Howe et al.8 and Van Velzen et al.9 observed that the 10 years survival rate for dental implants was 96.4% and 99.7% respectively. Globally, the market analysis of dental implants has shown an exponential increase over the last few years and a compound annual growth rate is expected to increase over the next few years, due to the higher prevalence of dental decay and periodontitis associated with dental loss, higher than before demand for cosmetic dental treatment and increased life expectancy.
Despite gaining popularity and hassle free amalgamation into dental practice, surveys carried globally in different countries have revealed conflicting details of knowledge, awareness, perceptions, expectations, outcomes and misconceptions about dental implants. Studies from countries such as the USA,10 Sweden,11 Austria12 and Norway13 have shown greater awareness among their population i.e. 77%, 76.2%, 63% and 70.1% respectively. Studies have shown that people have unrealistic expectations and are misinformed about the life span, maintenance and expertise required for placement of dental implants. These factors in turn may influence their choice of dental implant. Despite the availability of literature evidence from various parts of India, the existing results are more conflicting rather than convincing. Furthermore, no studies have compared the awareness on dental implants between dentate and partially/completely edentulous subjects. Hence, the present study was carried out to compare the knowledge and awareness on dental implants between dentulous and partially or completely edentulous adults in Chennai city.
Material and Methods
This cross sectional analytical observational study was approved by Institutional Ethical Committee and Review Board (SRMDC/IRB/2019/11) and the research was carried out in the outpatient Department of Periodontics, SRM Dental College and Hospital, Chennai. The study period was from May 2019 to February 2020 which was approximately 10 months. Convenience sampling was followed and the subjects fulfilling the selection criteria were recruited for the study. The purpose of the study was explained and written informed consent was obtained from each subject.
A self-explanatory questionnaire was prepared on the basis of previous studies in both English and Tamil languages. A bilingual expert in both English and Tamil languages checked the questionnaire and checked for equivalence in terms of content and meaning. Comprehensibility of the questionnaire was evaluated by randomly administering the questionnaire to 15 patients and their suggestions for improvement were included. Consistency and reliability were evaluated by twice administering the questionnaire to 20 subjects over a period of one week, and Cronbach's alpha of 0.8 was obtained, indicating acceptable internal consistency.
The questionnaire was administered to the patients during their routine visit, those presenting with pain and those not able to read English or Tamil were not included. The study sample included dentulous and partially or completely edentulous adults who were willing to participate in the study. A structured questionnaire was framed, which consisted of the demographic details, responses towards replacement and restoration of missing teeth and their knowledge and awareness on Dental implants (DI). Further their knowledge and awareness towards other replacements were also assessed. The questions were closed ended and the options covered the esthetic as well as the functional aspects of DI. The English or Tamil questionnaires were distributed to the respective subjects who are comfortable in the specific language. Any clarifications or assistance for completing the forms, if needed, were available at all times through trained interns.
A total of 533 subjects received questionnaires and any form with incomplete responses was not included for assessment. In the end, 500 forms with complete responses were considered for the analysis. The received forms were categorized into two groups as responses from edentulous groups and responses from dentulous groups with 250 forms in each group. Responses were entered in the excel sheet and then submitted to a statistical analysis.
Statistical Methods
To analyse the data SPSS (IBM SPSS Statistics for Windows, Version 25.0, Armonk, NY: IBM Corp. Released 2017) was used. Descriptive statistics like, percentage, mean standard deviation, minimum maximum were calculated. To compare proportions between groups, the Pearson Chi-Square test was applied. The significance level is fixed as 5% (α = 0.05).
Results
The demographic details of the study population were shown in Table 1. The study population consisted of a total of 500 subjects, including 250 participants with partial/complete edentulousness (116 males and 134 females) and 250 subjects without any missing teeth (124 males and 126 females). The mean age of group I subjects is 39.9±16.43 years and the mean age of group 2 subjects is 32.9±13.73 years. The majority of the participants in the study were graduates and employed in both groups.
Table 2 depicted the perception of study population towards replacement and restoration of missing teeth. It was observed that a significantly greater percentage of partial / complete edentulous subjects had dental problems than dentulous subjects. However, group 2 subjects significantly believed that missing teeth have to be replaced and loss teeth affect various vital functions such as mastication, speech and appearance.
Table 3 showed the comparison of knowledge and awareness of dental implants in the study population. There were no statistically significant differences in the awareness of dental implants among the study groups. Significant differences were noted with respect to the source of information on dental implants, the nature of implant surgery and the likelihood of complications among the study participants. Most of the study participants felt that cost was the main disadvantage factor associated with dental implant therapy. Significantly greater percentage of group 1 participants were not willing to receive dental implant treatment.
Discussion
The current observational research was conducted to determine and compare whether there is a disparity in the level of awareness and knowledge of dental implants as a replacement option for missing teeth in a sample of partially /completely edentulous and dentulous subjects in Chennai, South India. Many studies on knowledge and awareness of DI among the general population of various countries have previously been documented and it has been widely observed that western people reported higher levels of awareness.
Literature evidence on the same in Indian studies is unclear with contradicting reports, where in few authors observe higher levels of awareness and knowledge whilst many indicate lower or severe deficit in dental implant information. As health care professionals, it is essential for patients to be sufficiently educated about the risks and benefits of any interventions or treatment provided, thereby allowing them to be an active part in the treatment process. Misconceptions and myths about dental procedures often create a mental barrier that prevents patients from seeking dental care, and DI is no exception. Thus, cross sectional studies like these allow dental professionals to identify and bridge the knowledge gaps that create negative attitudes towards replacement of missing teeth using DI enabled through both individual education in a clinical set up and on a larger scale through mass media.
In this study it was observed that edentulous subjects (133, 53.2%) were more aware about dental implants as a replacement option for missing teeth than dentulous subjects (119, 47.6%) this perhaps can be attributed to the fact that they have missing teeth and probably be looking for option to replace them. This is supported by their response that missing teeth should be replaced (90.4%). The current study population had moderate level of awareness on DI and this was in contrast to the studies reporting higher awareness for instance Zimmer et al in the USA10 77%, Berge et al. in Norway13 70.1%, Esfahani and Moosaali in Iran14 76.7%, Tepper et al. in Austria12 72%, Al-Musawi and colleagues in Kuwait15 96.4%. Studies from the cities of Mangalore16 and Bhubaneswar17 have reported very poor awareness on DI i.e. 17.8% and 15.91% respectively. Likewise, cross sectional studies from Rajasthan18 and Madhya Pradesh19 have also reported inadequate awareness on DI i.e. 38% and 25.8% respectively. On the contrary, Ahmed Siddique et al.20 reported higher awareness (93.4%) among residents in Dharwad, Karnataka.
The main source of information on DI in the present group of edentulous subjects were family/friends followed by dentist, however in the dentulous subject’s dentist was the main source of information followed by family/friends, apparently in both the groups the role of media in dissipating knowledge on DI was very insignificant (3.75% and 14.28% respectively). On scrutiny, it was evident from the studies in Indian cities18,20,21,22 that media has a very minimal role in creating awareness on DI among the public in the Indian scenario, on the other hand in the US10 and Norway,13 the primary source of information was through the media. Rajesh Hosadurga et al.21 emphasised on the misinformation that could be created by the electronic and mass media and therefore recommended the dissemination of quality information from the dental practitioner. Hence, dentist should play a more dynamic role in dissemination of information to the public. In Hong Kong, media created fallacy that DI can restore the dentition to absolute normality in terms of function, appearance and quality of life was noted among adults, further they had unrealistic expectations, underestimated the expertise for placement and daily care needed and overestimated the longevity of DI.23 These observations highlight the need for creating better awareness.
On questioning, regarding the site of implant placement it was noticed that more dentulous subjects (110, 92.4%) were aware that DI were placed surgically in the jaw bone, whereas only 66% of edentulous subjects were aware about the placement site. This showed a greater deficit in the knowledge on the site of implant placement in the edentulous group in this population. Amit Gharpure and Prasad Bhange22 in their observational study among Mumbai city residents identified that only 65% knew that DI were placed in bone. Kuwaiti respondents felt that placement of metal within the jaw was dangerous and majority of them considered implant surgical procedure as difficult and complicated.15
Knowledge on the failures associated with DI was evaluated in this study group and it was noticed that the majority of the edentulous subjects had a misconception that dental implants were always successful whilst contrary dentulous subjects predominantly felt that dental implants can fail. The above finding further underscores the inadequate knowledge on DI longevity among the edentulous group in this population. Literature search showed comparable lack of knowledge in the Indian population. It was noticed that 46% of subjects expected DI to last lifelong in Dharwad20 and in Indore,19 48.1 % were not aware about the DI longevity and 49% felt that it lasted for their lifetime. On the contrary in their multicentre trial in China, Yao et al observed that the majority of them were well informed, knew about the complications associated with DI and almost 90% felt that implants were safe, well tested and should be placed only by a specialist dentist. They had better knowledge, knew that DI failed and did not last longer like natural teeth.24
Majority of the edentulous subjects were not willing to undergo DI placement, contrary to the dentulous group and this could possibly be attributed to the better knowledge on DI among the dentulous group. The former group believed that DI looked aesthetically far superior to other replacement prosthesis but higher cost and the associated long treatment time were the limitations. Likewise, the latter group also felt that high cost followed by the surgical procedure was the biggest disadvantage of DI. Pragathi Kaurani18 in their study reported that 56% were not willing for DI even after educating them about DI. Possibly less knowledge or lack of information, no clarity on the procedure, high cost, fear of surgery / complications and multiple other factors could possibly be the reasons for not choosing DI. In their systematic review, Michael edelmayer25 observed that 52.6%±25.4% subjects did not opt for DI due to high cost. In agreement with our observation, Indian studies have similarly reported that high cost was a barrier for not choosing DI and a wide perception that it can be afforded only by rich people.
Limitations of this study could be the small sample size, convenience sampling and being a self-reporting survey there is a likelihood that the respondents may not answer honestly.
Conclusions
Moderate levels of awareness on DI was observed in both the edentulous and dentulous subjects in this study. More than half of the edentulous subjects knew about DI as a replacement option for missing teeth compared to the dentulous subjects. Nevertheless, the latter group had better knowledge and information on DI than the former group. Dentists and family or relatives were the primary source of information and high cost, surgical procedure and long treatment duration were the limiting features for DI as a treatment option in both the groups. Finally, the majority of the dentulous subjects were willing for DI procedure than the other group. The study therefore highlights the need to disseminate better knowledge, to raise awareness on DI and to eliminate the associated misconceptions, thereby facilitating the general population to take maximum advantage of these novel biomaterials to serve the dual purpose of aesthetics and function.
Acknowledgement: Nil
Source of funding: Nil
Conflict of interest: None
Authors Contribution:
Dr.Tadepalli Anupama conceptualized and gathered the data with regard to this work. Dr. Tadepalli Anupama and Dr. Appukuttan Devapriya analysed these data and necessary inputs were given towards the designing of the manuscript. Dr.Tadepalli Anupama,Dr. Appukuttan Devapriya, Dr. Subramanian Sangeetha, Dr.Jenefa Judithdiscussed the results and commented on the manuscript and contributed to the final manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=4016http://ijcrr.com/article_html.php?did=4016
Pjetursson BE, Heimisdottir K. Dental implants–are they better than natural teeth? Eur J Oral Sci. 2018;126:81-7.
Meffert RM, Langer B, Fritz ME. Dental implants: a review. J Periodontol. 1992;63(11):859-70.
Turkyilmaz I, Company AM, McGlumphy EA. Should edentulous patients be constrained to removable complete dentures? The use of dental implants to improve the quality of life for edentulous patients. Gerodontol. 2010;27(1):3-10.
Trulsson M, Van der Bilt A, Carlsson GE, Gotfredsen K, Larsson P, Müller F, et al. From brain to bridge: masticatory function and dental implants. J Oral Rehab. 2012;39(11):858-77
Srinivasan M, Meyer S, Mombelli A, Müller F. Dental implants in the elderly population: a systematic review and meta?analysis. Clin Oral Implants Res. 2017;28(8):920-30.
Torres-Alemany A, Fernández-Estevan L, Agustín-Panadero R, Labaig-Rueda C, Mañes-Ferrer JF. Clinical Behavior of Short Dental Implants: Systematic Review and Meta-Analysis. J Clin Med. 2020;9(10):3271.
Simonis P, Dufour T, Tenenbaum H. Long? term implant survival and success: a 10–16? year follow? up of non? submerged dental implants. Clin Oral Implants Res. 2012;21(7):772-7
Howe MS, Keys W, Richards D. Long-term (10-year) dental implant survival: A systematic review and sensitivity meta-analysis. J Dent. 2019;84:9-21.
Van Velzen FJ, Ofec R, Schulten EA, Ten Bruggenkate CM. 10?year survival rate and the incidence of peri? implant disease of 374 titanium dental implants with a SLA surface: a prospective cohort study in 177 fully and partially edentulous patients. Clin Oral Implants Res. 2015;26(10):1121-8.
Zimmer CM, Zimmer WM, Williams J, Liesener J. Public awareness and acceptance of dental implants. Int J Oral Maxillofac Implants. 1992 Jun 1;7(2)
Narby B, Bagewitz IC, Söderfeldt B. Factors explaining desire for dental implant therapy: analysis of the results from a longitudinal study. Int J Prosthodont. 2011 Sep 1;24(5).
Tepper G, Haas R, Mailath G, Teller C, Zechner W, Watzak G, et al. Representative marketing-oriented study on implants in the Austrian population. I. Level of information, sources of information and need for patient information. Clin Oral Implants Res. 2003;14(5):621-33.
Berge TI. Public awareness, information sources and evaluation of oral implant treatment in Norway. Clin Oral Implants Res. 2000;11(5):401-8.
Esfahani OF, Moosaali F. Awareness and knowledge of patients toward dental implants as an option in replacing missing teeth: a survey in Kerman, Iran. J Adv Periodontol Implant Dent. 2018 9;8(2):43-8.
Al-Musawi A, Sharma P, Maslamani M, Dashti M. Public awareness and perception of dental implants in randomly selected sample in Kuwait. J Med Imp Surg. 2017;2(116):2.
Mayya A, D'souza J, George AM, Shenoy K, Jodalli P, Mayya SS. Knowledge and awareness of dental implants as a treatment choice in adult population in South India: A hospital-based study. Indian J Dent Res. 2018 ;29(3):263.
Satpathy A, Porwal A, Bhattacharya A, Sahu PK. Patient awareness, acceptance and perceived cost of dental Implants as a treatment modality for replacement of missing teeth: A survey in Bhubaneswar and Cuttack. Int J Public Health Dent. 2011;2(1):1-7.
Kaurani P, Kaurani M. Awareness of dental implants as a treatment modality amongst people residing in Jaipur (Rajasthan). J Clin Diagn Res. 2010;4(6):3622-6.
Kumar S, Chauhan A. Knowledge and Awareness of Dental Implants in Indore: An Exploratory Study. Alcohol. 2015;241:38-9.
Siddique EA, Bhat PR, Kulkarni SS, Trasad VA, Thakur SL. Public awareness, knowledge, attitude and acceptance of dental implants as a treatment modality among patients visiting SDM College of Dental Sciences and Hospital, Dharwad. J Indian Soc Periodontol. 2019 ;23(1):58.
Hosadurga R, Tenneti S, Hegde S, Kashyap RS, Kumar A. Awareness, knowledge, and attitude of patients toward dental implants: A web-based questionnaire study. J Dent Implant. 2015;5(2):93.
Gharpure AS, Bhange PD, Gharpure AS. Awareness of dental implant treatment in an Indian metropolitan population. J Dent Implant. 2016;6(2):62.
Wang G, Gao X, Lo EC. Public perceptions of dental implants: a qualitative study. J Dent. 2015;43(7):798-805.
Yao J, Li M, Tang H, Wang PL, Zhao YX, McGrath C, et al. What do patients expect from treatment with Dental Implants? Perceptions, expectations and misconceptions: a multicenter study. Clin Oral Implants Res. 2017;28(3):261-71.
Edelmayer M, Woletz K, Ulm C, Zechner W, Tepper G. Patient information on treatment alternatives for missing single teeth-Systematic review. Eur J Oral Implantol. 2016;9(Suppl 1):S45-57.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareEffect of Oral Pregabalin as a Premedicant on Haemodynamic Response to Laryngoscopy and Intubation
English2429Pravinkumaar REnglish Aswini LEnglish Uma REnglish Shirishkumar ChavanEnglishIntroduction: Laryngoscopy and tracheal intubation are considered the most noxious stimuli, leading to adverse hemodynamic pressor response, especially in cardiovascular compromised patients, necessitating the need to attenuate the pressor responses. Aim: To study the effects of pregabalin in attenuating the variations in heart rate and blood pressure and relieving anxiety and providing sedation. Methods: Sixty adult patients between 18-60yrs of both gender of ASA status I and II scheduled for elective surgeries under General anaesthesia satisfying the inclusion criteria were selected and randomly allocated into 2 groups- Group A (Pregabalin 300mg orally) and Group B (Placebo) by closed envelope method. Parameters like SBP, DBP, HR, MAP, SPO2 were noted down. 60 minutes after giving the drug, the Sedation score and Anxiety score were noted down. Results: After premedication (90 minutes later) with oral Pregabalin 300mg, sedation score, anxiety score, heart rate, systolic blood pressure, diastolic blood pressure, MAP was significantly reduced Pregabalin group than in the placebo group at intubation. Hence pregabalin proved to be effective in blunting the hemodynamic stress response to laryngoscopy and intubation compared to the control group. There was no incidence of bradycardia or hypotension intraoperatively in any group. There was postoperative sedation in the pregabalin group, but it did not interfere with the patient’s recovery. The patients in the pregabalin group were less anxious, quiet and comfortable before and after the surgery. Conclusion: Oral administration of pregabalin 300mg effectively suppressed the cardiovascular response to laryngoscopy and intubation. Pregabalin provided better anxiolysis and sedation without any change in the respiratory pattern compared to the placebo tablet.
EnglishPregabalin, Attenuation, Laryngoscopy, Anxiolysis, PremedicationINTRODUCTION
In spite of vast advances in the art of anesthetizing a patient, General anesthesia is still the gold standard when the need to secure the airway arises. So every Anesthesiologist must gain proficiency in administering general anesthesia to a patient in the safest possible manner. Endotracheal intubation consists of inserting an endotracheal tube inside the trachea to maintain airway patency and protection and provide positive pressure ventilation. This is done by direct laryngoscopy but alternative techniques like fibreoptic intubation or retrograde intubation are employed in particular situations.
Laryngoscopy and intubation are considered to be the most noxious stimuli which can lead to adverse hemodynamic pressor response following intubation.1 This is usually tolerated by healthy individuals but in susceptible patients, even these hemodynamic fluctuations can have deleterious effects. Left ventricular compromise, myocardial ischemia and cerebral hemorrhage can be precipitated by a sudden increase in blood pressure and heart rate in such patients. Hence adequate preoperative sedation, anxiolysis and analgesia help to ensure cardiovascular stability during induction, laryngoscopy and intubation.2 Anxiety still remains a major problem for most patients before any surgery.
Many drugs like opioids, benzodiazepines, volatile agents, lignocaine spray, beta-blockers, calcium channel blockers have been tried to attenuate these adverse haemodynamic pressor responses due to airway instrumentation as well as to decrease anxiety.2 Most common adverse effect of opioids are respiratory depression, PONV and delayed bowel function recovery. The common adverse effects of benzodiazepines are the variability in patient response and respiratory complications. The adverse profile of these drugs creates the need for an alternative drug with sedative, anxiolytic property and efficacy in reducing pressor responses with minimal adverse effects.2,3
Recently, an increasing emphasis has been made on the use of non-opioid drugs as a part of the multimodal regimen for decreasing anxiety and obtunding the intubation response. Many recent studies show that Gamma-aminobutyric acid (GABA) mimetic drugs like gabapentin and pregabalin decrease the stress response due to laryngoscopy and intubation.
Pregabalin is a drug with analgesic, anticonvulsant and anti anxiety2 effects mainly used for the management of neuropathic pain, neuralgia occurring post herpes infection and as an adjuvant for the treatment of partial-onset seizures. Its effectiveness in providing postoperative pain relief and reducing the dose of parenteral analgesics are well documented in several studies.4,5,6 Only minimal evidence is available in our literature related to the cardiovascular effects of pregabalin in patients undergoing surgery.7,8 Hence in this study we decided to find out the efficacy of pregabalin in attenuating the pressor response to tracheal intubation.
AIM
To study the effects of pregabalin in attenuating the variations in heart rate and blood pressure and also in relieving anxiety and providing sedation.
MATERIALS AND METHODS
A Prospective, double-blinded, randomized, placebo-controlled trial was undertaken in ESIC Medical College & PGIMSR, KK. Nagar, Chennai-78, in the department of Anaesthesiology for a period of one year from April 2018 to March 2019 after obtaining ethical committee clearance as well as informed consent from all the patients (EC approval No.06/2018).
Sixty adults patients between 20-60 years of either sex of ASA grade I or II scheduled for elective surgeries under general anaesthesia were included in this study after approval of the institutional ethical committee.
Inclusion Criteria
ASA grade I and II
Age 20 – 60 years of either sex.
Mallampatti class I and II
Patients with BP 0.05). But the data reveals the existence of a statistically significant association in difference in heart rate distribution between the Pregabalin group and BCT group during premedication, induction, intubation, 3mins,5mins and 10 mins after intubation (p < 0.05).
While analysing SBP distribution among 60 patients undergoing elective surgeries under general anaesthesia, it was observed that the mean pre-operative SBP in the Pregabalin group was 119.8 ± 9.6mmHg and in the BCT group the mean pre-operative SBP was 120.9± 12.7 mmHg (p= 0.706, unpaired t-test).
During premedication, the mean SBP in the Pregabalin group was 110.3±14.6 mmHg and in the BCT group the mean pre-operative SBP was 116.2±13 mmHg (p= 0.102, unpaired t-test). During induction, the mean SBP in the Pregabalin group was 101.3±8 mmHg and in the BCT group the mean pre-operative SBP was 107.9±15.1 mmHg (p= 0.04, unpaired t-test). During intubation, the mean SBP in the Pregabalin group was 104.7±13.9 mmHg and in the BCT group the mean pre-operative SBP was 113.4±16.7 mmHg (p= 0.03, unpaired t-test) showing a significant decrease of 16 mmHg in the Pregabalin group and 8 mmHg in the BCT group from baseline preop value and significant increase of 3 mmHg in Pregabalin group and 6 mmHg in BCT group from induction value. After intubation the mean SBP in Pregabalin group was 102.6±11.1 mmHg at 1 min, 101.1±10.6 mmHg at 3 mins, 101.9±8.8 mmHg at 5 mins and 101.2±9.9 mmHg at 10 mins and in BCT group the mean SBP was 114±18.8 mmHg at 1 min, 108±15.9 mmHg at 3 mins, 106±11.8 mmHg at 5 mins and 109.1±13.9 mmHg at 10 mins. The data reveals the existence of a statistically non-significant difference in SBP distribution between the Pregabalin group and BCT group during pre-operative, premedication, 3 mins and 5 mins after intubation (p > 0.05). But the data reveals the existence of a statistically significant difference in SBP distribution between the Pregabalin group and BCT group during induction, intubation and 10 mins after intubation (p < 0.05).
While analyzing DBP distribution among 60 patients undergoing elective surgeries under general anaesthesia, it was observed that the mean pre-operative DBP in the Pregabalin group was 77±7.46 mmHg and in the BCT group the mean pre-operative DBP was 79.17±7.58 mmHg (p= 0.269, unpaired t-test).
During premedication, the mean DBP in the Pregabalin group was 73.20±10.2 mmHg and in the BCT group the mean pre-operative DBP was 79.03±8.97 mmHg (p= 0.022, unpaired t-test). During induction, the mean DBP in the Pregabalin group was 66.23±7.12 mmHg and in the BCT group the mean pre-operative DBP was 70.73±10.37mmHg (p= 0.055, unpaired t-test). During intubation, the mean DBP in the Pregabalin group was 69.27±10.52 mmHg and in the BCT group the mean pre-operative DBP was 77.87±14.35 mmHg (p= 0.01, unpaired t-test) showing a significant decrease of 8 mmHg in the Pregabalin group and 1.5 mmHg in the BCT group from baseline preop value and significant increase of 3 mmHg in Pregabalin group and 7 mmHg in BCT group from induction value. After intubation the mean DBP in Pregabalin group was 67.77±8.19 mmHg at 1 min, 67.10±6.29 mmHg at 3 mins, 67.53±8.27 mmHg at 5 mins and 66±10.12 mmHg at 10 mins and in BCT group the mean DBP was 78.17±14.29 mmHg at 1 min, 73±11.13 mmHg at 3 mins, 71.03±9.5 mmHg at 5 mins and 74.87±11.98 mmHg at 10 mins. The data reveals the existence of a statistically non-significant difference in DBP distribution between the Pregabalin group and BCT group during pre-operative, induction and 5 mins after intubation (p > 0.05). But the data reveals the existence of a statistically significant difference in DBP distribution between the Pregabalin group and BCT group during premedication, intubation, 1 minute, 3 mins and 10 mins after intubation (p < 0.05).
While analysing MAP distribution among 60 patients included in this study, it was observed that the mean pre-operative MAP in the Pregabalin group was 91.20±7.15 mmHg and in the BCT group the mean pre-operative MAP was 93.03±8.76 mmHg (p= 0.378, unpaired t-test).
During premedication, the mean MAP in the Pregabalin group was 85.53±10.95 mmHg and in the BCT group the mean pre-operative MAP was 91.47±9.62 mmHg (p= 0.03, unpaired t-test). During induction, the mean MAP in the Pregabalin group was 77.87±6.63 mmHg and in the BCT group the mean pre-operative MAP was 83.17±11.15 mmHg (p= 0.029, unpaired t-test). During intubation, the mean MAP in the Pregabalin group was 81±11.18 mmHg and in the BCT group the mean pre-operative MAP was 89.77±14.42 mmHg (p= 0.011, unpaired t-test) showing a significant decrease of 10 mmHg in the Pregabalin group and 3 mmHg in BCT group from baseline preop value and significant increase of 3 mmHg in Pregabalin group and 6 mmHg in BCT group from induction value. After intubation the mean MAP in Pregabalin group was 79.33±8.84 mmHg at 1 min, 78.33±7.12 mmHg at 3 mins, 79±7.73 mmHg at 5 mins and 77.80±9.49 mmHg at 10 mins and in BCT group the mean MAP was 90.07±15.41 mmHg at 1 min, 84.7±12.28 mmHg at 3 mins, 82.77±9.57 mmHg at 5 mins and 86.30±12.14 mmHg at 10 mins. The data reveals the existence of a statistically non-significant difference in MAP distribution between the Pregabalin group and BCT group during pre-operative and 5 mins after intubation (p > 0.05). But the data reveals the existence of a statistically significant difference in MAP distribution between the Pregabalin group and BCT group during premedication, induction, intubation, 1 minute, 3 mins and 10 mins after intubation (p < 0.05).
The mean preop and postop sedation score in the Pregabalin group was 2 ± 0.00 and 2.43 ± 0.50, respectively (p-value Englishhttp://ijcrr.com/abstract.php?article_id=4017http://ijcrr.com/article_html.php?did=4017
King BD, Harris LC, Greifenstein FE, Elder JD, Dripps RD. Reflex circulatory responses to direct laryngoscopy and tracheal intubation performed during general anesthesia. Anesthesiology. 1951 Sep 1;12(5):556-66.
Field MJ, Oles RJ, Singh L. Pregabalin may represent a novel class of anxiolytic agents with a broad spectrum of activity. Br J Pharmacol. 2001 Jan;132(1):1-4.
Kovac AL. Controlling the hemodynamic response to laryngoscopy and endotracheal intubation. J Clin Anesth. 1996 Feb 1;8(1):63-79.
Ghai A, Gupta M, Hooda S, Singla D, Wadhera R. A randomized controlled trial to compare pregabalin with gabapentin for postoperative pain in abdominal hysterectomy. Saudi J Anaesth.. 2011 Jul;5(3):252.
Kohli M, Murali T, Gupta R, Khan P, Bogra J. Optimization of subarachanoid block by oral pregabalin for hysterectomy. J Anaesthesiol Clin Pharmacol. 2011 Jan;27(1):101.
Durkin B, Page C, Glass P. Pregabalin for the treatment of postsurgical pain. Expert Opin Pharmacother. 2010 Nov 1;11(16):2751-8.
Ali A, Elnakera A, Samir A. Effect of Two Different Doses of Gabapentin on the Intraocular Pressure and Hemodynamic Stress Responses to Laryngoscopy and Tracheal Intubation. Int Sch Res Notices. 2013:1-5.
Pristautz H, Biffl H, Pinl F, Leitner W, Parsché P, Borkenstein J. The influence of a beta-adrenolytic premedication on cardiovascular parameters and plasma free fatty acids during esophago-gastro-duodenoscopy (author's transl). Wiener medizinische Wochenschrift (1946). 1979 Dec 1;199(24):707-12.
Eren G, Kozanhan B, Hergunsel O, Bilgin U, Demir G, Cukurova Z. Pregabalin blunts cardiovascular responses to laryngoscopy and tracheal intubation. J Anesthesiol Reanim. 2009;7:82-7.
Rastogi B, Gupta K, Gupta PK, Agarwal S, Jain M, Chauhan H. Oral pregabalin premedication for attenuation of haemodynamic pressor response of airway instrumentation during general anaesthesia: A dose response study. Indian J Anaesth. 2012 Jan;56(1):49.
Gupta K, Bansal P, Gupta PK, Singh YP. Pregabalin premedication-A new treatment option for hemodynamic stability during general anesthesia: A prospective study. Anesth Essays Res. 2011 Jan;5(1):57.
Doddaiah DB, Singh NR, Fatima N, Singh SS, Singh HK, Singh KS. A comparative study of oral pregabalin and oral gabapentin in the attenuation of hemodynamic response to laryngoscopy and intubation. J Med Soc. 2017 Jan 1;31(1):14.
Sundar AS, Kodali R, Sulaiman S, Ravullapalli H, Karthekeyan R, Vakamudi M. The effects of preemptive pregabalin on attenuation of stress response to endotracheal intubation and opioid-sparing effect in patients undergoing off-pump coronary artery bypass grafting. Ann Card Anaesth. 2012 Jan 1;15(1):18.
Waikar C, Singh J, Gupta D, Agrawal A. Comparative study of oral gabapentin, pregabalin, and clonidine as premedication for anxiolysis, sedation, and attenuation of pressor response to endotracheal intubation. Anesth Essays Res. 2017 Jul;11(3):558.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareAntimicrobial Properties of Three Different Bioactive Compounds of Cassia Species Against S. mutans Serotype C (ATCC 25175). An Invitro Study
English3037Ann Polachirakal TharakanEnglish Madhura PawarEnglish Sonal KaleEnglish Noreen QaziEnglish Rahul DeshpandeEnglish Suchita Abhay GaikwadEnglishIntroduction: Cassia species (Caesalpinaceae) is a medicinal plant used in traditional Indian medicine for various ailments. In this study, three different bioactive compounds of two medicinal plant species Cassia tora and Cassia fistula were obtained and their antimicrobial properties were compared and evaluated against S.mutans serotype C (ATCC25175) and were conducted as a triple-blind study to identify their effectiveness. Aim: The study aims to evaluate and compare the antimicrobial properties of three different Bioactive Compounds of Cassia species and 0.2% chlorhexidine against S. mutans serotype C (ATCC 25175). Results: All the Bioactive Compounds had good antimicrobial activities based on their zones of inhibition; the highest zone of inhibition in mm was formed by Extract 8 which was Cassia Flower extract having a mean inhibitory zone of 9.93mm +0.76. Stastatistical analysis of the results with Kruskal Wallis and Mann Whitney Post Hoc test proved that at any concentration of Extract 8 the inhibition results are comparable to that of 0.2% chlorhexidine with p=0.05. The results confirmed the antimicrobial potential of the Bioactive Compound of Cassia Flower and hence it can be used as a preventive means for dental caries. Conclusion: The Bioactive Compound of Cassia Flower extract derived from cassia plants are only required in minute quantities as compared to their crude extracts. The study confirmed the antimicrobial potential of the plant at different concentrations can be used as preventive and therapeutic measures in preventive dentistry and due to its reduced potency can be used in children effectively.
EnglishBioactive compounds, Chlorhexidine, Cassia, Dental caries, Herbal medicinesINTRODUCTION:
The Global Burden of Disease Study in 2016 estimated that 2.4 billion people suffer due to dental caries of permanent teeth worldwide and an additional 486 million children suffer from caries of primary teeth. 1 Thus, prevention is important as it not only detrimentally impacts the quality of life but also becomes a financial drain due to the need for extensive treatments. Prevention can be achieved by maintaining the ecological balance of the naturally existing cell structures. Zaura et al. in 2014 reported that maintaining the stability of the oral biome is important to prevent ‘dysbiosis’ and according to the author acute infections of the oral mucosa occur but are rare. 2
The oral microbiota survives the daily chemo-mechanical insults from either food or oral hygiene practices which results in variations in temperature, pH or symbiotic microbes. By maintaining the state of dynamic equilibrium within a community of organisms subject to gradual changes an ecological homeostasis can be achieved.
According to He et al., 2011 and Schlafer et al., plaque microflorae have a symbiotic relationship with the host, acting as a barrier to opportunistic pathogens and carrying out metabolic processes that benefit the host.3,4 The emerging need is to target pathogenic microorganism thus shifts the focus towards maintaining the ‘holobiont’. 5
Bowden in 1996 reported that Mutans streptococci, particularly Streptococcus mutans as significant odontopathogens that are implicated to be highly associated with caries in humans.6 Streptococcus mutans being acidogenic and aciduric drives the microbial ecological shift that leads to dental caries and thus appears in primary tooth of children even under six years of age. 7, 8
Chemotherapeutic antimicrobial agents are known to be lethal for the normal commensals and cellular structures. Chlorhexidine is the commonly used potent agent with a proven efficiency which also targets the natural microflora. 9,10 It has a risk of developing skin injuries, such as skin erythema, burns, blisters discoloration of teeth and xerostomia in the mouth. 11,12 Naturally occurring organic substances have fewer disadvantages compared to synthetically obtained chemical plaque or caries inhibiting agent and are milder for use especially in children and infants.13
Cassia species (Caesalpinaceae) is a medicinal plant used in traditional Indian medicine for various ailments and grows annually in all tropical areas.14 Over 5000 species of cassia flowering plants exist and possesses significant anti-inflammatory, antimicrobial antifungal properties and antioxidant properties. 15,16
Bioactive Compounds are the main active ingredients or a chemical substance which may be found in all parts of the plant and have biologically beneficial effects.17 Thus, the aim of the study was to compare and evaluate the antimicrobial properties of three different Bioactive Compounds of Cassia species and 0.2% chlorhexidine against S. mutans serotype C (ATCC 25175).
METHODS:
This study was approved by the Institutional ethics committee of Dr DY Patil Vidyapeeth Pune, Maharashtra, India (ref: DPU/R&R(D)/32(21)/19) and was conducted as a triple blind study. The aim was to evaluate and compare the antimicrobial properties 3 different bioactive compounds at three concentrations (200mcg, 400mcg, 600mcg) and 0.2% chlorhexidine gluconate against S. mutans serotype C (ATCC 25175).
Extract Preparation: 18
The extracts of cassia species were obtained from the scientist which were from the two medicinal plant species Cassia tora and Cassia fistula from Western Pune Maharashtra, India, shade dried authentication was done by comparing with herbarium specimens preserved in Botanical Survey of India, Pune (Maharashtra). Authentication no of Cassia tora BSI/WC/Cert/2015/SG01, Cassia fistula is BSI/WC/Cert/2015/SG02.18 The extracts were then finely pulverized and exactly weighed plant material was utilized to prepare extracts with measured volumes of solvents like ethyl acetate, acetone, ethanol, methanol and distilled water then removed under pressure. Weighed amounts of the extracts marked at Extract 6, Extract 7 and Extract 8 were then collected from the scientist and utilized for the study.
Microbiological assay laboratory processing: 19
Well diffusion method was used to determine zone of inhibition of 3 bioactive extracts in the concentration of (200µg , 400µg, 600µg) against mutans serotype C (ATCC 25175). All the tests were performed under sterile conditions in triplicate by standard norms and protocols . 0.2% chlorhexidine against S. mutans serotype C (ATCC 25175) was used as positive control. Adequate amount of Mueller Hinton Agar was evenly distributed over the surface of 15 cm diameter petri-dish to a thickness of 5 mm and allowed to solidify under aseptic conditions. Streptococcus mutans serotype C (ATCC 25175) was inoculated with a sterile spreader on the agar medium. Standard wells were made with a cupborer (9.0mm)
Then 0.2% chlorhexidine gluconate, bioactive Compounds of cassia species with concentration of 200µg , 400µg, 600µg in 0.5ml DMSO solvent was inserted in separate wells of agar plates inoculated with Streptococcus mutans serotype C (ATCC 25175). The plates were incubated at 37 ± 0.1? C for 24 hours. The same procedure was followed for different concentrations of bioactive compounds. After incubation, the plates were observed for zone of inhibition and measured in millimeters.
RESULTS:
The zones of inhibition in mm was obtained. The results were compared statistically with chlorhexidine in the form of mean and standard deviation. The p values were obtained. Kruskal Wallis and Mann Whitney Post Hoc test was conducted to analyze the data.
The below tables and graphs projects the mean and standard deviation of inhibition zones at 200µg, 400 µg, 600µg for the three Bioactive compound extracts- Extract 6, Extract 7, Extract 8 and 0.2%chlorhexidine gluconate against S. mutans serotype C (ATCC 25175) and their comparison.
The Table no.1, Graph no.1 showed the extracts with inhibition zones at 200µg, 400 µg, 600 µg for the three Bioactive compound extracts- Extract 6, Extract 7, and Extract 8 were compared and evaluated against S. mutans serotype C (ATCC 25175). At 200µg concentration the highest zone inhibition in mm was formed by Extract 8 concentration having mean inhibitory zone of 2.03mm ±0.86. At 400µg concentration the highest zone inhibition in mm was formed by Extract 8 concentration having mean inhibitory zone of 6.57mm±0.81. At 600µg concentration the highest zone inhibition in mm was formed by Extract 8 concentration having mean inhibitory zone of 9.93mm +0.76. At all concentrations extract 8 showed the highest zone of inhibition. For all concentrations of Extracts 6, 7,and 8 at 200µg, 400µg and 600µg there was a significance of p= 0.027.The mean inhibition zone against S. mutans serotype C (ATCC 25175) formed by 0.2% chlorhexidine which was 16.07±0.30 (Graph 2).
The Table no.2 depicts the Post hoc test of Kruskal Wallis and Mann Whitney presenting differences between the extracts 6, 7 and 8 at concentration of 200µg, 400 µg, 600 µg revealed that a significant difference was present between 200µg and 600µg concentrations with p=0.021. A significantly large inhibition zone was formed against S. mutans serotype C by 600 µg concentration as compared to 200 µg concentration. No significant difference was found between 200 µg and 400 µg concentration as well as 400 µg and 600 µg concentration.
For Extract 7 at 200 µg Post hoc test revealed that a significant difference was present in inhibition zone when compared to 600µg extract the significance was p = 0.022. No significant difference was found between 200 µg and 400 µg concentration as well as 400 µg and 600 ug concentration.
For Extract 8 at 200µg extract, 400µg extract and 600µg Post hoc test revealed that a significant difference was present between 200µg and 600µg with p= 0.022. A significantly large inhibition zone was formed against S. mutans serotype C by 600 µg concentration. No significant difference was found between 200 µg and 400 µg concentration as well as 400ug and 600 ug concentration.
The Table no.3 showed the difference between the inhibition zones of Extract 6, 7 and 8 at different concentrations 200µg ,400 µg, 600µg and 0.2% chlorhexidine. The mean inhibition zone against S. mutans serotype C (ATCC 25175) formed by 0.2% chlorhexidine which was 16.07±0.30 (Graph 2).
For Extract 6 a significant difference was found between 200µg extract concentration and 0.2%chorhexidine with p=0.046. No significant difference was found between 400ug and chlorhexidine, 600ug and chlorhexidine indicating that the higher concentration of bioactive compounds showed a comparable action as that of chlorhexidine. The difference between 600 µg of Extract 6 and 0.2 % chlorhexidine was 9.53+0.050 with p=0.05.
For Extract 7 at 200µg, 400µg, 600µg and 0.2% chlorhexidine no significant difference was present between any of the extracts and chlorhexidine indicating that at any concentration of Extract 7 the inhibition results are comparable to that of 0.2% chlorhexidine with p=0.05. The difference between 600 µg of Extract 7 and 0.2 % chlorhexidine was 9.43+0.050.
For Extract 8 at 200 µg, 400 µg 600µg and 0.2% chlorhexidine no significant difference was present between any of the extracts and chlorhexidine indicating that at any concentration of Extract 8 the inhibition results are comparable to that of 0.2% chlorhexidine with p=0.05. The difference between 600 µg of Extract 8 and 0.2 % chlorhexidine was only 6.13+0.050.
DISCUSSION:
Current evidence suggests that the cariogenic factors that drive streptococcus mutans to be virulent is its potential to thrive in acidic environment’s, its ability to lower the pH, ferment simple sugars, synthesize sucrose, promote its adhesion and buildup the plaque-ecology especially for those having a low socioeconomic status with limited access to healthcare.20 Milsom et al. described that children with an already existing caries lesion have a 5–6 times higher incidence of developing new caries lesions compared to previously caries-free children. 20
Peterson et al (2014) concluded with next-generation sequencing (NGS) that Streptococcus-species was found to be the most abundant genus (>50% of the microorganisms)in the microbial composition of the dental plaque.21 Damle et al (2016) concluded that the number of s mutans colonies increases with increasing age and it is more in children with lesions that can be seen clinically and the amount of S. mutans in the saliva is directly proportional to the colonized surfaces. 22
In this study chlorhexidine(CHX) was used as the control as it is the most extensively used anti-plaque and anti-bacterial agent and it is highly active against the s. mutans strain. Among the available chemotherapeutic agents, chlorhexidine mouthwash is considered as the “gold-standard” due to its proven efficiency, but it exhibits cytotoxic activity on ectodermal cells causing altered taste sensation and extended used causes xerostomia, brown-staining of teeth and fillings. 23
Therefore, the nature-based alternatives with less side effects would be beneficial than the chemically prepared agents. They also have a two-fold advantage of minimal side-effects and being alcohol-sugar free. Nature-based plant products like Aloe vera, Bloodroot Garlic and Propolis have several advantageous properties anti-microbial, wound healing, anti-helminthic, anti-inflammatory, anti-fungal properties of medicinal plants. 24
In this study Cassia plant species was selected for their anti-inflammatory, hypoglycaemic, antiplasmodial properties. 25 Thus can be used as a broad-spectrum antibacterial agent that is nature based . It is easily obtainable, in Asia, South Africa, Mexico, China, East Africa and Brazil thus making it cost effective. 26
Bioactive compounds are substances are present within all part of the plant such as flavonoids which includes a huge group of naturally occurring organic compounds. It is found in a large variety of plants including fruits, seeds, grains, tea vegetables, nuts, and wine. 26
The Microbiological assay of well diffusion method was used to determine zone of inhibition and after incubation at 37ºC for 24 hours as per standard protocols. The diameters of inhibition zones produced by the plant extract were measured in mm.
Statistical analysis of the results with Kruskal Wallis and PostHoc Mann Whitney Test and concluded that the mean and standard deviation of inhibition zones at 600µg for the three Bioactive compounds extracts- against S. mutans serotype C (ATCC 25175) identified that the highest zone inhibition in mm was formed by Extract 8 concentration having mean inhibitory zone of 9.93mm +0.76 followed by Extract 7 was 6.63 mm+0.30 inhibition zone. The least effective concentration of Bioactive compound of cassia species was found with Extract 6 which formed a small zone of 6.53 mm+0.55.
The three bioactive compounds provided by the scientist were Quercetin (Extract 6), Gallic acid (Extract 7), and Cassia flower (Extract 8). All three bioactive compounds have antimicrobial properties based on their zones of inhibition, but the extract labelled as number 8 which is Cassia flower (Tora and Fistula) showed the highest antimicrobial zone when compared to the three extracts.
Quercetin (Extract 6) was isolated and found from both Cassia tora L as well as Cassia Fistula. 26 Quercetin is the main bioflavonoids known for its anti-inflammatory, anti-hypertensive, vasodilator effects, anti-obesity, anti-hypercholesterolemic and anti-atherosclerotic activities.26 It is a naturally occurring flavonoid pigment present in many fruits and vegetables. It is antioxidant rich and plays an important role in helping the body. It is not only an antioxidant but also has anti-inflammatory, and anticancer activities.27 Quercetin induces apoptosis by inducing the dissociation of Bax from Bcl-xL, activating caspases, and inhibiting phosphorylation. 27 It is metabolized immediately by enzymes in the epithelial cells and further metabolized by the liver. Thus quercetin has proven effects that benefit the oral health. 27 This study proved that Quercetin has an antibacterial effect with a zone of inhibition of 6.53 mm+0.55. This was compared to the zone of inhibition of 0.2% chlorhexidine which was 16.07mm. The zone of inhibition was also compared to the other extracts and was found to be the least.
Gallic acid (GA) is in the group of hydroxybenzoic acids. 28 Many plant extracts have been found to inhibit the growth of oral bacteria , particularly s.mutans and thus may prevent the formation of dental caries. It is the most popular of trihydroxybenzoic acids. An important source of gallic acid is also tea containing up to 4.5 g/kg fresh weight in tea leaves it also occurs mostly in certain red fruits, black radish, and onions. Apart from its phytochemical role, gallic acid is also used in tanning, ink dyes, and the manufacture of paper. 28 Effects include antihyperglycemic, antilipid peroxidative, antioxidant antimicrobial, anti-inflammatory, anticancer, cardioprotective, gastroprotective, and neuroprotective effect.29 Gallic acid can inhibit motility, adherence and biofilm formation of Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus mutans, Chromobacterium violaceum, and Listeria monocytogene. 29 In this study the zone of inhibition of Gallic acid on streptococcus mutans serotype C (ATCC 25175)was evaluated at the 600µg concentration the zone was 6.63 and compared with 0.2% chlorhexidine which was 16.07. The zone of inhibition in mm for Extract 7 (Gallic Acid) was more when compared to bioactive compound of cassia species Extract 6 (Quercetin) .
Cassia flower also known as the ‘Golden Shower’ is widely grown as a decorative tree for its beautiful bunches of yellow flowers. Cassia plants have bright yellow flowers of characteristic- bell shape drop. 30 Cassia provides dyes and is widely used for its medicinal properties. The plant has antipyretic and analgesic effect.31 It was found that extracts of Cassia fistula flowers contained tannins, flavonoids, and anthraquinones compounds in higher amount.32 Cassia flowers has known antibacterial and antifungal activity. In the present work, the extracts are obtained from Cassia fistula flowers. All the Bioactive Compounds had good antimicrobial activities based on their zones of inhibition but of all the three; the extract of cassia flower showed the highest zone inhibition in mm was formed by Extract 8 (Cassia Flower) concentration having mean inhibitory zone of 9.93mm +0.76. Mann Whitney test revealed that at any concentration of Extract 8 the inhibition results are comparable to that of 0.2% chlorhexidine with p=0.05. The difference between 600 µg of Extract 8 and 0.2 % chlorhexidine was only 6.13+0.050.
The Cassia flower extract can be an excellent substitute for chlorhexidine which can be can prepared in various forms like mouthwashes, gels, sustained release forms, intracanal medicaments, lollipops etc. The bioactive compound extract of cassia flower has a possibility to be used as new antimicrobials for children and adults as well as for prevention of dental caries. Nowadays, the patients are more aware of the harmful effects of synthetic formulations and prefer a natural herbal alternative that is well tolerated by the body. Thus, these natural herbal formulations with their bioactive compound extract can offer a non- potent resolution with minimal adverse effects to improve the oral health of children.
CONCLUSION:
Nature-based cassia plant species is available in all seasons and easily obtainable in many countries and hence provides a novel therapeutic future for combating oral diseases like caries in especially in children. Based on the findings of the study, it was concluded that: (1)The bioactive components of cassia flower extracts appears promising against Streptococcus mutans serotype c (ATCC 25175) and can be used effectively as a novel compound especially in children due to the nature based non synthetic properties for combating dental caries. (2) Future studies are needed to determine the antimicrobial activity of Cassia flower plant extract against Streptococcus mutans on whole saliva to understand its efficacy against polymicrobial or mixed culture. (3) Lastly toxicological investigations of Cassia plant extract also need to be found out to confirm its safety[A1] for human trials.
ACKNOWLEDGEMENTS:
We acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. We 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.
There was No Funding or Financial support and No Conflict of interest.
*Significance at pEnglishhttp://ijcrr.com/abstract.php?article_id=4018http://ijcrr.com/article_html.php?did=4018
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareAyurvedic Management of Serous Pigmentary Epithelial Detachment Associated with Cystoid Macular Edema: A Case Report
English3851Narayanan NNEnglish Kumar AEnglish Krishnendu SEnglish Agaja PLEnglishBackground: Pigmentary epithelial detachment is classified based on its contents into drusenoid, serous, vascularized, or mixed. It may have ocular and/or systemic involvement. Management options in modern medicine have not been proven effective, hence alternative options may be sought. Case Report: A 70-year-old male who presented with the blurring of vision in his right eye (OD) and diminished vision in his left eye (OS), and who was previously diagnosed with serous PED and who had undergone multiple rounds of LASER photocoagulation, is presented here. He reported for eight rounds of inpatient Ayurvedic management, which involved administering oral medicines and external therapies for both eyes and the head. Results: Improvement in visual acuity fundus photography and optical coherence tomography scanning was noted throughout the eight courses of treatment. Conclusion: The main aim of management was to restore vision as much as possible while giving the patient a better quality of life. This study illustrates that cases of serous PED with cystoid macular oedema can be successfully managed using Ayurveda, and these treatments can be considered as an alternative option.
EnglishCase report, holistic approach, Kriyakalpa, TimiraIntroduction
Physiological forces that maintain adhesion between the retinal pigment epithelium (RPE) and the inner layer of the Bruch’s membrane are disrupted in the different types of PED.1 Long-standing cases have the predilection to develop choroidal neovascularization (CNV), the recognition of which is a major concern secondary to its increased risk for vision loss.2 Serous PED, though having a sometime association with exudative age-related macular degeneration, has a favorable prognosis.3 Blurred vision seen in this variety of PED may be associated with induced hyperopia in some cases.4 Patients over 60 years tend to have a poor prognosis, although variation in the speed of deterioration is demonstrable. No treatment has been proven effective for serous PED, neither have recommendations been established. Although injection of anti-vascular endothelial growth factors (anti-VEGF) may stabilize vision, it carries a 10% risk of RPE tear.5 Cystoid macular edema and macular scarring occur independently of PED. In light of the above, management in the realms of complementary and alternative medicine (CAM), including Ayurveda, may be sought.
Methodology
The efficacy of an Ayurvedic protocol to manage serous PED with cystoid macular edema and macular scar in a 70-year-old male is described in this case report. The report adheres to the Case Report (CARE) guidelines to ensure transparency and efficacy in reporting.6 Institutional Ethics Committee clearance was not required for the study; however, written informed consent was obtained from the patient prior to documenting his case.
Case Report
The patient presented with blurring of vision in his right eye (OD – oculus dexter) since 8 years and diminished vision in his left eye (OS – oculus sinister) since 1993. In 1993, he contracted malaria, for which he was prescribed Lariam mefloquine. Blurring of vision OS commenced soon after this, but as it neither increased nor decreased, the patient did not seek ophthalmic consultation. In 2007, he experienced blurring of vision with floaters OD and deterioration of vision OS. He was diagnosed with pigment epithelial detachment and macular scarring and was prescribed anti-VEGF injection. He underwent 3 rounds of injection, but got no relief. His past history is notable for cardiac problems and gouty arthritis, for which he is under medication. His immediate family members do not present with similar complaints. Personal history readings were normal. Review of systems and vital signs were normal.
He was taking Simvastatin (1 tablet at bedtime), Ramipril (1 tablet in the morning), Aspirin (1 tablet in the morning), and Ibuflam (1 tablet as and when needed) when he was admitted for his first two courses of treatment. Ibuflam was halted prior to admission for the third course, and all medicines except Ramipril were halted before the fourth course of treatment. Ramipril was continued throughout the remainder of the treatments. The patient had started Benzbromazone (1 tablet at night) prior to admission for his fifth course. Brilique (1 tablet at night), Atrovastatin (1 tablet at night), and Metoprolol (1 tablet at night) were being consumed when the patient came for his sixth course of treatment, and were continued through the seventh and eighth courses. (Table 1)
Unaided distant visual acuity ( DVA) was LogMAR 0.778 OD and LogMAR 1.778 OS, aided DVA was LogMAR 0.477 OD and LogMAR 1.778 OS, and near visual acuity (NVA) was N18in both eyes OU (oculus uterque). Anterior segment examination showed normal findings OU. Direct and consensual pupillary reflexes were normal OU. Posterior segment examination by ophthalmoscopy demonstrated a sharply-delineated elevation and a “honey-comb” formation at the macula OD, and a dense macular scar, elevation at the macula, and a few small hemorrhages OS.
Laboratory investigations conducted at the first course of treatment were hemoglobin percentage, erythrocyte sedimentation rate, and lipid profile analysis, which included total cholesterol, triglycerides, high-density lipo-proteins, low-density lipoproteins, and very low-density lipo-proteins. (Table 2)
Ashta Sthana Pariksha7demonstrated normal Nadi (pulse), Mutra (urine), Mala (excreta), and Sabda (sound), Anupalipta Jihva (non-coated tongue), Anunshna Sita Sparsha (lukewarm touch), abnormal vision, and normal Akrti (stature). Dasavidha Pariksha8 demonstrated a Prakrti (somatic constitution) of Kapha and Vata, normal Sara (essence of tissues), Samhanana (compactness), and Pramana (measurement), medium Sattva (psyche) and Satmya (habituation), low Ahara Sakti (digestion) and Vyayama Sakti (capacity for exercise), and Jirna Vaya (advanced age).
A diagnosis of serous pigment epithelial detachment, cystoid macular edema, and macular scar was made based on the findings. Comparison to Timira (blurring of vision), a Drishtigata Roga (disease of vision) as per Ayurveda was made due to the patient’s symptom of blurring of vision matching with the feature of inability to see distant objects as described in Timira.9
Vulnerability Assessments administered prior to all treatments grouped the patient in the geriatric cohort. Fall Risk Assessment determined that the patient has a visual deficit and no disorientation, self-care deficit, problems with motility, history of a fall, or impaired judgment. Psychological assessment determined that the patient was calm and could carry out his day-to-day activities without assistance.
The patient underwent 8 courses of Ayurvedic in-patient therapy. Two rounds were done in 2013, and one round every year from 2014-2019. His tailored Ayurvedic protocol included oral medicines (Table 3) and external therapies for both the eyes (Kriyakalpa) and head (Table 4). He was also advised to continue his allopathic oral medicines at the appropriate times. Pancakarma (bio-purification), generally a requisite in the management of Drishtigata Roga, was not attempted for this patient because of his advanced age.
All medicines were manufactured by Sreedhareeyam Farmherbs India, Pvt. Ltd., the hospital’s GMP-certified drug manufacturing unit.
Outcome Measures and Results
Assessment was done by unaided and aided DVA, posterior segment examination, and optical coherence tomography (OCT) scanning. Initial posterior segment examination was done by ophthalmoscopy.In-house fundus photography and OCT scanning were done at admission before the fifth and sixth courses of treatment; at both admission and discharge of the seventh course; and at discharge after the eighth course of treatment.
Unaided and aided DVA and NVA was maintained from the end of the first course till discharge after the third course of treatment. Unaided DVA improved to LogMAR 0.602 OD and LogMAR 1.477 OS and aided DVA improved to LogMAR 0.301 OD and LogMAR 1.477 OS at admission for the fourth course of treatment and was maintained till discharge after the seventh course. Unaided and aided DVA OD improved to LogMAR 0.477 and LogMAR 0.176 with maintenance of the other values at admission for the eighth course. The same readings were reported at discharge after the eighth course of treatment.
Laboratory investigations were conducted at all courses of treatment, except the third course. The results of these are described in Table 4.
Posterior segment examination at discharge after the first course of treatment demonstrated gradual reduction and eventual resolution of the “honey-comb” lesion at the macula OD. Complete resolution of the lesion with persistence of the raised pigmentary elevation OU and macular scar OS was demonstrable at the end of the second course of treatment.
An OCT macular scan brought by the patient at admission for his 4th course of treatment showed a dome-shaped elevation at the macula with multiple cystoid lesions with areas of hypo-reflectivity within them OU (Figures 1a and 1b).
Fundus photography, started at the 4th course of treatment, demonstrated gradual reduction in the pigmentary epithelial elevation OU, although macular scarring OS still persisted. (Figures 2a, 3a, 3b, 4a, and 4b).
OCT macular scanning demonstrated gradual reduction and ultimate resolution of the cystoid lesions and macular edema. (Figures 2b, 3c, 3d, 4c, and 4d).
A timeline of events for this case is provided in Table 5.
Discussion
The patient’s ocular symptoms started shortly after a course of Lariam mefloquine, a medication used for chemo-prophylaxis against malaria. Maculopathy and optic neuropathy have been described in single cases as side effects to mefloquine chemo-prophylaxis.10 A drug safety study demonstrated pseudo-vitiliform macular dystrophy, central serous retinopathy, macular scarring, and bilateral maculopathy in 9 patients out of 23 cases of retinal disease.11This patient’s blurred vision could be due to macular scarring as a result of lariam mefloquine.
Timira is a dreadful condition that warrants immediate management to prevent it from progressing to Kaca(diminished vision) and Linganasa (blindness).12 It encompasses a wide range of symptoms from indistinct vision (AvyaktaRupa) to Andha(total blindness). The pathology of Timira and all Drishtigata Rogas (diseases of vision) revolves around the Patalas or layers of the eye. Susruta describes Timira when the Doshas settle in the third Patala,13 while Vagbhata describes it when the second Patala is afflicted.14
The scarring of the macula was due to excess Kapha lodging in the retina. Cystoid macular edema was the result of Vata being aggravated at the macula resulting in a crack in the tissue. The accumulation of sub-retinal fluid at the macula was due to excess Kapha seeping through the crack. Detachment of the pigmentary epithelium was due to aggravation of Vata, resulting in the tissue’s detachment.
Oral medicines were prescribed with special care so as to not cause any untoward reactions with the patient’s concomitant allopathic medication. The medicines were instrumental in normalizing metabolism, maintaining homeostasis among the three Doshas, and augmenting the effects of the allopathic medication. Medicines with Guduci (Tinosporacordifolia Miers.) were additionally aimed at the gouty arthritis, as Guduci is the ideal medicine for gout as per Ayurveda. Another medicine specifically indicated for gouty arthritis was the KokilakshakamTablet, described by Ashtanga Hrdaya in the management of Vatarakta, the Ayurvedic correlation of gout. Other medicines were aimed at reducing the edema, normalizing retinal metabolism, and improving vision. The discharge medicines augmented the effects of the inpatient prescriptions.
Kriyakalpas such asAnjana, Tarpana, and Putapaka are indicated after complete Suddhikara (purification) of both the Kaya (body) and Siras (head). However,the dominance of Kapha in this patient warranted the initial application of Anjana from the course of treatment onward. This is echoed in the management of KaphajaAbhishyandaby Acarya Susruta, in which Kriyakalpas such as Anjana and Putapaka may be initially administered.15Netra Dhara and Bidalaka facilitated more rapid expulsion of toxins from the eyes by acting on the eyelids. The use of Tarpana at certain intervals of treatments was to prevent untoward increase of Vata, the prime Dosha in Vriddhavastha. As Timira is a Nanatmaja Vikara (unique disease) of Vata, its management with Tarpana is warranted. The head treatments augmented the effects of the Kriyakalpa and enabled absorption of the essential elements through the scalp to reach the target tissues of the retina.Sirodhara was done with oil at the first course of treatment and with decoction at the sixth and seventh courses. This was due to stabilizing the Doshas in the head.
The majority of the ingredients have the property of Rasayana or rejuvenation. It is a Karma that reinvigorates the Rasadi Dhatus (seven tissue elements) and nourishes them to health.16Acarya Caraka explains that advanced age and conditions due to it warrant some form of Rasayana. This property is effected by not only plants such as Guduci (TinosporacordifoliaMiers.), Guggulu (Commiphoramukul Linn.), Pippali (Piper longumLinn.) and Triphala (Terminalia chebulaRetz.,Terminalia bellericaLinn., and EmblicaofficinalisGaertn.), but also by mineral ingredients such as bitumen, iron, copper, and sulfur.
Conclusion
Two challenges in this case were to maintain vision and improve retinal findings. A concerted effort made by the oral medicines and external treatments resulted in improvements in both vision and retinal findings. Despite these, the retinal scar still persisted. However, the patient felt comfortable with the results of his treatment and was pleased to report for further courses. Multiple rounds of treatment garnered positive results; it reflects the multiple times that treatment needs to be administered in Drishtigata Rogas as per Vagbhata. The results of this report may be analyzed by large-scale sample trials.
Acknowledgment
The authors acknowledge Sreedhareeyam Ayurvedic Eye Hospital and Research Center, and Sreedhareeyam Farmherbs India Pvt. Ltd., for their help in preparing this case report. 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 the authors/editors/publishers of all those articles, journals, and books from where the literature for this article has been reviewed and discussed.
Conflicts of Interest: None declared
Sources of Funding: None declared
Authors’ Contribution: Dr. N. Narayanan Namboothiri collected the data and reviewed the article. Dr. Aravind Kumar wrote the draft and analyzed the data. Dr. Krishnendu Sukumaran analyzed the data and reviewed the article.
Abbreviations:
PED: pigmentary epithelial detachment
OCT: optical coherence tomography
DVA: distant visual acuity
NVA: near visual acuity
LogMAR: logarithm of the minimal angle of resolution
OD: oculus dexter
OS: oculus sinister
OU: oculus uterque
Previous Publications in the International Journal of Current Research and Review
Narayanan Namboothiri Narayanan, Aravind Kumar, Krishnendu Sukumaran, Agaja Peethambaran Leena, An Ayurvedic Protocol to Manage Retinitis Pigmentosa - A Case Report, Int J Cur Res Rev, July 2020; 12(13):25-32 (http://dx.doi.org/10.31782/IJCRR.2020.12135)
Narayanan Namboothiri Narayanan, Aravind Kumar, Krishnendu Sukumaran. An Ayurvedic Protocol to Manage Rhegmatogenous Retinal Detachment and the Resultant Macular Hole - A Case Report,Int J Cur Res Rev, July 2020;12(14):10-16 (http://dx.doi.org/10.31782/IJCRR.2020.12143)
Narayanan Namboothiri Narayanan, Sreekala Nelliakkattu Parameswaran, Sreekanth Parameswaran Namboothiri, Anjaly Naduvathu Vasudevan, Aravind Kumar, Krishnendu Sukumaran. Management of Proliferative Diabetic Retinopathy and its Associated Conditions using Ayurvedic Therapies: A Case Series, Int J Cur Res Rev, September 2020;12(17):10-22 (http://dx.doi.org/10.31782/IJCRR.2020.121713)
Parameswaran SN, Kumar A, Sukumaran K. Management of Central Serous Chorioretinopathy Using Ayurvedic Outpatient Therapies: A Case Report. Int J Cur Res Rev, November, 2020; 12(21):129-135 (http://dx.doi.org/10.31782/IJCRR.2020.12211)
Sreekanth Nelliakkattu Parameswaran, Aravind Kumar, Krishnendu Sukumaran. An Ayurvedic Protocol to Manage Myopia in Children: A Case Series.Int J Cur Res Rev., 2020;12 (22):57-65 (http://dx.doi.org/10.31782/IJCRR.2020.12228)
Sreekala Nelliakkattu P, Manjusree Radhakrishnan P, Aravind Kumar, Krishnendu Sukumaran. Non-Ischemic Central Retinal Vein Occlusion (CRVO) and its Management using Ayurvedic Therapies: A Case Series. Int J Cur Res Rev, December 2020;12(24): 85-95 (http://dx.doi.org/10.31782/IJCRR.2020.122423)
Englishhttp://ijcrr.com/abstract.php?article_id=4019http://ijcrr.com/article_html.php?did=4019
Bowling B, Kanski’s Clinical Ophthalmology: A Systematic Approach, Eighth Edition, Elsevier, Limited. 2016, 606pg.
Zayit-Soudry S., Moroz I., Loewenstein A., Retinal pigment epithelial detachment. Surv. Ophthalmol. 2007;52(3):227-243
Thorell MR, Pigment Epithelial Detachment, American Academy of Ophthalmology, 2020, https://eyewiki.aao.org/Pigment_Epithelial_Detachment
Kanski JJ, Bowling B, Kanski’s Clinical Ophthalmology: A Systematic Approach, Seventh Edition, Elsevier Saunders, an imprint of Elsevier Limited, 2011,618 pg.
Bowling B, Kanski’s Clinical Ophthalmology: A Systematic Approach, Eighth Edition, Elsevier, Limited. 2016, 607pg.
Gagnier J, Kienle G, Altman DG, Moher D, Sox H, Riley DS, CARE group, The CARE guidelines: Consensus-based clinical case-reporting guideline development, Glob Adv Health Med. 2013;2(5):38-43
Kumari A. (Ms.), Tiwari PV. (Ms.), Yogaratnakara: A Complete Treatise on Ayurveda, Part I, Chaukhambha Vishwabharati, Varanasi, First Edition, 2010, 7-20pg.
Sharma RK., Dash B., Caraka Samhita: Text with English Translation and Critical Exposition based on CakrapaniDatta’s Ayurveda Dipika, Vol. II, Chaukhambha Sanskrit Series Office, Varanasi, Reprint 2013, 260-67pg
Murthy KRS, Ashtangahrdaya of Vagbhata: Text, English Translation, Notes, Appendices, and Index, Vol. III, Krishnadas Academy, Varanasi, 2000, 121pg.
Walker RA, Colleaux KM, Maculopathy associated with mefloquine (Lariam) therapy for malaria prophylaxis, Can J Ophthalmol.2007;42:125-126
Adamcova M, Schaerer MT, Bercaru I, Cockburn I, Rhein HG, Schlagenhauf P, Eye disorders reported with the use of mefloquine (Lariam) chemoprophylaxis: A drug safety database analysis, Travel Med Infect Di. 2015, http://dx.doi.org/10.1016/j.tmaid.2015.04.005
Murthy KRS, Ashtangahrdaya of Vagbhata: Text, English Translation, Notes, Appendices, and Index, Vol. III, Krishnadas Academy, Varanasi, 2000, 121 pg.
Sharma PV, Susruta Samhita: With English Translation of Text and Dalhana’s Commentary alongwith Critical Notes, Vol. III, Chaukhambha Vishwabharati, Varanasi, 2010, 101 pg.
Murthy KRS, Ashtangahrdaya of Vagbhata: Text, English Translation, Notes, Appendices, and Index, Vol. III, Krishnadas Academy, Varanasi, 2000, 101pg.
Sharma PV, Susruta Samhita: With English Translation of Text and Dalhana’s Commentary alongwith Critical Notes, Vol. III, Chaukhambha Vishwabharati, Varanasi, 2010, 161 pg.
Sharma RK., Dash B., Caraka Samhita: Text with English Translation and Critical Exposition based on Cakrapani Datta’s Ayurveda Dipika, Vol. III, Chaukhambha Sanskrit Series Office, Varanasi, Reprint 2013, 4 pg.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareComparison of Preoperative and Postoperative Nose Scores in Septal Deviation
English5257R. M. Bala AshwathyEnglish B. C. SurekhaEnglishIntroduction: Deviated nasal septum (DNS) is a common condition, mainly causing nasal obstruction in a person. It is usually asymptomatic but may cause interference in daily life in some. Hence symptomatic DNS patients undergo septoplasty. Septoplasty is a conservative surgical procedure, correcting the deviated parts of nasal septum. Some patients have persistent symptoms even after septoplasty. NOSE (Nasal Obstruction Symptom Evaluation) scale was used as a tool to measure nasal obstruction and evaluate the outcomes of septoplasty, in DNS patients. Aim of the Study: To compare the NOSE scores before and after conducting septoplasty in DNS patients and evaluate the effectiveness of septoplasty. Material and Methods: A prospective study was conducted in a tertiary care hospital in DNS patients undergoing septoplasty. NOSE scores were obtained preoperatively and postoperatively from them and analyzed. Results: A total of 20 patients were included in the study, for a period of 2 months from January 1, 2020 to February 28, 2020. Both male and female were included in the study. The mean age of the patients was 37.2 years. The preoperative NOSE scores showed mild obstruction in 2 (10%), moderate obstruction in 11(55%) and severe obstruction in 7(35%). The postoperative NOSE scores showed persistent nasal obstruction in 1 (5%) patient. The mean and SD of preoperative NOSE score was 47.25 and 19.83 respectively. The mean and SD of postoperative NOSE score was 0.25 and 1.11 respectively (PEnglishDeviated nasal septum, NOSE scale, Septoplasty, Nasal obstruction, Septal correction, Birth traumaINTRODUCTION
Septal deviation is a condition characterized by deviation or displacement of nasal septum. It is called deviated nasal septum (DNS). There are different types of DNS like anterior dislocation, C-shaped deformity, S-shaped deformity, spurs and thickening 1-3. It is commonly caused by trauma and developmental abnormality. Traumatic incidents in childhood or those inflicted during labour in vaginal birth can cause development of DNS in later stages of life 1-4. A frontal or lateral blow in accidents is also commonly seen in DNS. Developmental errors in formation of nasal septum, abnormal intrauterine postures compressing the nose, conditions like cleft palate are commonly seen. In later stages of life, mouth breathers like hypertrophy and nasal polyp or tumors cause DNS. Some degrees of racial and hereditary factors also play a role 5. Deviated nasal septum may be asymptomatic but some patients usually present with complaint of nasal obstruction most commonly, followed by headache, external deformity, anosmia, etc. Sometimes untreated DNS can lead to complications like sinusitis, middle ear infections, etc 7. The definitive treatment is universally accepted as surgical correction or ‘septoplasty’. However, the benefits of septoplasty, as perceived by the patient, widely vary over different grades of satisfaction, ranging from complete alleviation of symptoms to a total failure. Pre and post operative assessment of symptoms are necessary for outcome analysis. Hence septoplasty, a conservative surgical management, where most deviated parts are removed and septal framework is corrected and repositioned, is done for DNS. But it is usually avoided in children unless it is very severe. Though septoplasty is conducted as a common procedure some patients may have persistent symptoms. There are many questionnaires available; some of them only contain items related to nasal symptoms whereas others also include general quality of life items. We want to focus on the surgical results per se and would therefore prefer a questionnaire that specifically assesses nasal symptoms. The Nasal Obstruction Symptom Evaluation (NOSE) questionnaire8-10 has been validated and used in many countries, but one item is difficult to translate into the Norwegian language.
Questionnaires using a single visual analogue scale (VAS) for obstruction have been used in several studies 11. We believe that use of separate and continuous scales for obstruction in different situations (day, night, and during exercise) will yield clinically relevant information about the patient’s symptoms and how they change in response to surgery. Other nasal symptoms and the use of nasal medication should also be taken into account in surveying the results. As patient’s perception of nasal airflow is of primary concern, the improvement in subjective score of patient’s symptoms is definitely an important outcome parameter of management plan in order to address the complex problem. This is a disease-specific quality of life instrument for subjective assessment of nasal obstruction. It is in a form of a questionnaire containing five symptoms in increasing severity. The results of septoplasty are thereby evaluated using NOSE (Nasal Obstruction Symptom Evaluation) scale, to observe and record the improvement seen before and after patients undergoing septoplasty. This comparison of preoperative and postoperative NOSE scores will reveal the efficiency of septoplasty in deviated nasal septum.
AIM AND OBJECTIVES
To analyze the changes in NOSE survey, before and after conducting septoplasty in DNS patients.
To assess the specific improvement in patients following septoplasty.
To evaluate the outcomes of septoplasty.
MATERIAL AND METHODS
A prospective study with Ethical committee approval number SMC/IEC/2020/03/317 was conducted in a tertiary care hospital. A total of 20 patients with nasal septal deviation, posted for septoplasty in ENT department, were analyzed in this study, for a period of two months, from 1st January, 2020 to 28th February, 2020. Written informed consent was obtained from all patients. The study was based on NOSE (Nasal Obstruction Symptom Evaluation) scale. All the patients with symptoms of nasal congestion, nasal obstruction, trouble to breathe through nose, trouble to sleep and trouble while exercise, who came to ENT department were included in the study. The NOSE scores were obtained preoperatively and postoperatively 2 weeks after septoplasty. The NOSE scale was obtained from each patient. The preoperative and postoperative NOSE scores were recorded, totaled and compared for each patient and changes were assessed and the outcome of septoplasty was evaluated including demographic analysis.
INCLUSION CRITERIA
All patients between 20 years and 65 years of age were included in the study.
All patients with symptoms of nasal congestion, nasal obstruction, trouble to breathe through nose, trouble to sleep, trouble while exercise or exertion were included in the study.
EXCLUSION CRITERIA
Patients less than 20 years and more than 65 years of age were excluded from the study
Patients with nasal polyp, allergic rhinitis and fracture of septum or nasal bone were excluded from the study.
STATISTICAL METHODS
Continuous data was represented as mean ± SD. Categorical data was represented as value (%). Paired t-test was the statistical tool used in the study. Data were analyzed with SPSS software (version 22.0 for Windows, IBM Corp., Armonk, NY). P value less than 0.05 was considered statistically significant.
RESULTS
A total of 20 patients were in this study. Demographic details were analyzed for each subject. Among them 15 (75%) were male and 5 (25%) were female. The mean age was 37.2 years with a range, 20-62 years. The age wise and gender wise distribution of the study subjects is given in Figure 1.
All the 20 patients, undergoing septoplasty, were evaluated based on NOSE (Nasal Obstruction Symptom Evaluation) scale. The NOSE scale covers mainly five symptoms, namely, nasal congestion/stuffiness, nasal blockage/obstruction, trouble breathing through nose, trouble to sleep, unable to get enough air through nose while exercise or exertion. The scale grades each symptom in the increasing order of severity. The NOSE scale used in this study is shown in Table 1. The survey was conducted preoperatively first and post operatively, 2 weeks after the surgery. The patients graded the severity of the symptoms from 0 to 4. 0- no problem, 1- very mild, 2- moderate, 3- fairly bad, 4- severe, as given in Table 1. The values were summed to 20. The mean and SD of preoperative NOSE score was 9.45 and 3.96. The mean and SD of postoperative NOSE score was 0.05 and 0.22 (PEnglishhttp://ijcrr.com/abstract.php?article_id=4020http://ijcrr.com/article_html.php?did=4020
Moorthy PN, Kolloju S, Madhira S, Jowkar AB. Clinical study on deviated nasal septum and its associated pathology. Int J Otolaryngol Head Neck Surg. 2014 Mar 10;2014.
Regmi R. Analysis of Symptoms and Types of Deviated Nasal Septum- A Clinical Study. Int J Health Allied Sci. 2018;4(1):20-23.
Ajmal DM, Usman DN. Relation between chronic sinusitis and deviated nasal septum. Int J Sci Res Dent Med Sci. 2017;16(05):42–5.
Alotaibi A, Almutlaq BA. Post-surgical Outcomes of Patients Undertaken Septoplasty with Regard to Initial Clinical Complains. Res Otolaryngol. 2017;6(6):73-80.
Chambers KJ, Horstkotte KA, Shanley K, Lindsay RW. Evaluation of improvement in nasal obstruction following nasal valve correction in patients with a history of failed septoplasty. JAMA Facial Plast Surg. 2015 Sep 1;17(5):347-50.
Bezerra TF, Stewart MG, Fornazieri MA, Pilan RR, Pinna FD, Padua FG, et al. Quality of life assessment septoplasty in patients with nasal obstruction. Braz J Otorhinolaryngol. 2012 Jun;78(3):57-62.
Gandomi B, Bayat A, Kazemei T. Outcomes of septoplasty in young adults: the Nasal Obstruction Septoplasty Effectiveness study. Am J Otolaryngol. 2010 May 1;31(3):189-92.
Kahveci OK, Miman MC, Yucel A, Yucedag F, Okur E, Altuntas A. The efficiency of Nose Obstruction Symptom Evaluation (NOSE) scale on patients with nasal septal deviation. Auris Nasus Larynx. 2012 Jun 1;39(3):275-9.
Stewart MG, Smith TL, Weaver EM, Witsell DL, Yueh B, Hannley MT, et al. Outcomes after nasal septoplasty: results from the Nasal Obstruction Septoplasty Effectiveness (NOSE) study. Otolaryngol Head Neck Surg. 2004 Mar;130(3):283-90.
Stewart MG, Witsell DL, Smith TL, Weaver EM, Yueh B, Hannley MT. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004 Feb;130(2):157-63.
Rhee JS, Sullivan CD, Frank DO, Kimbell JS, Garcia GJ. A systematic review of patient-reported nasal obstruction scores: defining normative and symptomatic ranges in surgical patients. JAMA Facial Plast Surg. 2014 May 1;16(3):219-25.
Spiekermann C, Savvas E, Rudack C, Stenner M. Adaption and validation of the nasal obstruction symptom evaluation scale in German language (D-NOSE). Health Qual Life Outcomes. 2018 Dec;16(1):1-6.
Samad I, Stevens HE, Maloney A. The efficacy of nasal septal surgery. J Otolaryngol. 1992 Apr 1;21(2):88-91.
Schwentner I, Dejakum K, Schmutzhard J, Deibl M, Sprinzl GM. Does nasal septal surgery improve quality of life?. Acta Otolaryngol. 2006 Jul 1;126(7):752-7.
Konstantinidis I, Triaridis S, Triaridis A, Karagiannidis K, Kontzoglou G. Long term results following nasal septal surgery: focus on patients’ satisfaction. Auris Nasus Larynx. 2005 Dec 1;32(4):369-74.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareComparison between Device Closure and Surgical Method of Closure in Atrial Septal Defects in a Tertiary Health Care Setup
English5862Manoj KumarEnglish Navneet K SrivastvaEnglish Dharmendra K SrivastavaEnglish Subhash S RajputEnglish Sudharshan VijayEnglishBackground: Atrial septal defect (ASD) comprise 7-10% of the congenital heart diseases in adults. For decades surgical repair has been the treatment of choice with excellent survival in long term follow up. However, like every cardiac surgery, there are complications related to cardiopulmonary bypass, residual scars and mental agony. Less invasive methods such as percutaneous transcatheter device closure have been developed. Aim: To compare surgical repair and device closure methods for management of ASD in terms of efficacy, intraoperative, post-operative complications and length of hospital stay. Materials and Methods: The present study was done in a tertiary health centre in northern India and comprised of 80 patients with a proven isolated ASD who had undergone surgical repair (n=50) and device closure (n=30). They were reviewed and analysed for comparison among the two methods. Results: The successful closure rate was 100% in the surgical group and 93.3% in device closure. There was a significant difference in operative time between the surgical group and the device groups. The length of stay in the intensive care unit and postoperatively in the hospital was shorter in the device group than in the surgical group. In terms of complications, arrhythmia was seen in 16% of surgical patients and 20% device group. Wound infection/ groin hematoma was in 12% patients of surgical and in 13.3% patients of device. Conclusion: It can be summarised that surgical closure of ASD is comparable to transcatheter device closure with some limitations in either group. Procedural success is more in the surgical group with no chance of device migration and embolisation which is a fatal complication of device closure. However, the surgical group has its limitations in terms of post-operative pain and hospital stay.
EnglishAtrial septal defect, Comparison, Congenital heart disease, Device closure, SurgeryIntroduction: Atrial septal defect (ASD) accounts for 7-10% of congenital heart defects in adults. 1More recent epidemiological data suggest that ASD occur in 1.6 per 1000 live births. 2 This increase can be attributed to improvements in imaging technology. Advanced maternal age is also thought to be a risk factor for ASD. The gold standard in the treatment of ASD is direct surgical closure of the defect. It is associated with excellent survival in long-term follow; however, complications due to sternotomy, cardiopulmonary bypass, residual scars and mental agony do persist. Hence, in recent times ASD are being increasingly closed by transcatheter implantation of occluder devices.3The decision to manage ASD depends on technical factors. Small ASD with adequate septal rims are suitable for transcatheter closure, whereas surgical closure should have opted when the defect is too close to the atrioventricular valves, the coronary sinus, or the vena cavae.
Methods: [1]
Subjects: The study cohort comprised of 80 patients with isolated ASD during a period of twelve months August 2018 to July 2019. The inclusion criteria were an ostium secondum ASD without any associated cardiac anomaly. The patients were divided into two groups according to their treatment options. There were 50 patients in group A (surgical repair) and 30 patients in group B (Transcatheter device closure). Medical records were reviewed for demographic features like height, weight, age and their baseline characteristics like size, type of ASD and pulmonary hypertension were recorded.
Operative technique :
Surgical repair (Group A): ASD was approached by either of the three incisions- median sternotomy, right anterolateral thoracotomy and or vertical infra-axillary thoracotomy as per the patient’s height, weight and sex. A pericardial patch was used in all cases. All patients required cardiopulmonary bypass (CPB) in this group.
Transcatheter device closure (Group B): Femoral vein was used for catheterization and the defect was closed with a guidewire. Transthoracic echocardiography (TEE) and or angiography was used to assess the diameter of ASD and a corresponding occluder was placed across the defect.
Successful ASD closure was defined if they had no (Englishhttp://ijcrr.com/abstract.php?article_id=4021http://ijcrr.com/article_html.php?did=4021
Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol.2002;39(12):1890-900.
Chelu RG, Horowitz M, Sucha D, Kardys I, Ingremeau D et al. Evaluation of atrial septal defects with 4D flow MRI-multilevel and inter-reader reproducibility for quantification of shunt severity. MAGMA. 2019;32(2):269-279.
Tsuda, T., Davies, R.R., Radtke, W. et al. Early Surgical Closure of Atrial Septal Defect Improves Clinical Status of Symptomatic Young Children with Underlying Pulmonary Abnormalities. Pediatr Cardiol. 2020; 41:1115–1124.
Siddiqui WT, Parveen S, Siddiqui MT, Amanullah MM. Clinical outcomes of surgically corrected atrial septal defects. J Pak Med Assoc. 2013;63(5):662-665.
Ak K, Aybek T, Wimmer-Greinecker G, Ozaslan F, Bakhtiary F, Moritz A, Dogan S. Evolution of surgical techniques for atrial septal defect repair in adults: a 10-year single-institution experience. J Thorac Cardiovasc Surg. 2007;134(3):757-764.
Naik MJ, Chua YL. Minimally invasive repair of atrial septal defects--a case series. Ann Acad Med Singap. 2000;29(6):735-749.
Vida VL, Tessari C, Fabozzi A, Padalino MA, et al The evolution of the right anterolateral thoracotomy technique for correction of atrial septal defects: cosmetic and functional results in prepubescent patients. Ann Thorac Surg. 2013;95(1):242–24
Grohmann, J., Höhn, R., Fleck, T., Schnoor, C. and Stiller, B. Transcatheter closure of atrial septal defects in children and adolescents: A single-center experience with the GORE® septal occluder. Cathet. Cardiovasc. Intervent. 2014;84: E51-E57.
Kim, Michael S, Andrew, John Carroll. Transcatheter closure of intracardiac defects in adults. Jof intervent cardiol. 2007;6:524-45.
Du, Zhong-Dong, Oi Ling, Jonathan Rhodes, Mary, Ziyad Choice of device size and results of transcatheter closure of atrial septal defect using the amp later septal occluder.J of interventcardiol. 2002;15(4 ): 287-92.
Özdemir E, Varis? E, Kiris? T, Emren SV, Nazli C, Tokaç M. In-Hospital cost comparison of transcatheter closure versus surgical closure of Secundum atrial septal defect. Int J Cardiovasc Acad. 2018;4:28-31.
KotowyczMark, Judith Therrien, Raluca, Colum, Louise Long-term outcomes after surgical versus transcatheter closure of atrial septal defects in adults.JACC. Cardiovascular interventions 2013; 6(5): 497-503..
Ooi YK, Kelleman M, Ehrlich A, Glanville M, Porter A, et al. Transcatheter Versus Surgical Closure of Atrial Septal Defects in Children: A Value Comparison. JACC Cardiovasc Interv. 2016; 119(1):79-86.
Chen, Q., Cao, H., Zhang, GC, Liang WC, Fan XU et al Midterm follow-up of transthoracic device closure of an atrial septal defect using the very large domestic occluder (44–48 mm), a single Chinese cardiac center experience. J Cardiothorac Surg. 2017;12, 74
Berger F, Vogel M, Alexi-Meskishvili V, Lange PE. Comparison of results and complications of surgical and Amplatzer device closure of atrial septal defects. J Thorac Cardiovasc Surg 1999;118:674-680.
DiBardino DJ, McElhinney DB, Kaza AK, Mayer JE Jr. Analysis of the US Food and Drug Administration Manufacturer and User Facility Device Experience database for adverse events involving Amplatzer septal occluder devices and comparison with the Society of Thoracic Surgery congenital cardiac surgery database. J Thorac Cardiovasc Surg. 2009;137(6):1334-1341.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareA Review on Inhalant Abuse Risk in Adolescents
English6367SnehaEnglish Saini EEnglishInhalant abuse is a significant and precarious arising problem noticed among teens and youngsters throughout the world. Due to their high potential to rapidly induced euphoria and no prohibition to their use and purchase, they are highly misused by all ages. Some domestic inhalants of abuse containing volatiles and aerosols such as petroleum products, stationery products (glue, fluid, marker) and sometimes medical anaesthetic gases also and Bagging, snorting and huffing are some common methods adopted by users for inhalation. In the case of regular users or dependency, some serious consequences like the failure of kidney, liver, nervous system arising. This review studied the previous case reports and surveys performed in the field of inhalants abuse and highlight the issue of problems related to inhalant abuse by collecting data and record of past users.
English Inhalant, Abuse, Adolescents, Health risk, SocietyIntroduction
More than thousands of household products contain menacing chemicals. When these dangerous chemicals are properly used they make our life better but people who handle these chemicals have to be careful to protect themselves and the others around them. Nowadays many parents are bothered about drugs such as marijuana, cocaine, LSD (Lysergic Acid) and alcohol. They are always aware about the harmful effects and disorder related to these drugs of abuse but they usually disregard the popularity and risk produced to their children from familiar inhalants of abuse containing household volatile products such as spray paints, nail polish remover, glues, petroleum products( gasoline, kerosene, diesel ) which can cause death (regular use for a long time), toxicity or addiction; however, kids these days are quickly discovering that public household products are economical and easy to obtain. Inhalants are one of the least studied or discussed groups of abused substances and their rate of abuse is increasing as well.1 Inhalant abuse means “breathing intentionally” of gas or vapors with the purpose of “getting high’’ and for “recreational’’ or to achieve an altered mental state. Inhalants are the chemicals found in certain household and workplace products that produce chemical vapours. These vapours can be used by individuals to produce mind alerting affects and rapidly absorbed into the brain to produce a quick ‘high.2 Usually the youth or adolescent select inhalants because of their ease of access, low prices, broad availability, legal vending and potential to rapidly induce euphoria.3 Abuse of inhalants is a worldwide problem that is especially common in individuals from minority and marginalized populations, and is strongly correlated with the social determinants of health . It frequently affects younger children, compared with other forms of substance abuse and crosses social and ethnic boundaries . Sometimes the demand of the inhalants is due to peer group pressure and the street kids mostly start using inhalants to overcome their pain of hunger, cold. This misusage starts providing opportunity for mind alerting experiences and becomes very soon a dependency.3Misuse of inhalant is sometimes referred to as “ the forgotten drug epidemic” because a big part of American adolescents have been involved in this activity at a certain age; yet the outcome of these sort of drugs of abuse are not reported as commonly as the consequences of other drugs like prescription painkillers or even cocaine.4
Classification of Inhalants:
Inhalants broadly classified into four categories on the basis of their form.5
Volatile solvents –Liquids that are vaporizing at room temperature, when inhaled cause a state of intoxication. As an examples- Paint thinner, dry cleaning fluids, petrol, kerosene, glues, correction fluids, felt tip markers, paint remover and so on.
Aerosols- Aerosols is the sprays that containing solvents and the propellants. An examples being- Spray paints, deodorants, hair sprays, fabric protector spray etc.
Gases- Gases usein the household products as well as in hospitals includes-nitrous oxide, ether, chloroform.
Nitrates – Inhalants of this catagoriesdiverse from other inhalants because they first expand blood vessels and relaxing the muscles.
Such as- Medical supplies – food preservatives, amyl nitrite found in certain adhesives and solvents etc.
From all the categories, the volatile substances are available as legal ingredients of many common domestic products. More than 1,000 products are used as inhalants in the world. Some of them ordinary household goods, including - nail polish remover, petrol, kerosene, glue, spray paint, correction fluid (liquid paper),shoe polish, spray paint, cleaning fluids, rubber cement, headache balms.1 Common ways that are used by the teenagers for inhale such products are Huffing, sniffing or snorting, dusting, bagging, glading. ‘Sniffing’ implies the direct inhalation of the vapour from the container . In ‘bagging’ a plastic or paper bag sprayed or poured with fumes and hold it over your mouth and nose and inhales, this method increases the danger of suffocating. In spraying aerosol is sprayed straight inside the nose and mouth. A cloth is drowned in an inhalant and pressed into the mouth during ‘ huffing ’ . Huffing cause a feeling of euphoria that may take about 15 to 45 minutes to pass.6First the use of gasoline for euphoric and recreational purpose becomes popular in 1940s. In the united states demand of inhalants raised in 1950s among adolescents . Solvent sniffing spreader popularity in 1960s of some household items including nail polish remover, lighter fluid, shoe polish, spray paints.7 In most recent years, glue sniffing spreads as a serious problem in the homeless children in Mexico, south Asia, eastern Europe, Kenya and other undeveloped areas on all sides of the world.8 Most commonly misused products reported to united state poison center are petrol (41%), air fresheners (6 %) , paint (13%), propane (6%) during a period of 1996-2003.3 Such household products have been misused by different sections of the population but habit and dependency are raised among teens (Creighton, 2010). In the USA, the starting age of early volatile substance misuse averages around 13 years old with white and Spanish children more probably to combat with abuse and dependency problems involving these substances than other classes of society. Inhalant abuse usually comes before another gateway drugs such as tobacco, alcohol, marijuana, or other substance abuse.4One more class at risk of becoming habitual to inhalants – Especially , the members of dental department ( nitrous oxide gas as medical anesthetic) . Even if dependency and misuse risk are a compound of some still studied psychological, environmental and genetic factors, peoples who works as the endodontist or dental specialist have the association of misuse substance peril factor are probable to fight with dependency to such anasthetics, due to their near procedure to this inhalants. Function of nitrous oxide by dentists as an depressant in the surgery of withdraw four molar teeths . Nitrous oxide is abused by near about 5 % of dental practitioners, survey by ADA (American dentist association) Dentist Health and Awareness Committee.4
The Consultative signs of the substance abuse are resemble to that someone is under the impact of alcohol . Frequent key indicators includes– euphoria, dizziness, lightheadedness, blurred vision, lack of coordination, Slurred speech, some harmful chemicals present in the many types of inhalant products may generate different indicators after and during the inhalant intake. Abusing inhalant many times leading to symptoms like as –vomiting, nausea, confusion, loss of inhibitions, lack of control, interval of dozing dull that last for few hours.9
Common effects of abusing inhalants
Repeated inhaling high concentration of chemicals in the volatile solvents or aerosols spray have the potential to cause heart failure and death within minutes, heart starts overworking, rapidly, and irregularly that leads to the cardiac arrest or sudden sniffing death syndrome. It can happen at very first time or after several time use. Where the habit of inhalants misused repeatedly, dangerousness also increased in such cases. In the 1999, NIDA conduct a study showed that 19.7 % of 10th students and 15.4 % of 12th students said they had at least once time misused inhalants. According to 2011 article, Substance abuse and mental health services administration (SAMHSA ) investigate the issue of misusing inhalants amongs the teens and adults.10About 22 % of those who die from huffing do so the first time they try it. The use of inhalants don’t kill on the instant, it takes time to affect the body and the brain.11 A few detrimental and changeless consequences of inhalant abuse contains - liver or kidney mutilate (volatile solvents), blood oxygen depletion (paint thinners and varnish removers), slurred, fatigue and headache, weight loss, and anemia, fatigue, headache, brain and CNS(central nervous system) damage (aerosols, dewaxer , glues), connective tissue damage ( petrol),motor neuron disease and atrophy results walk lamely and stumble( petrol, gas cylinders, glues, cream dispenser ), hearing impairment (correction fluids, dry cleaning, gum, airbrush spray can ) etc.
The activity of misusing inhalants replaced air in the lungs and to take from the body of O2 causing damage cells in the brain called as hypoxia which part of brain is affected or damaged are responsible for the signs and symptoms of brain hypoxia. For example – Important brain area for memory is an hippocampus that is high sensitive to hypoxia . If someone hippocampus is damaged due to repeatedly abusing of inhalant results in lose the skill and capability to learn or he or she survive a difficult time period continue on simple conversation. Long standing abuse of volatile solvents, such as toluene break down the myelin sheath of fatty tissue that surrounds and protect nerves fibers, transmit messages effectively and quickly its break down leads to tremors or muscle spamming arms and legs, learning disabilities, hallucinations etc. Somebody can be suffocated because volatile substance are absorbed in the lobes of the lungs speedy than oxygen and finish up displacing oxygen, causing the consumer to lose sense and stop breathing. Consciously, chances of suffocation increases when inhaling by using a plastic bag and paper in a closed area.
Therefore, the objective of this study was to trace the types (nature) of inhalants abused in India, Involvement of age group and gender type in these cases and trends (methods of use) commonly adopted by the addicts.
Status of inhalants among adolescent
Survey in Virginia from 1887 to 1996 revealed that 13-22 years aged males are more abusing inhalants as compare to females. A computerized report of deaths in Virginia was investigate to recognition of all deaths during this inhalants products misuse event. Report include the record of time/day, month, location of death, gender, substance misuse, past of drug abuse, anybody markings Survey results more than fifty deaths associated with intentionally abusing of volatile substance.12 Abusing from some household products arising the high risk of mortality and morbidity in adolescents all over the world because they are often unaware of health related issue and serious damage to their organs by inhalation of such products.13The negligence of substance abuse by adolescents was also discussed in literature. According to the survey nearly about 20% high and middle school students experiments with different delivery methods of inhalants substance. So it is need to emphasize on education and awareness among young, their parents and community.14An data of 2000-2001 NSDUH (National household surveys on drug abuse) in United states found that amid adolescents under the age of 17, the preponderance of lifespan use and history of use in past 8.8%, about 50.9% of inhalant users noticed using many types inhalants, 46.4% started using before their 13 age and nearly about 19.8% abused inhalant in one time in a weak. Adolescent also reported with the delinquent behavior, dependency, progression, multiple drug abuse.15 Some common inhalants like Glue sniffing demand and its threat to health in adolescents and children in India is a big problem for medical community. The popularity of glue sniffing increases continuously due to its easy availability, cheap rate and their misuse causes major risk for vital organs and sometimes results death. Therefore, awareness and education necessarily required to control of spreading of inhalant abuse.16 Key aspects of inhalant abuse, various methods used for different types of inhalants, chronic effects, morbidity and mortality rate among the youth and adolescents was discussed in clinical report which advised the requirement of realization and attention of the peoples regarding of misuse of substances by children and suggested the pediatrician’s role in prevention and identification.17 Sometimes peer group pressure, curiosity unemployment, poor family support makes it a primary initiative of abuse among the adolescents. Inhalant abuse and dependency from India include sniffing (67%), huffing (19%), bagging (14%) of typewriter erasing fluid due to their low prices, no legal control on sale, easily purchase from at all stationary/ general stores.18
It was also noticed that misuse of inhalants is a spreading problem amid those children who were lived with their families in the streets, with domestic violence was in their life, hunger, 7-8% of school droplet who had run away from villages.19The trend of substance abuse were high in male students, as the age increases the tendency of using inhalant also increase. A survey in district Ambala, Haryana (India) among the 7th to 12th standard students of age 13 to 19 years revealed 42% students used combination of more than one drugs also with alcohol (44.49%) and tobacco (14.42%) . Also the extent and addiction of substance abuse high in north areas and causing serious health impacts among students.20 Another structured questionnaire from the ‘UNDCP/WHO global in Manipur, (India) on primary prevention of substance abuse’ also concluded that males are more likely to be forever users. Also indicated that glue is the most commonest abusing inhalants in participants about 98(52.7%). Preponderance of inhalant abuse offers a demand to parents, society, health organization as well as state Govt. to should take up action at stage of school or at primary level.21As determined by a study in 2011, about 1/10th of the US population has misused or addicted to inhalants at a certain moment in their lives – we’re talking about 22.5 million people in the USA. The group at-risk for abusing these products are the youth, especially the underage. In another analysis of people subjected to this misuse for the first time in the previous one year, more than 68% of these users were the underage and were new to this activity. In one more study, about 58% of people who used inhalants initiated towards the end of ninth class. A 3rd survey showed that near about 20 % of middle and secondary school students had abused inhalants at one day in their life.4Near about 52 street children (5-17 year aged) in Nepal were addicted to glue sniffing for last 1 year. Among users 54.35% was tried more than 5 times in a day, Prevalence was 89.13% in those who had not awareness and knowledge about side effects of glue sniffing and 52.17% children sniffing such inhalant to overcome their problems or stress and also results of peer group pressure.22 Therefore, study for evaluation of public health and impact of substance misuse in adolescents should be conducted at various interval of time. Also, there is need of attention among street children because lack of guidance, without security, education, they are moving towards an dubious futurity.
Some reported Case study
Case 1. A case report of 32 year old patient who had the boot polish and alcohol dependency. Examination revealed that he was abusing boot polish for about last 6 months. In the beginning, he used to inhales a little bit but as the time progressed, then he started inhaling multiple times in a day. There was no family history of drug or alcohol dependence among first degree relatives.23
Sudden sniffing death of a 24-year old male which cause the cardiovascular and multi-organ system toxicity after inhaling a halogenated hydrocarbon containing keyboard dust cleaner.24
Case 2. Another case report on use of inhalants showing that it is not only present among male adolescent but it’s also a reason of concern for females. An episode of an adolescents female from New Delhi who randomly came in contact with this act of inhalation. At the age of 13 years patient discovered for the first time attraction to patrol’s smell and fell in dependency of its pleasant effect on herself . She started inhaling frequently not only from patrol but also from similar products kerosene. Unfortunately in unawareness of phenomena her family tried to stop her only by arguing with her without taking any professional help. Their relations kept worsening. Her school failures in sixth class and fourth class also had negative effects on her life. She hadn’t any other neurological disorder apart from this addiction. Overwhelming anxiety, personal failures or schizophrenia and some character disorders can bring assumptions of inhalants for self-treatment.25
Case 3. A case history of schizophrenia and petrol dependence of a 37 years old patient reported in psychiatry OPD, PGIMS, Rohtak. Parents complained of his petrol sniffing for 10 years. Patient used the cannabis in his adolescent age and when he was not able to get cannabis and he looked for alternate mean. Firstly patient inhales the boot polish and after few weeks also started petrol inhalation. He feels relaxed and hallucinogens after inhaling. In the starting patient only a bit inhales petrol but after a few months sniffing whole the day. His parents and neighbors noticed his dependency toward petroleum when he would shout, abusing and remain confined to his room and sniff large amount. On patient Mental examination found increased psychomotor activity but general physical examination was normal. After such findings patients were managed with tablets Risperidone 2mg 1HS, Baclofen 20m.26
Case 4. A 14 year old boy belonged to a lower working class family brought with grievance of deceptive onset or gradually gait instability for about last 50 days. Leading questions disclose that the child sniffing glue from polythene bags (5-6 times/day) for last 1 year. Examination showed he had neurosyphilis, motor ataxia. Other vital organs test resulted normal functions but MRI of brain showed mild diffuse cerebral atrophy and change in white matter. Counseling and management of patient for near about one month results his gait ataxia partially resolved. This study also discussed about another consequences and complications regarding to glue sniffing.27
Conclusion
Nowadays, abuse and pervasiveness of volatile substance in children and adolescents became a challenge for parents, society and heath community. According to record of last 2-3 years it is found that the problem of inhalant abuse is significantly present all over the world and is growing gradually among youth.
In India, it is observed that easy approachability at each home, absence of legal restriction of domestic use products such as glue, petroleum products, fluid makes them the most demandable inhalant objects in school age children. The category which is known to be the main target is formed by younger teens, even a part of adults and majority in homeless, uneducated and migrant status street children. All the previous studies and surveys indicated that males were more likely than females to have used inhalants for get a buzz. Also to be noticed that huffing, bagging, sniffing are the most popular pattern adopted by the users. In some users this activity can cause serious damage and failure of vital organs and could result in deaths. Therefor there is a strong need to understand and take some useful steps regarding this perilous problem. Some new tactics should be adopted such as family based treatment program, strong management strategies, increasing education level and efforts to replace danger and mind alerting substance in familiar products with low harmful alternative. According to forensic point of view it is found that there are some studies done in field of detection, identification, analysis of inhalants by the use of conventional and modern hyphenated techniques. Review concluded that there is also need of more knowledge and research of more sensitive methods and instrumental hyphenated techniques in all areas of identification, analysis of inhalants in metrics of toxicological importance is also significant. There is not sufficient work done according to forensic point of view. So, for this reason, its necessary to always update our education and information to select and established more approach, techniques for detection of inhalants.28 Therefore a global consciousness is much required to accept the use of inhalants as a high-risk problem and to face it in all respective fields in order to find some suitable solutions (to save more lives).
Acknowledgement:
I am grateful to all the authors/editors/publishers whose articles are cited and included in references of this manuscript.
Conflict of Interest
The authors declare that they have no conflict of interest.
Funding:
No funding.
Author Contributions:
S. drafted and conceived the article E.S and revised the manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=4022http://ijcrr.com/article_html.php?did=4022
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Praharaj SK, Verma P, Arora M. Inhalant abuse (typewriter correction fluid) in street children. J Addict Med 2008;2(4):175-7.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareEvaluation of the Anti-Diabetic Activity of Sophora Interrupta: Pharmacological Screening Against Streptozotocin-Induced Diabetic Rats
English6876Faheem IPEnglish Gopalakrishna BEnglish Mohsina FPEnglish Sarah PriyaEnglishIntroduction: Diabetes Mellitus (DM) is a highly prevalent metabolic disorder characterized by chronic hyperglycaemia. Though multiple conventional therapies are available these therapies are reported to have side effects. Aim: To evaluation of the anti-diabetic activity of Sophora interrupta by using the streptozotocin-induced diabetic rat model. Plants are potential sources of phytoconstituents with varied pharmacological activities. Methodology: The leaves and the stem bark of Sophora interrupta(SI) were collected and initial results of the phytochemical screening revealed that all the bark and leaf extract of the plant showed the presence of flavonoids, Saponins, steroids, alkaloids, tannins, phenolic compounds, triterpenoids and carbohydrates. Results: The results of acute toxicity studies demonstrated that animals did not display any drug-related behavioural, physiological and psychological changes. The streptozotocin model was used for the induction of diabetes. In diabetic rats, decreased bodyweight, High-density lipoprotein (HDL), reduced glutathione (GSH), Superoxide dismutase (SOD), Catalase (CAT) and increased level of Blood glucose, total cholesterol (TC), triglycerides (TG), low-density lipoprotein (LDL), very-low-density lipoprotein (VLDL) and TBARs was observed which was normalized by 200 mg/kg and 500 mg/kg extract of the plant. Conclusion: It shows that the ethanolic extract of SI showed significant antioxidant and antidiabetic activity directing it as a better therapeutic regimen in the treatment of diabetes and associated complications.
English Plant extract, High-density lipoprotein, Reduced glutathione, Total cholesterol, Triglycerides, Low-density lipoprotein, Very low-density lipoprotein
Introduction
DM is a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbances of carbohydrate, fat and protein metabolism resulting from defects in insulin secretion, insulin action, or both.1Diabetes is the sixth leading cause of death worldwide.2
Several pathophysiological processes are involved in the development of DM. These range from autoimmune destruction of the pancreatic β-cells with consequent insulin deficiency to abnormalities that result in resistance to insulin action. Deficiency and insufficient action of insulin on target tissues lead to carbohydrates, fats and proteins metabolism abnormalities.3
Oxidative stress has been suggested as a contributory factor in the pathogenesis of DM(4). Diabetes increases the production of tissue-damaging reactive oxygen species (ROS) by glucose autoxidation and/or non-enzymatic protein glycosylation (5). Hyperglycemia has been found to increase the production of ROS such as superoxide anion (O2–), and hydrogen peroxide (H2O2) which reduce nitrogen oxide (NO) bioavailability in cultured endothelial cells, and in vascular tissue (6). Endothelial dysfunction is a well-documented characteristic phenomenon in DM (5–7), and is attributed to decreased vasorelaxant, and increased contractile responses to physiological, and pharmacological stimuli.4
In conventional medical practice, the present therapies of DM are reported to have side effects. For instance; sulfonylurea causes weight gain due to hyperinsulinemia, biguanide cause body weakness, fatigue, lactic acidosis and alpha glucosidase inhibitor may cause diarrhoea while thiazolidinediones may increase LDL-cholesterol level.8
This raises the need for other sources of these inhibitors that have fewer side effects.9 Therefore, because of the side effects associated with the present antidiabetic drugs, there are need to develop effective, safe and cheap drugs for diabetes management. Such effective, safe and cheap drugs could be obtained by using medicinal plants which have been used by humans to prevent or cure diseases including diabetes since the dawn of civilization.10
Medicinal plants are used by almost 80% of the world’s population for their basic health care because of their low cost and ease in availability.11The use of herbal medicinal plants has always played a positive role in the control or prevention of diseases such as diabetes, heart disorders and various cancers.12 Some medicinal plants have been used in the production of various drugs singly or in combination and even as principal raw material for the production of other conventional medicines.13 Extracts from the other common species have also been used as medicine in treating various illnesses.14 Therefore, traditional medicine offers promising solutions to face the global increasing demands for new therapeutic agents. Insufficient data exist for most plants to guarantee their quality, efficacy and safety.15 However, the adverse effects of phytotherapeutic agents are less frequent compared with synthetic drugs, but well-controlled clinical trials have now confirmed that such effects really exist.16 In present study, pharmacognostic and pharmacological profile Sophora interrupta(SI) plant is explored.SI plant shows a plethora of pharmacological effects including its role in cancer treatment.17,19 as anti-ulcer. 20 anthelmintic.17 hepatoprotective21 and antioxidant activity. This cumulative data shows that SI plant have a wide spectrum of therapeutic potential. Thus, the beneficial effects of individual plant extracts in STZ-induced diabetes was assessed in the present study.
2. MATERIALS AND METHODS
2.1. Collection and Authentication of Sophora interrupta Plant
Fresh leaves and bark of SI were collected from Tirumala hills, Chittoor district from the state of Andhra Pradesh. The plant materials were taxonomically identified and authenticated by Dr. MadhavaChetty, Asst. Professor, Dept. of Botany, S.V. University, Tirupathi Andhra Pradesh, India and the sample voucher specimen and herbarium have been preserved in the Dept. Of Pharmacognosy, Luqman College of Pharmacy Gulbarga, Karnataka.
2.2. Preliminary phytochemical screening of SI plant extracts22,23
The phytochemical screening of leaf and bark of FD, SI and CM were carried out for the detection of alkaloids, carbohydrates, glycosides, phenolic compounds, flavonoids, protein and free amino acids, saponins, sterols, acidic compound, steroids, fixed oil and fats and terpenoids.23,24,25,26,27
2.3. Experimental animals:
Age-matched young Wistar rats weighing about 200-250 g were employed in the study. The animals have housed at approximately 24±1°C temperature and humidity of 55±5% with a 12-hour light/dark cycle. The animals were fed with a standard diet (standard chow from Ashirwad Industries, Ropar, India) and water ad libitum. The animals were acclimatized for at least 3-4 days before the initiation of the experiment and were observed for any sign of disease. The animals were maintained under proper conditions throughout the study. The experimental protocol was approved by the Institutional Animal’s Ethics Committee. The animals were sacrificed after a predetermined period of the treatment as per the study design to evaluate various parameters.
2.4. Acute toxicity study
Acute toxicity includes the effects of a single dose of a chemical/substance (or several doses within a 24-hour period) on the whole body, usually manifested over a period of 14 days. In the current study, acute toxicity of plant extracts were as per Organisation for Economic Co-operation and Development (OECD) guidelines. Acute toxicity study was performed in accordance with OECD guidelines 425.28 No adverse effect or mortality was detected in albino rats up to 3 gm/kg, per oral of extracts during the 24 to 72 hr observation periods. For this period the rats were continuously observed for 5 hr for any gross behavioral, neurological or autonomic toxic effect and lethal Fly after 24 to 72 hrs.
2.5. Induction of diabetes
Animals were injected with a single dose of streptozotocin (STZ; 65 mg/kg, i.p.) prepared in fresh citrate buffer (pH 4.5). The development of diabetes was confirmed after 72 h of the STZ injection. The animals having fasting blood glucose levels of more than 250 mg/dL were selected for the study.29
2.6. Experimental Protocol
Experimental animals were divided into five different groups (eight animals each). The plant extracts were evaluated for their antidiabetic effect at doses of 500 mg/kg per oral (p.o.) and glipizide (4 mg/kg, p.o.).
Group I (Untreated normal control rats): Normal control rats received only a normal diet and water during the experimental period but without any therapy.
Group ll (Plant extract-treated normal rats): Normal rats treated with a single dose of aqueous extract of SI orally at a dose of 500 mg/ kg daily one time, for 14 consecutive days.
Group III (Diabetic control rats): Rats of this group were STZ-induced diabetic models and were served as diabetic controls throughout the experimental period but without any therapy.
Group IV, V, VI (Plant extract treated diabetic rats): Diabetic models of rats treated with a single dose of aqueous extract of SI orally at a dose of 100, 200, 500 mg/kg daily one time, for 14 consecutive days.
Group VII (Glipizide Treated Diabetic Group): The diabetic rats after 1 week of STZ administration were treated with glipizide (4 mg/kg, p.o.) for 2 weeks.
2.7. Estimation of body weight
The body weight of each animal was measured before induction of STZ and periodically till the end of the study.
2.8. Biochemical estimation:
Blood samples were collected (under light anesthesia) by retro-orbital puncture method after overnight fasting and analyzed for Blood glucose level, lipid profile [Serum total cholesterol (TC), triglycerides (TG), low-density lipoproteins (LDL), very-low-density lipoproteins (VLDL) and high-density lipoproteins (HDL)]. Biochemical estimation was carried out using available laboratory kits of Erba Diagnostics Pvt. Ltd.
2.8.1 Estimation of serum glucose
Blood glucose level was estimated after 72 hours of STZ administration to confirm diabetes. Fasting blood glucose level was estimated on the 0th day, the 30th day and the 75th day.
2.8.2. Assessment of Blood lipid profile
The total cholesterol was estimated by cholesterol oxidase peroxidase
CHOD-POD (cholesterol oxidase-peroxidase) method (30) and serum triglyceride was estimated by glycerophosphate oxidase peroxidase GOD-POD method (31). The HDL was assayed by cholesterol oxidase peroxidase CHOD-POD method using manufacturer kit (30). Serum VLDL and LDL concentrations were calculated according to the Friedewald equation (Frideewald & wt, 1972).
LDL cholesterol = Total cholesterol (TC) – High-density lipoprotein (HDL) -Triglycerides (TG)/5.
2.8.3. Assessment of oxidative stress in serum samples
The oxidative and antioxidant parameters in serum samples were assessed by estimating TBARS (thiobarbituric acid reactive substance), GSH (glutathione), CAT (catalase) and SOD (superoxide dismutase) levels.Lipid peroxidation was determined by TBARS concentrations, which was spectrophotometrically measured at 532 nm(33). SOD and GSH-Px levels were determined using kits. SOD activity was measured by the method of Misra andFridovich(34). The GSH level was estimated using the methods described by Ellman(35). A standard curve was plotted using the reduced form of glutathione (0.1–1 mM), and the results were expressed as mM/g protein. Serum CAT activity was assayed using the Spectrophotometric method (36) at 620 nm and expressed as micromoles of hydrogen peroxide decomposed/min/milligram protein.
2.9. Statistical Analysis
Data were presented as mean± S.EM. For continuous variables, a student t-test was used to differentiate the mean difference. For comparison between more than 2 groups, the data were processed by one-way analysis of variance (ANOVA) followed by Dunnett’s post hoc test. *p < 0.05 was considered significant. Statistical analysis was performed using SPSS version 21.
3. Results
3.1 Preliminary Phytochemical screening in the leaves and barks extracts of SI Plant
Preliminary phytochemical screening of the crude, 1:10 and 1:100 extracts of all the four solvents (n-hexane, chloroform, ethanol and water) was performed in order to characterize the classes of compounds that are present in the leaf and bark of SI plant (Table 1). This qualitative screening included the tests were performed using reference methods (37,38). The results of the phytochemical screening revealed that all the bark and leaf extracts of the plant showed the presence of flavonoids, Saponins, steroids, alkaloids, tannins, phenolic compounds, triterpenoids and carbohydrates. All four extracts were found positive for alkaloids, flavonoids, phenols tannins, carbohydrates, saponins, cardiogylcoside and proteins. On the other hand, steroids and Anthraquinones are not present in either of the extracts. Moreover, ethanolic extract of leaf of SI (ELESI), aqueous extract of leaf of SI (WELSI), ethanolic extract of bark of SI (EBESI) and aqueous extract of bark of SI (WEBSI) found richer in these phytoconstituents as compared to hexane and chloroform extracts. Glycosides, anthraquinones, and reducing sugars are not present in either of the extract.
Note: “+++” indicates positive (Most Abundance), “++” indicates positive (Moderately present), “+” slightly positive, “–” completely absent.
3.2. Quantitative estimation of total phenolic, flavonoids and tannin content in the leaf and bark extracts of FD, SI and CM plants
The results for the total phenol, tannin and flavonoid estimation of all four extracts of SI are tabulated in table 2. The total phenolic, tannin and flavonoids content of n-hexane, Chloroform, ethanol and aqueous extracts in SI leaf part was ranged from 1.5 -27.5, 1.8-2.7 and 2.3-29.2 g GAE/100 g extract and in bark part was ranged from 3.2 -32.1, 2.6-3.4 and 3.1-35.3 g GAE/100 g extract respectively.
Values are mean of 3 replicate determinations + SD. GAE- Gallic acid equivalent, RE- rutin equivalent.
3.3. Acute Toxicity Study
The acute toxicity studies of SI leaves extract was carried out as per OECD guideline no. 423. The limit test dose used for the study was 2000 mg/kg. There was no gross evidence of any abnormality observed up to a period of 4-6 hrs or mortality up to a period of 24hrs at the maximum tolerated dose level of 2000 mg/kg body weight p.o. Results demonstrated that animals did not display any drug-related changes in behavior, breathing, skin effects, water consumption, and impairment in food intake, temperature, autonomic and neurological. Therefore, the extract seems to be safe at a dose level of 2000 mg/kg, and the LD50 was considered be >2000 mg/kg.
3.4 Effect of ethanolic leaf extract of SI (ELESI) on body weight
No difference in the initial body weight was observed in any experimental group. Two-way ANOVA revealed that STZ subjected rats gained less body weight than normal rats. After a period of 28 days of STZ, a prominent decrease in body weight was found as compared to normal rats (table 3). Higher dose of ELESI and standard drugs significantly prevent the decrease in body weight at 14 and 28 days. Lower dose treatment did not show a pronounced difference in body weight as compared to diabetic control rats.
3.5 Effect of extract on Blood Glucose level
The administration of extracts or standard treatment such as glipizide (4 mg/kg, p.o., 2 weeks) to normal rats did not produce any significant per se effects on various parameters assessed at the end of 4 weeks of treatment in the present study. Fasting blood glucose level was significantly elevated (p ? 0.05) after 3 days of STZ treatment with respect to control level. The results showed that rats in control group showed no significant change in blood glucose levels is observed at 7, 14, 21 and 28 day of experiment (table 4). No significant changes in blood glucose levels were observed after oral administration of 500 mg/kgbwt of SI in normal animals at 28 day of experiment when compared to control. However, treatment with single dose of STZ at a dose of 180 mg/kgbwt after 3 days caused significant increase (p ? 0.05) in blood glucose levels of rats. Whereas, oral administration of 100 mg/kgbwt, 200mg/kgbwt and 500mg/kgbwt of ethanolic leaf extract of SI for 28 days showed significant reduction (p?0.05) in blood glucose levels when compared to STZ treated group (Table 6). Treatment with Glipizide (4 mg/kg body weight, 4 weeks) significant decreased the glucose level at 7, 14, 21 and 28 days when compared with diabetic control rats.
Effect of extract on serum glucose. Data are mean ± SEM; Data were analyzed using one-way ANOVA followed by Tukey’s multiple test; *pEnglishhttp://ijcrr.com/abstract.php?article_id=4023http://ijcrr.com/article_html.php?did=4023
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareAssociation of Gut Microbiota with Ischemic Stroke: A Review
English7783Malhotra Jaspreet KaurEnglish Gupta ShrutiEnglish Kumari HemaEnglish Kumar KaushalendraEnglish Kumar GauravEnglishIntroduction: The gut microbiota and central nervous system (CNS) interact in a bidirectional manner. In response to physical and psychological stressors affecting secretion, motility and immune reactivity, the CNS modulates gut functioning. However, alterations in gut microbiota may cause neurochemical and behavioural changes. Cerebral stroke generates an immune and inflammatory response in the brain and various immune organs as well as affect the gut microbiota Objective: The present review paper aims to provide a comprehensive discussion on the association of gut microbiota with ischemic stroke. Methods: NCBI-PubMed database has been extensively searched to collect information regarding the gut microbiome and ischemic stroke. Results: In this paper, we discussed the gut-brain axis, regulation of intestinal γδT Cells, gut-immune response to brain injury, effect of gut microbiota on brain development, behaviour and neurotransmitters. Further, we highlight the pathways for systemic inflammatory response syndrome, Trimethylamine N-Oxide, and T regulatory cells to understand the underlying mechanism of neuronal dysfunction. Conclusion: CNS dysfunction due to ischemic insults affects gastrointestinal function through the vagus nerve signal, immune pathways, endocrine systems and neurotransmitters. The intestinal microbiota plays an imperative role in retaining metabolic homeostasis, immune system, and protection against pathogens.
EnglishGut microbiota, Ischemia, Cerebral stroke, Blood-Brain barrier, Neurotransmitters, CNSINTRODUCTION
Ischemia is the restriction of blood supply to the bodily tissues that causes a decrease in oxygen level thereby hampering cellular metabolism thus affecting cellular function and growth. A decrease in the availability of nutrients and inefficient removal of metabolic waste also leads to ischemia. The build-up of metabolic waste, mitochondrial damage and inability to maintain cell membranes may lead to tissue damage.1 Cerebrovascular accident (or stroke) are a type of brain injury resultant of lack of oxygen supply to a region of the brain due to lack of blood supply that could ultimately lead to permanent neurological deficits or even death.2 Based on the pathophysiology, brain stroke could be categorized into ischemic and hemorrhagic stroke. The cerebral ischemic stroke or cerebral ischemia accounts for 85% of all stroke occurrences rest being a hemorrhagic stroke. It was found out that the maximum number of stroke cases might be associated with behavioral factors like smoking, obesity, poor diet, and a sedentary lifestyle.3Recentstudies also suggest that altered gut microbiota could be considered as a risk factor for stroke. The gastrointestinal tract is considered as the major immune organ of the body which has the largest stock of immune cells accounting for about 70%.2 The human gastrointestinal tract is home to the dynamic and complex microbial population known as gut microbiota or gut microflora which has a marked effect on the host metabolism and maintenance of the healthy living condition of individuals.4 Multiple factors play a contributing role in the establishment of the human gut microflora since early childhood, diet being the fundamental factor throughout the life span. The intestinal microbiota plays an imperative role in retaining metabolic homeostasis, immune system, and protection against pathogens.5 The altered gut bacterial composition or microbial imbalance is known as dysbiosis has been found to have a direct association with the pathogenesis of many infections and diseases.6 The metabolites derived out of the gut-microbiota have a role in diseases like stroke and cardiovascular diseases.7 Trimethylamine N-oxide (TMAO) is a waste metabolite that is synthesized by gut microbiota which finds its association with both stroke and CVD.8 A vast difference occurs between the gut microbiome of an ischemic stroke patient and healthy individuals. However, there still lies a concern about the direct link between the patient’s intestinal flora and the brain stroke. A stroke dysbiosis index (SDI) differentiates between the microbial disparities in healthy individuals and patients.9 The GI tract tends to be a very unique system of the body due to its intrinsic nervous system, also known as the enteric nervous system; indicating an effect of the microbiota of neural and glial cells.10 The microbiota also tends to affect brain development and behaviour since gut microbiota plays a role in the maintenance of monoamine neurotransmitters levels.11The blood-brain barrier is responsible for proper maintenance of the functioning of neurons, a change in the gut microbiota could bring about an alteration in permeability of BBB.12 Gut microbiota holds the ability to synthesize the neurotransmitters and tend to play a mediating role in the interaction with the nervous system.13
Due to the high socioeconomic burden of ischemic stroke and its pathological consequences in enduring subjects, understanding the pathophysiology and association of ischemic stroke with dysbiosis is a major priority for neurological dysfunction research. The present review work provides a comprehensive discussion of the microbiota, gut-brain axis, regulation of intestinal γδT Cells, gut-immune response to brain injury, the effect of gut microbiota on brain development and behavior as well as on neurotransmitters.
MICROBIOTA-GUT-BRAIN AXIS
A bidirectional communication exists between the brain and the gut and its diverse microbiota which is referred to as the microbiota-gut-brain axis (Fig. 1). The signals are interchanged between the brain and the gut via both neuronal and non-neuronal mechanisms. The brain to gut signaling also called top-down signaling, the gut receives a neuronal signal via the parasympathetic and sympathetic nervous system. These neuronal signals are responsible for gut permeability, gut motility, immune cell activation, and microbiota composition.14
The gut to brain signaling also called bottom-up signaling occurs via several different processes. Firstly, the vagus nerve plays a dual role in transmitting signals between the gut and the brain. The vagus nerve is braced by the microbial compounds, hormones (like serotonin, peptide YY), and metabolites as illustrated in fig. 2. This results in stimulating hypothalamic neurons that are responsible for the regulation of pituitary secretions. Secondly, immunogenic endotoxins like lipopolysaccharide (LPS) from the microbiota can prompt neuroinflammation directly or via peripheral immune cell activation that can migrate to the brain. Lastly, the microbiota induced release of neurotransmitters, short-chain fatty acids, and bile compounds that enter the blood-brain barrier (BBB) through a systemic blood circulatory system.14This entire top-down and bottom-up signaling is a complex process cycle inclusive of the immune cells and neuronal signaling (fig. 2). Table 1 represents a few microorganisms that have a pathophysiological effect on the body that results in ischemic stroke. The vagus nerve, stress hormones, and the neurotransmitters are responsible to establish a communication link between the gut microbiota and the central nervous system that produces an effect on CNS thus playing a role in its functioning and leading to the problem like a stroke under certain circumstances.
BRAIN-GUT AXIS AFTER STROKE
The predominant reason for ischemic stroke in the middle cerebral occlusion which is marked by inflammation and immune response. The treatment strategy involves the following - a) Thrombolysis by intravenous administration of plasminogen activator and; b) Thrombectomy to remove blood clot physically. With a restriction of the therapeutic window of 4.5 hrs.after the onset of the stroke. It is followed by many pathological events that are triggered by brain ischemia after recanalization and reperfusion, so-termed as ischemia-reperfusion injury. The two major problems are the prolongation of the therapeutic window of thrombolysis and endovascular thrombectomy and the development of treatment of tissue ischemia-reperfusion injury; which when solved would act as an effective treatment of ischemic stroke.17
The gut microbiome and the immune system has said to be coevolved and the interaction among them is required to keep animals and humans healthy. Dysbiosis generally leads to disparity in the T-cell population that triggers several autoimmune and inflammatory disorders. Th1 cells secrete pro-inflammatory cytokines IL-2, IL-12, TNF-α, and INF-γ to promote cellular immune response making it involved in the pathogenesis of stroke.18 Th-2 promotes a humoral response against allergens and parasites. The IL-17 produced by γδ T-cells doesn't require antigen to produce an immune response thus it is more rapid.17 The γδT-cells are abundant in the gut from where they cluster at the leptomeninges structure of the brain post-stroke.19An absence of Treg cells increases the post-stroke activation of the inflammatory cells including T-cells and microglia which ultimately indicates Treg cells play an evident role in dampening post-ischemic inflammation.20 Treg smothers the differentiation of Th17 and proliferation of γδT-cells in the gut so to maintain an anti-inflammatory environment. Various cells and their significance in the stroke are illustrated in Table 2.17
The gastrointestinal tract is a very unique system of the body due to the presence of its intrinsic nervous system, referred to as the enteric nervous system (ENS); which is made of an outer myenteric plexus and the inner submucosal plexus. The ENS plays an important role in gastrointestinal motility, adsorption, fluid secretion, and blood flow.10 A study showed that in rodents enteric neurons are largely formed during embryogenesis and in early postnatal life. During which, a minute population of Sox10-expressing neural crest-derived cells colonize the foregut and ultimately undergo multiplication to colonize the entire bowel thus forming to glial cells and neurons.21,22 A major percentage of the body's serotonin is produced by enterochromaffin cells (EC), a type of enteroendocrine cells located in the gut epithelium. It has been recorded that gut microbiota can induce the secretion of serotonin in the gut.23 The fact that mucosal and neuronal serotonin are different pools that are supported by different forms of rate-limiting enzymes tryptophan hydroxylase, which is used by neuronal and non-neuronal cells, with tryptophan hydroxylase (TPH) 2 used by neurons while TPH1 is used by EC cells.24 The activation of serotonin in ENS produces a neurogenerative and neuroprotective action.
Systematic inflammatory response syndrome after stroke
Damaged tissue after the stroke release inflammatory molecules and cellular debris, called the Damage-associated molecular patterns (DAMPs). These DAMPs hold a crucial role in the initiation of an inflammatory and immune response through pattern-recognition receptors (PRRs) like Toll-like receptors (TLR). This type of immune response is also called sterile inflammation.17 DAMPs along with cytokines are produced by brain ischemic tissues are released in circulation to reach the lymphoid or immune organs. This is a severe form resulting in systemic inflammatory response syndrome (SIRS). DAMP molecules come into the systemic circulation through the broken BBB and initiate SIRS after the stroke. This is accompanied by leaky gut post-stroke. This marks the initiation of systemic inflammation that begins with the innate immune response (mediated by innate immune cells neutrophils, microglia, macrophages and innate lymphocytes like γδT cells), to which follows the activation of adaptive immune cells after the stroke (mediated by T and B lymphocytes) 25 26as explained in fig. 3
GUT-IMMUNE RESPONSE TO BRAIN INJURY
The gastrointestinal tract is constituted by a wide range of pathogenic and commensal microorganisms. The intestinal lumen commensal flora, the mucosal immune system, and the epithelial immune system together constitute the GI. The GI has an efficient mucosal barrier and a multi-dimensional immune system consisting of scattered immune cells and lymphoid tissues called the gut-associated lymphoid tissues to protect pathogenic microorganisms and dietary antigens.17 27
The divulge of lumen bacteria and the toxins from the intestine into the circulation due to an increase in permeability or any injury, which is called the leaky-gut or sepsis depending on the severity; leads to systemic inflammation and thus serves as systemic inflammation response syndrome (SIRS).17 SIRS along with gut-lung, gut-liver, and gut-brain axis can result in multiple organ dysfunction syndromes (MODS) that could ultimately lead to death as explained in fig. 4. To restrict the invasion of toxins and gut microorganisms during the transport of nutrients, the gut has about 70% immune cells of the entire immune system along with the largest population of macrophages.17 Thus explaining how stroke finds its association with long-term multiple organ dysfunction.
The blood-brain barrier (BBB) is responsible for the maintenance of the proper functioning of neurons by controlling the passage of molecules across brain parenchyma and the blood. An experiment conducted with germ-free mice, that lacks normal gut microbiota showed an association with increased permeability of the BBB. The leakage of Evans blue dye from the vessels, use of radio-labeled ligand for in vivo Positron Emission Tomography, and damage of neurons after administration of R4A antibody confirmed this relation between increased permeability and in the lack of gut microbiota. The increased permeability of the BBB in germ-free adult mice could be because of disorganized tight junctions and reduced expression of transmembrane proteins claudin-5 and occludin. Tight junctions play a determinant role in the functional perpetuation of the BBB. The germ-free mice had a lesser amount of occludin and claudin-5 along with cytoskeletal changes and redistribution of tight junction protein altered the BBB integrity. Reduced expression of both occludin and claudin-5 is associated with increased permeability of BBB. The dispensing of normal flora from the pathogen-free mice increased the expression of occludin and claudin-5 that marked the decreased permeability of BBB. These observations direct towards the fact that the expression of occludin by the brain endothelial cells is sensitive towards the intestinal gut microbiota and its changes.12Humans show marked changes in their gut microbiota during the first and the third trimester of the pregnancy.28 Also, there is the permeability of embryonic BBB to maternal antibody.12 All these observations lead to an inference about the contribution of maternal gut microbiota to increased nutritional demand during the later stages of pregnancy that would require demanding control of BBB of the growing progeny.
Role of Regulatory T-cells in ischemic stroke
Treg cells are the type of lymphocytes finding their significance in immune homeostasis, suppression of extra immune response, and maintaining the immunological self-tolerance.29 A loss of Treg cells is considered to be the main cause of autoimmune disorders.30, 32The Treg cells can induce cytolysis of T cells in a granzyme-mediated manner and can also inhibit the T effector cell function through negative signals. Studies suggest that the number of circulating Treg cell fall drastically in the second day after the stroke onset, which is followed by an increase on the 7th day which sustains till the 3rd week.29 Treg cells also tend to cause an addition to the ischemic stroke via microvascular dysfunction and also tend to compromise the neurological function recovery. Thus influencing the stroke and its outcomes and also modulating the immune system.29 Inflammation is the major element in the pathophysiology of cerebral ischemia. The innate and adaptive immune cells play a role in the pathophysiology of stroke and play a role in secondary neurodegeneration by the release of neurotoxic factors and reactive oxygen and nitrogen species along with exopeptidases.19The paradox of T reg cells for neuroprotection& brain injury in ischemic stroke is illustrated in the fig. 5.
The positive effects
Certain studies have demonstrated that Treg cells play a valuable role in post-stroke events by stopping the secondary infarct growth in response to ischemia.29 The Treg cells tend to assert a protective mechanism by the release of the interleukin-10 cytokine (IL-10), which is an anti-inflammatory cytokine. IL-10 has a neuroprotective role and plays a role in the reduction of brain injury which is followed by artery occlusion.29 Treg also tends to confer protection against artery occlusion by slowing the rise of metalloproteinases-9 (MMP-9).29 The stroke-induced MMP-9 production leads to brain damage due to neutrophil infiltration which leads to the breakdown of the blood-brain barrier, on the contrary, Treg adoptive treatment inhibits MMP-9 production in the brain and blood within 1 day after ischemia 29 Tregshow their benedictory effect by directly acting on the peripheral immune system rather than acting on the brain tissue directly. The intestinal Treg plays a vital role in maintaining an anti-inflammatory abode in the gut by the smothering of differentiation of the T helper 17 cells and escalating the gδTcells19.
The negative effects
Studies suggest that the Treg cells could aggravate ischemic-reperfusion damage within 24 hrs of the stroke. Experimental studies have shown an increase in neuronal damage by inducing microvascular dysfunction by the Treg cells due to increased cerebral blood flow and reduced level of fibrin in the Treg-depleted mice within 24hrs after the artery occlusion thereby indicating less tissue damage. Treg cells were accumulated in the infract and the peri-infract area but couldn't cross the blood-brain barrier and were present in cerebral vessels, thereby suggesting low chances of the Treg cells to directly interacting with the parenchymal tissue and suggesting a higher probability to disrupt the microvascular structure. The post-stroke inflammation leads to tissue regeneration and repair which could be compromised due to immunosuppression caused by Treg cells.29 A regular synergy between the epithelial microbes and the immune system leads to immune system development, maintenance, and functions. Most abundant commensal microbes are found in the intestine that acts as a powerful regulator of the lymphocyte population including regulatory T cell (Treg) and gδTcells. gδTcells are located on epithelial surfaces and are responsible to aggravate brain injury by the release of IL-17.19
Relation of Trimethylamine N-Oxide with ischemic stroke
Trimethylamine N-Oxide (TMAO) is a metabolic waste product produced by gut microbiota that finds its association with stroke and cardiovascular disease. TMAO is generated through two steps. The trimethylamine (TMA) is produced from dietary nutrients like choline, L- carnitine by the gut microbiota enzyme TMA lyases. Further, in the next step, the TMA is absorbed and oxidized by hepatic flavin-containing monooxygenases (FMOs) to TMAO.8Fig. 6 shows the synthesis of TMAO and its association with ischemic stroke. The diet holds a crucial role in the formation of the TMAO. Since diet can modify the gut microbiota composition, the diet with meat, eggs, and other meat products has a high composition of phosphatidylcholine that escalates the production of TMAO. With a high-fat diet, the TMAO concentration also tends to increase in the blood.8
Few studies indicate the relation of TMAO concentration and stroke occurrence. A case-control study in a hypertensive group of the Chinese population demonstrated that a higher level of TMAO in blood marked an increased risk towards the first stroke. It was also inferred that people with low folate concentration and high TMAO concentration in blood have a higher rate of stroke. 8 31
In another case-control study on the Chinese patients with stroke and transient ischemic attack (TIA) had considerabledysbiosis of the gut microbiota, most importantly these patients showed lower plasma TMAO concentrations than control patients with asymptomatic atherosclerosis. which was explained by the fact that the treatment of stroke or TIA may have resulted in the reduction of TMAO levels.8
DISCUSSION
The gut microbiome and the immune system has said to be coevolved and the interaction among them is required to keep animals and humans healthy.The stroke-related injuries generally lead to disruption of the brain-gut axis thereby leading to the release of injury-induced DAMPs, the BBB alteration, cytokine release, leaky gut, and dysbiosis. The change in BBB after the stroke leads to increased permeability of the brain parenchyma making the entry of inflammatory and immune cells easy. The blood-brain barrier (BBB) is responsible for the maintenance of the proper functioning of neurons by controlling the passage of molecules across brain parenchyma and the blood. An experiment conducted with germ-free mice, that lacks normal gut microbiota showed an association with increased permeability of the BBB. The leakage of Evans blue dye from the vessels, use of radio-labelled ligand for in vivo Positron Emission Tomography, and damage of neurons after administration of R4A antibody confirmed this relation between increased permeability and in the lack of gut microbiota. The increased permeability of the BBB in germ-free adult mice could be because of disorganized tight junctions and reduced expression of transmembrane proteins claudin-5 and occludin. Tight junctions play a determinant role in the functional perpetuation of the BBB. The germ-free mice had a lesser amount of occludin and claudin-5 along with cytoskeletal changes and redistribution of tight junction protein altered the BBB integrity. Reduced expression of both occludin and claudin-5 is associated with increased permeability of BBB. The dispensing of normal flora from the pathogen-free mice increased the expression of occludin and claudin-5 that marked the decreased permeability of BBB. These observations direct towards the fact that the expression of occludin by the brain endothelial cells is sensitive towards the intestinal gut microbiota and its changes.12Humans show marked changes in their gut microbiota during the first and the third trimester of the pregnancy.28 Also, there is the permeability of embryonic BBB to the maternal antibodies.12 All these observations lead to an inference about the contribution of maternal gut microbiota to increased nutritional demand during the later stages of pregnancy that would require demanding control of BBB of the growing progeny.
CONCLUSION
The relationship between gut microbiota and stroke provides a promising area for research and development of control, prevention, and treatment methods for stroke. The brain-gut axis makes an important communication pathway via the vagus nerve and the neurotransmitters. This communication is essentially important for the maintenance of a healthy blood-brain barrier and also in keeping a check of behavioral activity and reducing anxiety-like responses. The role of Treg cell in ischemic stroke is also elusive that need extensive study. The exact mechanism of molecular changes during the stroke that confers a change in the brain-gut axis is still not clear. The extent to which inflammatory and immune cells change the disease progression provides a wide scope for research.
Acknowledgment: Authors are thankful to Galgotias University for providing the basic infrastructure for this work. The authors are highly grateful to Prof. Durg Vijay Rai, Former Vice-Chancellor, Shobhit University, Gangoh Saharanpur, Uttar Pradesh for the motivation and consistent encouragement during the entire review work.
Source of Funding: None
Authors’ Contribution: Malhotra Jaspreet Kaur wrote the whole manuscript; Gupta Shruti co-wrote the manuscript; Kumari Hemaand Kumar Kaushalendra co-wrote the manuscript; Kumar Gaurav provided ideas, created images and supervised the study.
Conflict of interest: None
Englishhttp://ijcrr.com/abstract.php?article_id=4024http://ijcrr.com/article_html.php?did=40241. Kalogeris T, Baines CP, Krenz M, Korthuis RJ. Ischemia/reperfusion. Compr Physiol. 2017;Dec 6;7(1):113-170.
2. Kumar G, Mukherjee S, Paliwal P, Singh S Sen, Birla H, Singh SP, et al. Neuroprotective effect of chlorogenic acid in global cerebral ischemia-reperfusion rat model. Naunyn Schmiedebergs Arch Pharmacol. 2019;Oct;392(10):1293-1309.
3. Boehme AK, Esenwa C, Elkind MSV. Stroke Risk Factors, Genetics, and Prevention. Circ. Res. 2017.120:472–495
4. Li N, Weng X, Sun C, Wu X, Lu M, Si Y, et al. Change of intestinal microbiota in cerebral ischemic stroke patients. BMC Microbiol. 2019;19: 191
5. Belkaid Y, Harrison OJ. Homeostatic Immunity and the Microbiota. Immunity. 2017.Apr 18; 46(4): 562–576.
6. Thursby E, Juge N. Introduction to the human gut microbiota. Biochem J. 2017.474 (11): 1823–1836
7. Tang WHW, Kitai T, Hazen SL. Gut microbiota in cardiovascular health and disease. Circ. Res. 2017.Mar 31;120(7):1183-1196.
8. Nam HS. Gut microbiota and ischemic stroke: The role of trimethylamine N-oxide. Stroke J. 2019.May; 21(2): 151–159
9. Xia GH, You C, Gao XX, Zeng XL, Zhu JJ, Xu KY, et al. Stroke dysbiosis index (SDI) in gut microbiome are associated with brain injury and prognosis of stroke. Front. Neurol. 10:397. doi: 10.3389/fneur.2019.00397
10. De Vadder F, Grasset E, Holm LM, Karsenty G, Macpherson AJ, Olofsson LE, et al. Gut microbiota regulates maturation of the adult enteric nervous system via enteric serotonin networks. PNAS June 19, 2018 115 (25): 6458-6463
11. Heijtz RD, Wang S, Anuar F, Qian Y, Björkholm B, Samuelsson A, et al. Normal gut microbiota modulates brain development and behavior. PNAS February 15, 2011 108 (7) 3047-3052;
12. Braniste V, Al-Asmakh M, Kowal C, Anuar F, Abbaspour A, Tóth M, et al. The gut microbiota influences blood-brain barrier permeability in mice. Sci Transl Med. 2014 6: 263RA158
13. Strandwitz P. Neurotransmitter modulation by the gut microbiota. Brain Research. 2018.Aug 15; 1693(Pt B): 128–133.
14. Durgan DJ, Lee J, McCullough LD, Bryan RM. Examining the Role of the Microbiota-Gut-Brain Axis in Stroke. Stroke. 2019.50:2270–2277
15. Winek K, Dirnagl U, Meisel A. Role of the Gut Microbiota in Ischemic Stroke. Neurol Int Open. 20171: E287–E293
16. Koren O, Spor A, Felin J, Fåk F, Stombaugh J, Tremaroli V, et al. Human oral, gut, and plaque microbiota in patients with atherosclerosis. PNAS March 15, 2011 108 (Supplement 1) 4592-4598
17. Arya A, Hu B. Brain–gut axis after stroke. Brain Circ. 2018 Oct-Dec; 4(4): 165–173
18. Pawluk H, Wo?niak A, Grze?k G, Ko?odziejska R, Kozakiewicz M, Kopkowska E, et al. The role of selected pro-inflammatory cytokines in pathogenesis of ischemic stroke. Clinical Interventions in Aging. 2020.15: 469–484.
19. Benakis C, Brea D, Caballero S, Faraco G, Moore J, Murphy M, et al. Commensal microbiota affects ischemic stroke outcome by regulating intestinal γδ T cells. Nat Med. 2016May;22(5):516-23.
20. Liesz A, Suri-Payer E, Veltkamp C, Doerr H, Sommer C, Rivest S, et al. Regulatory T cells are key cerebroprotective immunomodulators in acute experimental stroke. Nat Med. 2009Feb;15(2):192-9.
21. Wang X, Chan AKK, Sham MH, Burns AJ, Chan WY. Analysis of the sacral neural crest cell contribution to the hindgut enteric nervous system in the mouse embryo. Gastroenterology. 2011Sep;141(3):992-1002.e1-6.
22. Memic F, Knoflach V, Morarach K, Sadler R, Laranjeira C, Hjerling-Leffler J, et al. Transcription and Signaling Regulators in Developing Neuronal Subtypes of Mouse and Human Enteric Nervous System. Gastroenterology. 2018Feb;154(3):624-636.
23. Yano JM, Yu K, Donaldson GP, Shastri GG, Ann P, Ma L, et al. Indigenous bacteria from the gut microbiota regulate host serotonin biosynthesis. Cell. 2015Apr 9; 161(2): 264–276.
24. Spohn SN, Mawe GM. Non-conventional features of peripheral serotonin signaling-the gut and beyond. Nature Reviews Gastroenterology and Hepatology. 2017Jul;14(7):412-420.
25. Boehme AK, Kapoor N, Albright KC, Lyerly MJ, Rawal P V., Bavarsad Shahripour R, et al. Predictors of systemic inflammatory response syndrome in ischemic stroke undergoing systemic thrombolysis with intravenous tissue plasminogen activator. J Stroke Cerebrovasc Dis. 2014Apr;23(4):e271-6.
26. Vourc’h M, Roquilly A, Asehnoune K. Trauma-induced damage-associated molecular patterns-mediated remote organ injury and immunosuppression in the acutely Ill patient. Front. Immunol. 9:1330. doi: 10.3389/fimmu.2018.01330
27. Ahluwalia B, Magnusson MK, Öhman L. Mucosal immune system of the gastrointestinal tract: maintaining a balance between the good and the bad. Scand J Gastroent. 201752:11, 1185-1193
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29. Xu X, Li M, Jiang Y. The paradox role of regulatory T cells in ischemic stroke. Sci World J. 201310.1155/2013/174373
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareCustomized Gingival Retraction Cord using Additive Manufacturing: A Novel Technique
English8487A. HemavardhiniEnglish V. Vidyashree NandiniEnglish Mathivathani S PEnglish Shiney BoruahEnglishEnglish Impression making, Finish line, Marginal discrepancy, Gingival retraction, 3D printing, Polyurethane materialINTRODUCTION:
The success of fixed dental prostheses depends on various factors like selection of material, ideal design, the technique of impression and maintenance of proper oral hygiene. The accurate finish line geometry plays a major role in the survival of the restoration. This will be accomplished by proper retraction of the gingival tissue surrounding the prepared tooth. The retraction of gingiva is a method of deflecting the gingival tissues away from the tooth and helps in proper recording of finish line of the abutment. Retraction of the gingiva will produce horizontal and vertical space around the prepared finish line facilitating ample of space for the introduction of impression material.1 The precise recording of the finish line geometry will achieve good marginal adaptation along with better durability as well as the success of the restoration. The gingival displacement technique has been categorized as, chemical, mechanical, surgical and a combination of the above.2 Most commonly employed technique is a chemico-mechanical method, in which retraction cords are used with hemostatic agent2,3In mechanical or chemical-mechanical method the implementation of retraction cord on the prepared tooth is well known in practice compared with rotary gingival curettage and electrosurgery because of the irrelative predictability, success, and safety.4 In order to achieve effective gingival displacement, a cord of adequate thickness can be used to retract the gingiva so that sufficient amount of impression material can be introduced in to the gingival sulcus. The larger diameter cord that causes minimal trauma while placing in the gingival sulcus should be used. A common error of inexperienced dental practitioners is using a small diameter gingival cord. Although these cords cause less trauma, they do not provide sufficient gingival displacement of the gingival tissues.5Redesigning the retraction cord and application of the minimum force can easily over the drawbacks of using the retraction cord technique.
The main aim of the technique is to fabricate a customized mechanical gingival retraction cord for abutment tooth by 3D printing technology which acts as an alternative to the conventional mechanical gingival retraction method. Various dental products are fabricated by Additive manufacturing which acts as a potentially useful technique. Of the various 3D printing technology available, the Fused deposition modeling printer is a robotic glue gun; an extruder moves over a stationary platform or vise versa.6 The software slices objects into various layers and transfers the coordinates to the printer. Thermoplastic materials must be used. Biodegradable polymer polylactic acid is the most commonly used material. Similar materials have also been used as scaffold structures for ‘bioprinting.7Thermoplastic polyurethane is widely made available as biomaterials in the field of medical science for fabricating various medical devices.
The Gingival cuff designed here is a customized 3D printed one using thermoplastic polyurethane material to facilitate a simple, inexpensive and easy gingival retraction method without damaging the surrounding gingival tissue.
The proposed technique was approved by the Institutional Scientific and Ethical Review Board and prior approval was procured before the commencement of the study (IEC approval:1475/IEC/2018).
TECHNIQUE:
1. Measure and record the dimension of the gingival sulcus of the tooth to be prepared using William’s Periodontal Probe by inserting it parallel to the long axis of the tooth and move along the tooth. The sulcus depth is measured from the deepest point of penetration to the free gingival margin. (FIG-1)
2. Obtain upper and lower diagnostic impression.
3. Measure the bucco-lingual and mesio-distal width of the tooth to be prepared from diagnostic cast of the patient using digital Vernier calliper.(FIG-2,3)
4. The recorded measurements are loaded in the CAD designing software (CATIA V5-[Part1.CATPart]) (FIG-4).The CAD designing of the gingival cuff is done with the following measurement :
The Inner diameter of the cuff: Mesiodistal and labiolingual diameter of the tooth
The height of the cuff: Gingival sulcular depth of respective tooth
The angulation for the outside slanter: 2o
Finally, which makes it a shape sketch design.
5. Print the retraction cord in the 3D printing machine (Ultimakersophie, Model no. ULTIMAKER 3P03, Brand-IMIK, Utrecht Netherlands.) using 0.2mm nozzle size and material used being thermoplastic polyurethane material. (FIG-5,6)
6. After tooth preparation, insert the customized gingival retraction cord using a cord packer, tack the cord in the sulcus from the mesial side of the tooth to distal crevice and retain it in the sulcus for 3-4min.(FIG-7)
7.The 3D printed cord is removed from the gingival sulcus and an elastomeric impression is obtained.
In comparison with the existing commercial gingival retraction cords this customized gingival retraction cord by 3d printing technology is advantageous in terms of time, manipulation of gingival tissue, controlling of bleeding and is very cost-effective. It even controls the thickness of the cord, so that it can deliver a constant amount of force on to the gingival tissue.
Discussion:
The purpose of this technique was to analyse the impact of the gingival displacement on the marginal fit of a restoration. A properly fit restoration prevents the damage of the periodontium.3Gingival tissues are sensitive to mechanical or chemical trauma.8 The main drawback of the chemical-mechanical method is the rapid collapse of sulcus after removal which prevent accurate impression making, Trauma to epithelial attachment, is Time-consuming, Risk of sulcus contamination, Painful.1In the conventional method, the amount of displacement takes time and most of the time it leads to trauma of the gingival tissue because the operator is not aware of the sulcular anatomy. Many studies have described the use of knitted or braided, impregnated or unimpregnated strings or fibers of different materials as a mechanical gingival displacement method.4The unique knitted design of the retraction cord can exert a gentle, constant outward force following placement, and as the knitted loops try to open, it dilates the free gingival margin.9Some of the drawbacks reported can be listed as the traumatic injury to the gingival tissue by slippage of the instrument or excessive packing force during packing eventually resulting in gingival recession. Mechanical compression built up in the sulcular area limits the GCF flow but once the cord is removed rebound increase in GCF flow can occur compromising moisture control. In this technique the sulcular anatomy is pre-measured and based on the readings the 3D cuff is designed digitally and fabricated to occupy the exact form and shape of the gingival sulcus. This will prevent compression and trauma to the gingival tissue thereby helps in achieving the desired displacement aiding in finish line exposure. Additive manufacturing or 3d printing according to the American Society for Testing and Materials (ASTM) is the process of joining materials to make objects from 3D model data, usually layer upon layer, as opposed to subtractive manufacturing methodologies.6The material used thermoplastic polyurethane, is a biocompatible material with good abrasion resistance and tear resistance, so the chances of tearing during placing it into the sulcus is less and it is cost effective.10 Thermoplastic polyurethane (TPU) are linear, segmented block copolymers with excellent properties such as durability, flexibility, elasticity, biostability fatigue resistant, and insulating properties. These polyurethanes have a vital role in developing many medical devices such as catheters, endotracheal tubes, blood bags, drug delivery vehicles, heart pacemakers connectors, orthopedic splints, vascular grafts and patches.11 Because of non-thrombogenic characteristics polyurethanes are used in cardiovascular areas.12 TPU comprises of hard and soft segments.13Diisocyanide and short-chain extender molecules like diols or diamines are used to manufacture the hard segments. The high interchain interactiveness of hard segments is due to the hydrogen bonds and even acts as reinforcing fillers for the soft matrix. On the contrary, soft segments which have long, linear flexible polyether or polyester facilitates the interconnecting of two hard segments. Hard segments differ from soft segments in terms of rigidity and polarity.14 TPU is a biocompatible material with good abrasion performance; high tear propagation resistance; high damping power; and high resistance to oils, fats, and many solvents.15
Limitations of the study:
The amount of gingival retraction obtained is not quantified.
It requires an in-office 3D printer.
The incorporation of hemostatic agents can be employed in future studies.
Conclusion :
This article described a customize gingival retraction cord fabricated using 3D printing technology which aids as an alternative to the conventional gingival retraction method with improved properties in term of feasibility and compatibility. The gingival retraction technique is easy and safe to use. Thus, the newly advanced technique have been found to be cost-effective and even controls the thickness of the cord, so that it can deliver a constant amount of force onto the gingival tissue.
Conflict of interest:
No potential conflict of interest with respect to the research, authorship and/or publication of this article.
Funding:
No financial support received for the research, authorship and/or publication of this article.
Acknowledgement:
The authors acknowledge the support provided by Mr. Kalaiselvan for printing the retraction cords
Englishhttp://ijcrr.com/abstract.php?article_id=4025http://ijcrr.com/article_html.php?did=4025
Safari S, Vossoghisheshkalani Ma ,Vossoghi Sheshkalani Mi, Hoseinni Ghavam F, Hamedi M. Gingival Retraction Methods for Fabrication of Fixed Partial Denture: Literature Review. J Dent Biomater. 2016;3(2):205-213.
Phatale S, Marawar PP, Byakod G, Lagdive SB, Kalburge JV. Effect of retraction materials on gingival health: A histopathological study. J Indian SocPeriodontol. 2010;14(1):35-39.
Wostmann B, Rehmann P, Trost D, Balkenhol M. Effect of different retraction and impression techniques on the marginal fit of crowns. J Dent. 2008;36(7):508-512.
Anupam P, Namratha N, Vibha S, Anandakrishna GN, Shally K, Singh A. Efficacy of two gingival retraction systems on lateral gingival displacement: A prospective clinical study. J Oral BiolCraniofac Res. 2013;3(2):68-72.
Donovan TE, Chee WW. Current concepts in gingival displacement. Dent Clin North Am. 2004;48(2): 433-444.
GaliSivaranjani, Sirsi Sharad. 3d printing: the future technology in prosthodontics. J Dental and Oro-facial Res. 2015; 11(1):37-40.
Dawood A, Marti Marti B, Sauret-Jackson V, Darwood A. 3D printing in dentistry. Br Dent J. 2015;219(11):521-529.
Prasad KD, Hegde C, Agrawal G, Shetty M. Gingival displacement in prosthodontics: A critical review of existing methods. J Interdiscip Dentistry 2011;1:80-86.
Huang C, Somar M, Li K, Mohadeb JVN. Efficiency of Cordless Versus Cord Techniques of Gingival Retraction: A Systematic Review. J Prosthodont. 2017;26(3):177-185.
Akindoyo JO, Beg MDH, Ghazali S, Islam MR, Jeyaratnam N, Yuvaraj AR. Polyurethane types, synthesis and applications – a review. RSC Adv. 2016;6(115):114453-114482.
Joseph J, Patel R.M, Wenham A, Smith J.R. Biomedical applications of polyurethane materials and coatings. Trans IMF.2018; 96(3):121-129.
Burke A, Hasirci N. Polyurethanes in biomedical applications. Adv Exp Med Biol. 2004;553:83-101.
OsmanAzlinFazlina, Martin Darren James. Thermoplastic Polyurethane (TPU) / Organo- fluoromicaNanocomposites for Biomedical Applications: In Vitro Fatigue Properties, IOP Conf. Series: Materials Science and Engineering. 2019;701-709.
Dicesare P, Fox WM, Hill MJ, Krishnan GR, Yang S, Sarkar D. Cell-material interactions on biphasic polyurethane matrix. J Biomed Mater Res A. 2013;101(8):2151-2163.
Pucci A.Smart and Modern Thermoplastic Polymer Materials. Polymers (Basel). 2018;10(11):1211-1213.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareA Study of Pro Brain Natriuretic Peptide (PRO BNP) Levels in Asymptomatic Subjects with Type 2 Diabetes Mellitus
English8893Ashutosh Arun BandgarEnglish Virendra Chandrashekhar PatilEnglishIntroduction: Brain natriuretic peptide (BNP) is a thirty two-amino acid peptide. It is synthesized mainly in the left ventricle of the heart as a 108 amino acid prohormone pre-pro BNP (γ-BNP). Objectives: To measure pro Brain Natriuretic Peptide (pro-BNP) levels in subjects with Type 2 Diabetes mellitus. Methods: That we have used for the present study prospective, observational, non-interventional cohort study done in patients admitted in Krishna Hospital and Medical Research Centre, Karad with the diagnosis of Type 2 Diabetes Mellitus. Results: We have seen the Distribution of pulse rate, blood pressure, blood sugar, serum HbA1c and serum creatinine, Distribution of serum lipids, serum pro BNP and Left ventricular ejection fraction (LVEF) in the study population. Conclusion: The measurement of pro BNP level in a patient with type 2 diabetes mellitus will be valuable for early prediction of heart failure and its outcome.
EnglishPro Brain Natriuretic Peptide, Type 2 Diabetes Mellitus, Pulse Rate, Blood PressureINTRODUCTION:
Diabetes mellitus is one of the leading causes of morbidity and mortality globally. The development of diabetes mellitus requires corresponding amendments in the therapy and identification of the disease severity is therefore important for predicting prognosis, treatment, preventing complications, reducing complications and mortality.1 Brain natriuretic peptide (BNP) is a thirty-two-amino acid peptide. It is synthesized mainly in the left ventricle of the heart as a 108 amino acid prohormone pre-pro BNP (γ-BNP). The hormone is an effective vasodilator and a natriuretic factor regulating salt and water homeostasis in the body. It is stored in the human cardiac tissue predominantly as BNP-32 with a smaller amount of the precursor pre-pro BNP. The circulating plasma forms of BNP are BNP-32 and the NH2-terminal portion pro-BNP (Nt-pro BNP). It is an easy measure for the assessment of cardiac function. As a response to myocardial wall stretch, pre-pro BNP is synthesized and processed to pro BNP; which is further processed to the biologically inactive NT-pro BNP fragment and the biologically active BNP fragment. These measurements can be useful for diagnosing heart failure, including left ventricular diastolic dysfunction and left ventricular diastolic dysfunction.
Relation between pro BNP and blood pressure
Anuva Mishra et al. observed that the mean systolic blood pressure (SBP) among his study population was 128.2±9.8 mm Hg and had a weak +VE correlation with the pro BNP levels (‘p’=0.46) whereas the mean DBP among them was 82±7.8 mm Hg and had a weak +VE correlation with pro BNP level (‘p’=0.56). A study conducted by Sasaki N et al, observed a strong +VE correlation of SBP and pro-BNP (‘p’Englishhttp://ijcrr.com/abstract.php?article_id=4026http://ijcrr.com/article_html.php?did=40261. Kenny HC, Abel ED. Heart failure in type 2 diabetes mellitus: impact of glucose-lowering agents, heart failure therapies, and novel therapeutic strategies. Circ Res. 2019 Jan 4;124(1):121-41.
2. Mishra A, Bhanja SS. An Interrelationship between Nt Pro-Bnp Level, Glycemic Control And Myocardial Ischemia in Type 2 Diabetes Without Overt Cardiac Disease. IOSR j. biotechnol. Biochem. 2018;4(2): 2455-2458
3. Sasaki N, Yamamoto H, Ozono R, Fujiwara S, Kihara Y. Association of N-Terminal Pro B-Type Natriuretic Peptide With Blood Pressure and Pulse Pressure in Elderly People?- A Cross-Sectional Population Study. Circ J. 2018;82(5):2049-2054.
4. Masugata, Hisashi, Senda, Shoichi, Inukai, Michio, Himoto, Takashi, Hosomi, Naohisa, et al. Analysis of association between brain natriuretic peptide levels and blood pressure variability. Exp Ther Med. 2014;8(4):21-24.
5. Hamano K, Nakadaira I, Suzuki J, Gonai M. N-terminal fragment of probrain natriuretic peptide is associated with diabetes microvascular complications in type 2 diabetes .Vasc Health Risk Manag. 2014;10(10):585-589.
6. Gaede, Peter , Hildebrandt, P , Hess, G , Par,ing, H.-H , Pedersen, Oluf. Plasma N-terminal pro-brain natriuretic peptide as a major risk marker for cardiovascular disease in patients with Type 2 diabetes and microalbuminuria. Diabetologia. 2006;48(10). 156-63.
7. Bertoni AG, Hundley WG, Massing MW, Bonds DE, Burke GL, Goff DC Jr. Heart failure prevalence, incidence, and mortality in the elderly with diabetes. Diabetes Care. 2004 ;27(3):699-703.
8. Belagavi AC, Rao M, Pillai AY, Srihari US. Correlation with NT proBNP and left ventricular ejection fraction in elderly patients presenting to emergency department with dyspnoea. Indian Heart J. 2012;64(3):302-304.
9. Dal K, Ata N, Yavuz B, Sen O, Deveci OS, Aksoz Z, et al. The relationship between glycemic control and BNP levels in diabetic patients. Cardiol J. 2014;21(3):252-6.
10. Sahu Ashok , Gupta T, Kavishwar, A, Sarkar PD, R.K.Singh. Diagnostic Role of NT Pro BNP in Diabetes Type 2 Patients Associated with Cardiovascular Disease Risk, A Study from Central India. J Med. 2010;11(1):33-38
11. Rosiak M, Postula M, Kaplon-Cieslicka A, Trzepla E, Czlonkowski A, Filipiak KJ, Opolski G. Metformin treatment may be associated with decreased levels of NT-proBNP in patients with type 2 diabetes. Adv Med Sci. 2013;58(2):362-8.
12 Carsten Tscho¨pe, Mario Kas?ner, Dirk Westermann, Regina Gaub, Wolfgang C. Poller, Heinz-Peter Schultheiss. The role of NT-proBNP in the diagnostics of isolated diastolic dysfunction: correlation with echocardiographic and invasive measurements. European Heart J. 2005;26(6), 2277–2284
13. Tschöpe C, Kašner M, Westermann D, Gaub R, Poller WC, Schultheiss HP. The role of NT-proBNP in the diagnostics of isolated diastolic dysfunction: correlation with echocardiographic and invasive measurements. Eur Heart J. 26(21), 2277-2284.
14 Dobson M. Nature of the urine in diabetes. Medical Observation Enquiries. World J Diab .2016;7(1):1-7
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareComparative Study on Maternal and Child Health Services Utilization among Rural Women of Varanasi and Jaunpur
English9498Dubey AKEnglish Singh R.EnglishIntroduction: Maternal and child health facilities are the leading significances of community health programs. According to In Indian culture, the mother is the underpinning of the family and children are upcoming of the country. According to WHO maternal and child health services can be defined as “promoting, preventing, therapeutic or rehabilitation facility or care for the mother and child.” Aim: This study is to assess the utilization of antenatal care services in two divisions of Uttar Pradesh Varanasi (Chitaipur) Jaunpur (Rehati). Methodology: Cross-sectional study, sampling technique- simple random sampling using interview schedule questionnaire. Chitaipur, Rehati, statistical test i.e., Z test is used for the comparison between two districts of Uttar Pradesh. Result: This study indicates that between two districts of village i.e. Chitaipur, Rehati. Chitaipur is a better utilization of ANC care Comparison than Rehati. Conclusion: Uttar Pradesh has hugely proceeded in terms of maternal health in recent times, motionless some key areas require prompt attention. Spreading of information and assistance regarding the utilization of ANC services should be stimulated to achieve a reduction in maternal mortality.
EnglishAntenatal checkup (ANC), Utilization, Married women, Pregnant women, Comparative, Maternal Health ServicesIntroduction: “Women’s health issues from Womb to tomb.’’ Maternity is the most important position a women can have in her life but can be a life frightening event as well. Complications of pregnancy and child birth are major cause of death and disability among of reproductive age leading to high maternal mortality in India. During pregnancy any women can develop serious complications that require medical care. In the International Statistical classification of diseases and related health problems. Tenth revision, 1992(ICD-10), WHO defines maternal death as “The death of women while pregnant or within 42 days of termination of pregnancy, regardless of the duration site of the pregnancy or its management but not from accidental or incidental cause .1
For all women who dies, 30-50 women suffer from injury, infection, or disease. Pregnancy-related complications are among the leading causes of death and disability for women aged 15-49 in developing countries. The desired outcome of pregnancy is always a healthy mother and healthy baby. Because there is no reliable way to predict which women will develop pregnancy complications is essential that all pregnant women have access to high quality obstetric care throughout their pregnancies. Maternal complication and poor perinatal outcome are highly associated with non-utilization of antenatal and distribution care services and poor socioeconomic conditions of the patients. Poorer results are seen in undid than booked patients.2
In low and middle – Income countries, less than half of all pregnant women have a minimum of four antenatal care visit .3
In India, the reproductive and child health programme aims at providing at least three antenatal checkup which should include a weight and blood pressure check, abdominal examination against tetanus and iron and folic acid prophylaxis, as well as anemia management.4
The National maternity benefit scheme has been modified Janani Suraksha yojana (JSY). It was launched on 12th April 2005. It is a 100 percent centrally sponsored scheme under national rural health mission. The scheme focuses on poor pregnant women with special attention. Tracking each beneficiary each beneficiary registered under this yojana should have a Janani Suraksha Yojana (JSY) card along with a Maternal and child health (MCH) card. Accredited Social Health Activist, Anganwadi worker ASHA /AWW any other identified link worker under the overall supervision of the Auxiliary Nurse Midwife, Medical Officer, Primary Health Centre ANM and MO, PHC should mandatary prepare a micro -plan. This will effectively help in monitoring antenatal checkup, and standing delivery care. Uttar Pradesh is a low performing state under Janani Suraksha yojana.5
Hence, it becomes essential to analyze and study the utilization of maternal health services in Uttar Pradesh and identified districts with poor performance. This will provide track to the policy makers and Government to effectively employ its programmes under Janani Shishu Suraksha Karyakram (JSSK).
The present study focuses on developing indicators to measure the adequacy of antenatal care. In particular, this study aims to describe the adequacy of antenatal care for women in the context of a population in two different districts of Uttar Pradesh;( Varanasi) chitaipur and (Jaunpur) Rehati.
Objectives -To compare the data on maternal and child health care services two district wise Varanasi and Jaunpur in rural areas.
2- To compare the maternal and child health utilization among two districts of village chitaipur in (Varanasi), Rehati in (Jaunpur) in rural areas.
Methodology: A cross sectional study, Random sampling techniques, population – The total population 1343 (rural Chitaipur) Varanasi and 1143 (rural Rehati) Jaunpur among married women (15-49) maternal health utilization I selected randomly 60 married women in (Varanasi) chitaipur village ,60 married women in (Jaunpur) Rehati total married women in 120 selected during 15 January 2019 to 18 March 2019.
Tools: Interview Schedule questionnaire.
Statistical Analysis: The z-test for two population proportion has been applied to compare various study indicators. The hypothesis is given by:
Ho: There is no difference in study variable in the two regions.
H1: There is significant difference in study variable in the two regions.
The test statistic is given by:
Where, p1= proportion of first population
p2=proportion of second population
n1= sample size of first population
n2= sample size of second population and
The corresponding P value is calculated and if p>0.01, Ho is accepted otherwise rejected at 1% level of significance.
Result- Figure-1 describes that almost 11.6% are graduate in Varanasi (Chitaipur) compared to Jaunpur (Rehati) 50% of rural subjects were illiterate. Varanasi is better educational level compared than Jaunpur. Incidence of early marriage (below 18 years) was high in Jaunpur in rural area. In this study majority of subjects were. In this study, majority of Subject were age group 20-24 years, that is, 50% in Jaunpur compared than Varanasi 33.3%in rural area. In the study participants 61.66 were housewives and only 23.33 % did the job tailoring at home. Comparatively, In Varanasi 57.67% were housewives and only 16.63% did the job of ornament making at home. In the present study in Varanasi 93.3% Hindu, 6.7% Muslim. Comparatively in Jaunpur 68.3% Hindu, 31.7% Muslim women. In the present study in Varanasi (Chitaipur) 83.3% joint family, 16.7% Nuclear family. Comparatively in Jaunpur (Rehati)81% of joint family ,18.3% Nuclear family.
Figure-2 shows that the percentage of mothers who did not get registration within twelve weeks of pregnancy is higher in Varanasi (65%) than Jaunpur (42.5%) which is statistically significant at 1% level of significance. p-value for the indicator is 0.0082 which is less than 0.01 thus the difference between Varanasi(chitaipur) and Jaunpur (Rehati) is statistically at 1% level of significance.
Shows that the percentage of Mothers who got registered with Auxiliary nurse midwife, commonly known as (ANM) with in twelve weeks of pregnancy is higher in Varanasi (60%) then Jaunpur (30%) which is statistically significant at a 1% level of significance. P value for the indicator is 0.0005 which is less than 0.01 thus the difference between Varanasi(chitaipur) and Jaunpur (Rehati) is statistically at 1% level of significance.
Shows that percentage of mother who had three antenatal care visits in pregnancy is higher in (Varanasi) Chitaipur (58.33%) than (Jaunpur) Rehati (16.67%) which is statistically significant at 1% level of significance p value for the indicator is 0 which less than 0.01% thus the difference between (Varanasi) Chitaipur and Jaunpur (Rehati) is statistically significant at 1% level of significance.
shows that percentage of mother who consumed iron and folic acid for 100 days when they were pregnant is higher in Varanasi (Chitaipur) (53.33%) than Jaunpur (Rehati) 23.33 which is statistically significant at 1% level of significance p value for the indicator is 0.0004 which less than 0.01thus the difference between Varanasi (Chitaipur) and Jaunpur (Rehati) is statistically at 1% level of significance.
shows that percentage of mother who received Tetanus toxoid (TT) immunization in pregnancy is higher in Varanasi (Chitaipur) (76.67%) than Jaunpur (Rehati) (38.33 %) which is statistically significant at 1 % level of significance p value for the indicator 0 which less than 0.01 thus the difference between Varanasi (Chitaipur) and Jaunpur (Rehati) statistically significant at 1% level of significance.
Discussion: The results indicates that there were significant differences in utilization of maternal health care services between the two districts of Uttar Pradesh Varanasi (Chitaipur), and Jaunpur (Rehati). Overall Varanasi is better utilization of maternal and child health care services. Comparison then other similar study of Uttarakhand, Almora, Champawat, Nainital and Udham Singh Nagar had better usage of maternal health care facilities.6 Shows that the percentage of mothers who did not get registration within 12 weeks of pregnancy is higher in Varanasi (Chitaipur), 65% then Jaunpur (Rehati), 42.5% which is statistically significant at 1% level of significance p value for the indicator is 0.0082 which less than 0.01 thus the difference between Varanasi (Chitaipur) and Jaunpur (Rehati) is statistically significant at 1 % level of significance. The similar study, A greater percentage (85%) of women were registered early, according to a study in Rajasthan (Ramakant Sharma, 2006-07.6 Mother who had antenatal visit in pregnancy is higher in Varanasi (Chitaipur)58.33% than the percentage of women who went for three or more than three ANC checkups was also reported to be high in West Bengal, Assam and Orissa i.e., 97.8%,89.6% and 83% i.e., 83%,97.8% and 89.6% respectively and comparatively low in U.P, M.P and Rajasthan i.e72.8%,65.5% and 65.4% respectively (MOHFW,2007). According to NFHS-3, almost half the women (52%) received three or more antenatal checkups across India. As compared to our country E. Materia et al. (Ethiopia,1993) reported that a greater proportion (61%) of the women received antenatal care reported having had 3 or more visits according to a study regarding MCH service utilization.8 In the present study, only 53.33 % women consumed hundred IFA tablets in Varanasi (Chitaipur) than Jaunpur (Rehati 23.33%. A smaller proportion of women in our Nation. Similar study consumed hundred IFA tablets as per NFHS-III data i.e., 26% and 23% respectively. The percentage of women who consumed hundred IFA tablets was found to be very high i.e., 98% in Kerala (Sumitra, 2006).9 In the present study, Mother who had received in Varanasi (Chitaipur) 76.67% TT vaccination is higher than Jaunpur (Rehati) 38.33%. Mothers whose last birth was protected against neonatal tetanus 93.2% in Varanasi comparison than Jaunpur 90.9%. Varanasi is better than Jaunpur utilization of maternal and child health care. (NFHS4).10 In the present study Mother who had received financial assistance under Janani sukkahs yojana (JSY) for birth delivered in an institution 76.67% in Jaunpur (Rehati) comparison than Varanasi (Chitaipur) 46.67%. The Similar study According to (NFHS-4 2015-16) Mother who received financial assistance under (JSY) for birth delivered in an institution 56.3% in Varanasi in rural area 53.7% in Jaunpur in rural area.11 In this study, good awareness level is identified about the facilities provided by the scheme Mamoni as compared to other schemes. In other part of India different studies are conducted to asses the level of awareness regarding Maternal and child health care schemes. According to study by Kannan et.al awareness level about JSY is about 62.3%.12 Overall, ASHA/ ANM is very important role for pregnant women in village level.
Conclusion: Utilization of maternal and child health care MCH services was poor in both rural area in Jaunpur (Rehati), Varanasi (Chitaipur). Awareness of women concerning her health assumes special implication in the Indian context because the maternal health problems are mainly due to ignorance, poverty, and lack of knowledge regarding the issue. It is therefore very important to first focus on services for the increasing awareness level of the mother. A special attention in rural area of Jaunpur. A sustained and attentive information education and communication campaign to improve the awareness amongst community on MCH will help in improving the quality, accessibility, and utilization of maternal health care services provided by the government agencies in both rural areas. Maternal women are belonging to vulnerable group because every people are able to be easily physically, emotionally or mentally hurt or influenced in the society. But communication is a good platform to aware the pregnant women in our health. In rural area so many modes of communication to aware the health-related information for pregnant women. So, there is need of effective communication strategy to improve the quality of life of pregnant women.
Acknowledgement: We acknowledge the respondent Village level Medical staff Asha, ANM, and Dr Alok Kumar Pandey (Assistant professor in IRDC, BHU) for the total support and necessary permission Required for the article.
Conflict of Interest: Nil
Funding: Self finance Study no second party funding involved. The authors alone are responsible for the writing of this article.
Englishhttp://ijcrr.com/abstract.php?article_id=4027http://ijcrr.com/article_html.php?did=40271-Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the UN Maternal Mortality Estimation Inter-Agency Group. Lancet. 2016;387(10017):462–74.
2-Owolabi AT, Fatusi AO, Kuti O, Adeyemi A, Faturoti SO, Obiajuwa PO. Maternal complications and perinatal outcomes in booked and unbooked Nigerian mothers. Singapore Med J. 2008;49(7):526–31.
3-Multimedia [Internet]. Who.int. [cited 2021 Mar 19]. Available from: http://www.who.int/media
4-Özlü F, Erdem S, Göçen U, Demir F, Atalay A, Akçal? M, et al. What are the non-cardiac prognostic factors affecting mortality in neonates with aortopulmonary shunt J Matern Fetal Neonatal Med. 2021;34(3):416–21.
5-Kumar P, Chauhan S, Patel R, Srivastava S, Bansod DW. Prevalence and factors associated with triple burden of malnutrition among mother-child pairs in India: a study based on National Family Health Survey 2015-16. BMC Public Health. 2021;21(1):391.
6-Nic.in. [cited 2021 Mar 19]. Available from: https://jalan.nic.in/scheme/janani-surksha
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8-Kalam MA, Sharma SK, Ghosh S, Roy S. Change in the prevalence and determinants of consanguineous marriages in India between National Family and Health Surveys of 1992-1993 and 2015-2016. Hum Biol. 2021;92(2):93–113.
9-Materia E, Mehari W, Mele A, Rosmini F, Stazi MA, Damen HM, et al. A community survey on maternal and child health services utilization in rural Ethiopia. Eur J Epidemiol. 1993;9(5):511–6.
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Total number of pages – 11
Total number of figure - 2
Total number of tables - 4
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareEfficacy of Cervical Manipulation on Hand Grip Strength and Upper Limb Function: A Randomized Controlled Trial
English99104Anjali AEnglish Malik MEnglish Gera CEnglish Kaur JEnglishBackground: Non-specific neck pain is the most common health concern among the general population. It leads to functional disabilities of the upper limb and pain. Assortment of approaches includes manual therapy that has been used for the management of neck pain. Improving Grip strength, reducing functional disabilities of the upper limb and reducing pain intensity are important objectives in the treatment of non-specific neck pain. Methods: A randomized, controlled trial with concealed allocation, intention-to-treat analysis and blinded assessors in which patients were randomly allocated into 2 groups; the Experimental group (n=26) and the Control group (n=26). Patients in the experimental group were received the cervical manipulation session; hot pack and TENS for two weeks. Patients in the control group were received the hot pack and TENS alone for two weeks Participants were recruited from different clinics and hospitals of Hisar. The outcomes were DASH Score and handgrip strength. All subjects were evaluated at the baseline and post-session (after 2 weeks). Results: A total of 52 subjects have participated in the study, including 18 males and 33 females. The mean ages of the subjects were 33.05 years old. Data analysis was done by using paired t-test. This study resulted that the grip strength and DASH Score after the intervention were significantly improved in the experimental group as compared to the control group. In addition, the performance of handgrip strength [left (p≤0.000) (95% CI= -13.11, -9.85) and right (p≤0.000) (95% CI= -12.57, -9.85] and upper limb functions [DASH Score (p≤0.000) (95% CI= -14.25, -19.46] was superior in experimental group as compared to that of the control group. Ethics and Dissemination: The proposed examination was done after moral endorsement from the Institutional Ethics Committee, Departmental Research Committee, and B.O.S. & R. of the Department of physiotherapy, G.J.U.S&T, Hisar in September 2019, Vide letter no. PTY/2019/1014, dated 11.09.19. Conclusion: Cervical manipulation can improve the Handgrip strength and upper limb functions in non-specific neck pain.
EnglishCervical manipulation, Manualtherapy, Grip-strength, Upper limb function, Non-specific neck pain, DASH scoreIntroduction
“Non-specific neck pain (NP) is characterized as pain in the back and parallel part of the neck between the superior nuchal line and the spinous process of the thoracic vertebra without any signs or indications of major basic pathology and no significant impedance with exercises of everyday life just as with the absence of neurological signs and explicit pathologies like fracture and tumor”.1 Non – explicit neck pain may radiate down to the shoulder, arm, and fingers giving "a tingling sensation", crunching sound when turning the neck, functional limitation, and pain while moving the neck.2 Upper appendage disability can be estimated utilizing the inability of the arm, shoulder, and hand (DASH) scale which is a reliable outcome measure in estimating upper appendage incapacity in vague neck pain. Handgrip strength can be evaluated by estimating the measure of static power that the hand can press around a dynamometer.3
The primary symptom of non-specific neck pain is the pain around the cervical area, occipital area, suboccipital muscles, shoulders, and upper appendages. Numbness, paresthesia, tingling, and weakness also occur in upper appendages. Tenderness is also present, mainly in the lower cervical areas (C5-C6), where disc degeneration is progressively obvious.4 The cause of neck pain can be disc herniation, extreme movement of the cervical spine, long-term awkward posture and lifestyle choices, and tissue injury in the neck. Cervical stability continuously diminishes and can prompt the loss of cervical lordosis.5Assortment of approaches has been successful for the management of neck pain. These strategies of treatment include home exercise programs, manual therapy, endurance training, strength training, and electrotherapy modalities.6
Manual therapy such as cervical mobilization and cervical spinal manipulation (CSM) are used as an effective treatment of patients with neck pain and headache. CSM is defined as low amplitude and high-velocity thrust that is applied passively to articular surfaces of a joint within its anatomical limit to restore functions and to reduce pain. 7 Manipulation of the spine involves a high–velocity thrust that is applied through either a long or short lever arm. The “long lever” method involves numerous vertebral articulations at the same time (e.g. rotatory manipulation of the thoracolumbar spine) while the “short–lever” method includes a low amplitude thrust that is aimed at a particular degree of the vertebral segment. Manipulation has been utilized in the treatment of muscle tension-type headache, migraine, neck pain, and stiffness. Mobilization includes low-velocity passive movement which can be halted by the patient. The speed of the technique (not really the measure of power), in this manner, separates manipulation from mobilization.8 Literature suggests that the use of manual therapy (manipulation & mobilization) can reduce pain and functional limitation in patients suffering from non-specific neck pain.
The present study was done to evaluate the efficacy of cervical manipulation on handgrip strength and upper limb functions in patients of non-specific neck pain. The study includes Grip strength as an outcome measure because in this study we want to show the impact of neck pain on handgrip strength and if the neck disability index was considered as an outcome measure then the focus of the study would be neck disability instead of handgrip strength. As the title of the study was "Efficacy of Cervical Manipulation on Hand Grip Strength and Upper Limb Function" in this study grip strength took as a primary outcome measure.
Methodology:
A randomized controlled preliminary was conducted after approval from the Institutional Ethics Committee of the Department of Physiotherapy, G.J.U.S&T, Hisar. The RCT was registered with the Clinical trial registry of India (Registration no. CTRI/2020/01/022638.
Consent was taken from each participant. Following study enrollment and completion of baseline evaluation, members were arbitrarily designated into the experimental or control group using computer-generated random number tables and delineated by gender.
Sample size calculation
The sample size was calculated using (Minimally Clinical Important Difference) MCID of DASH score=13.0 along with standard deviation of DASH score=17.6 from previous studies considering a dropout rate of 5%. 9 Using the following formula.10
Here, is standard normal variate as in most of the studies P esteems are viewed as huge underneath 0.05, thus 1.96 is utilized in the equation
p = Expected extent in population dependent on past investigations or pilot considers
d = Standard deviation.
Selection criteria
Patients suffering from non-specific neck pain were included in this study. In the study patients with radicular and without radicular pain, were included. Patients having a complaint of neck pain with age group between 18-65 years who did not receive any concomitant intervention for neck pain were included in this study. Patients having a past history of stroke or transient ischemic attack, severe neck pain due to infection, fracture, progressive neurological deficiency, herniated nucleus pulposus, and myelopathy were excluded from selection criteria.
Procedure:
52 subjects took part in the examination, including 19 guys and 33 females. The participants were randomly allocated into 2 groups i.e. Experimental group (n=26) and the Control group (n=26) respectively as explained in the flowchart of Figure -2. Grip strength was evaluated by using a handheld dynamometer and upper limb functions were assessed by the DASH (disabilities of the arm, shoulder, and hand) scale. To measure grip strength we used a Jamar hydraulic dynamometer that is an easy, fast, and reliable method. The Jamar hydraulic dynamometer was seen as exceptionally dependable (ICC= 0.98) i.e. 98% and substantial (ICC =0.99) i.e. 99% for estimating handgrip strength. 11 The dynamometer was lightly held around the readout dial by the examiner to prevent inadvertent dropping. As shown in Figure-1 the subjects were in a sitting situation with their shoulder adducted, impartially pivoted elbow flexed at 90° lower arm in nonpartisan position, wrist between 0-30° dorsiflexion and 0-15° ulnar deviation for each strength test scores were recorded for each treatment. The therapist was standing in front of the subject.
Assessment and examination: Patients were thoroughly assessed and examined by using palpation and prone leg length test to evaluate cervical malalignment. Functional movements were examined for any limitation and dysfunction. Special tests like Spurling test and slump test were used to exclude specific pathologies.
Intervention: Before giving any intervention, the pre-intervention data was collected in which the handgrip was measured Experimental group received sessions of cervical manipulation, hot pack, and TENS for two weeks, thrice weekly. Cervical manipulations include Axis lateral correction technique, Atlas correction, and Diagonal correction atlantoid arch, “The Pistol”- Ventral malaligned vertebrae, Rotational adjustment of the axis, Rotational correction of C3-C6 and C7 rotation correction.
The subjects in the Control group received only a hot pack and TENS for two weeks, thrice weekly. After 2 weeks post-intervention of handgrip strength and upper limb functions were re-evaluated. Data so obtained was analyzed for any statistical significance.
Data analysis:
Outcome measures were analyzed for any statistical significance. SPSS latest version 26 programming was utilized to break down the information. Assessment for the differences between pre-and post- grip strength and DASH score of experiment and control group was done by Paired t-tests. The mean change in grip strength and DASH score between groups was compared to the independent t-test. P esteem was set at ≤ 0.05 level. 95% certainty 95% confidence interval was also Calculating
Results:
A total number of 52 patients with non-specific neck pain were randomized into experimental (n=26) or control groups (n=26). Intention to treat analysis was done. The mean age of patients in the experimental group was 31.15 and in the control group was 35.12. Three patients dropped out of the study. The post-intervention data were collected for ‘Intention to treat analysis. Baseline characteristics were similar between the two groups
Baseline Comparisons-
As shown in Table 1 the baseline comparisons of outcome measure between the Experimental and Control Group. Baseline data was analyzed for any statistically significant difference. The Analysis shows that the baseline data was similar (p-value= 0.113, 0.130 and 0.04 respectively)
Data normality was evaluated through Kolmogorov-Smirnov (K-S) test andLilliefors corrected K-S test. Results showed that the data was normally distributed.
Pre-Post comparison-
Results show a statistically significant improvement in the Experimental group as compared to the control group. As shown in Table-2 the grip Strength left (p≤0.000) (95% CI= -13.11, -9.85) and right (p≤0.000) (95% CI= -12.57, -9.85) as well as DASH Score (p≤0.000) (95% CI= -14.25, -19.46) were improved significantly in experimental Group. However, there was no significant improvement in the control group.
Comparison between Groups:
The examination between the experimental and control groups as shown in Table 3. Results show a statistically significant improvement of Experimental group (p≤0.00)in terms of grip strength right (MD=10.96; 95% CI= 7.65, 11.49), left (MD=11.42; 95% CI= 7.94, 11.75) and DASH score (MD=-16.85; 95% CI= 10.34, 15.52) as compared to control groupin grip strength right (MD=1.38), left (MD=1.57) and DASH score(MD=-3.92).
DISCUSSION:
The essential goal of this examination was to explore the impact of cervical manipulation on handgrip strength and upper limb functions. Effect of grip strength was evaluated using a hand-held dynamometer and upper limb function was evaluated using DASH questionnaires. DASH is a valid and reliable tool for testing upper limb disability.3
Data was analyzed by using a t-test and significant positive improvements in handgrip strength and upper limb functions were observed. Results of the present study suggest that cervical manipulation is effective in the improvement of grip strength and upper limb function in patients with non-specific neck pain. The Experimental group had a statistically significant increase in grip strength and decreases in hand and shoulder disability. The grip strength is a decline in subjects suffering from severe neck pain. 12 Reduction of hold quality and continuance is because of the impedance with the capacity of the nervous system to start hand muscle through motor units. Besides, the fear-avoidance reaction was found in patients with incessant neck torment inspired by a paranoid fear of injury prompts disuse atrophy and decreases the inability to produce and retain force.2
Cervical manipulation can be beneficial in non-specific neck pain patients. Spinal manipulation works via neurophysiological and biomechanical mechanisms. During manipulation, the application of mechanical force may start many neurophysiological reactions that cause an increase in range of motion and decrease in pain.13 The experimental group end up being more helpful in all terms in treating mechanical Neck Pain and pain referred to the upper limb. Firstly, this can be since grip strength had straightforwardly identified with neck pain as grip strength was diminished in neck pain with serious neck disability. Hence, neck pain, grip strength, and neck inability are negatively correlated. 14 Grip strength was influenced by motor control. The neck muscles in the presence of neck pain and isometric muscle fatigue affect the handgrip. 15
Results showed a significant decrease in the DASH Score of the experimental group i.e. improvement in useful exercises as per DASH with (pEnglishhttp://ijcrr.com/abstract.php?article_id=4028http://ijcrr.com/article_html.php?did=40281. Hidalgo B, Hall T, Bossert J, Dugeny A, Cagnie B, Pitance L. The efficacy of manual therapy and exercise for treating non-specific neck pain: A systematic review. J Back Musculoskelet Rehabil. 2017;30(6):1149–69.
2. Gauns S V, Gurudut P V. A randomized controlled trial to study the effect of gross myofascial release on mechanical neck pain referred to the upper limb. International Journal of Health Sciences (Qassim). 2018; 12(5): 51–59.
3. Roh YH. Clinical evaluation of upper limb function?: Patient’s impairment, disability and health-related quality of life. Journal of Exercise Rehabilitation 2013;9(4):400-405.
4. López-de-Uralde-Villanueva I, Sollano-Vallez E, Del Corral T. Reduction of cervical and respiratory muscle strength in patients with chronic nonspecific neck pain and having moderate to severe disability. Disability and Rehabilitation. 2018;40(21):2495–504. https://doi.org/10.1080/09638288.2017.1337239
5. Mahmoud NF, Hassan KA, Abdelmajeed SF, Moustafa IM, Silva AG. The Relationship Between forwarding Head Posture and Neck Pain?: a Systematic Review and Meta-Analysis. Current Reviews in Musculoskeletal Medicine 2019;12:562–577. https://doi.org/10.1007/s12178-019-09594-y.
6. Hurwitz EL, Morgenstern H, Harber P, Kominski GF, Yu F, Adams AH. A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients With Neck Pain?: Clinical Outcomes From the UCLA Neck-Pain Study. American Journal of Public Health | 2002;92(10):1634–41.
7. Kranenburg HA, Schmitt MA, Puentedura EJ, Luijckx GJ, Schans CP Van Der. Adverse events associated with the use of cervical spine manipulation or mobilization and patient characteristics: A systematic review. Musculoskeletal Science and Practice. 2017; 28:32-38.http://dx.doi.org/10.1016/j.msksp.2017.01.008
8. Griswold DW, Learman K, Kolber MJ, Relief P, Cleland JA. Pragmatically Applied Cervical and Thoracic Non-thrust versus Thrust Manipulation for Patients with Mechanical Neck Pain?: A Multicenter Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy.2018;48(3):137-145.
9. Koorevaar RCT, Kleinlugtenbelt Y V., Landman EBM, van’t Riet E, Bulstra SK. Psychological symptoms and the MCID of the DASH score in shoulder surgery. Journal of Orthopaedic Surgery and Research 2018;13(1):1-7. https://doi.org/10.1186/s13018-018-0949-0.
10. Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian Journal of Psychological Medicine. 2013;35(2):121–6.
11. Bellace J V., Healy D, Besser MP, Byron T, Hohman L. Validity of the Dexter Evaluation System’s Jamar dynamometer attachment for assessment of handgrip strength in a normal population. J Hand Ther. 2000;13(1):46–51.
12. Kalra S, Pal S. Correlational study of chronic neck pain and handgrip strength in physiotherapy practitioners.International Journal of Yoga, Physiotherapy and Physical Education. 2017;2(4):30–2.
13. Anderst WJ, Ms TG, Ms. CL, Bs SR, Dc KG, Dc MS. Intervertebral Kinematics of the Cervical Spine Before, During and After High-Velocity Low Amplitude Manipulation.The Spine Journal.2018 Dec;18(12):2333-2342. https://doi.org/10.1016/j.spinee.2018.07.026
14. Ramdati V, Soni N. THE CORRELATION BETWEEN CHRONIC NECK PAIN AND HAND GRIP STRENGTH INDENTISTS OF GUJARAT.International Journal of Current Advanced Research.2019;8(09):8–10. DOI: http://dx.doi.org/10.24327/ijcar.2019.3899.20029
15. Egwu MO, Ajao BA, Mbada CE, Adeoshun IO. Isometric Grip Strength and Endurance of Patients With Cervical Spondylosis and Healthy Controls: A Comparative Study. Hong Kong Physiother J. 2009;27(1):2–6. Available from: http://dx.doi.org/10.1016/S1013-7025(10)70002-6
16. Vance CGT, Dailey DL, Rakel BA, Sluka KA. Using TENS for pain control: the state of the evidence. Pain Management. 2014;4(3):197–209.
17. Bautista-Aguirre F, Oliva-Pascual-vaca Á, Heredia-Rizo AM, Boscá-gandía JJ, Ricard F, Rodriguez-Blanco C. Effect of cervical vs. thoracic spinal manipulation on peripheral neural features and grip strength in subjects with chronic mechanical neck pain: a randomized controlled trial.European Journal of physical and rehabilitation Medicine 2017 June;53(3):333-41 doi: 10.23736/s1973-9087.17.04431-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcarePrevalence of Subclinical Hypothyroidism in High-Risk Individuals Attending Medicine Outpatient Department (OPD) in Tertiary Care Hospital
English105108Anand D BangEnglish Nitin N JadhavEnglish Virendra C PatilEnglish Aparna P PatangeEnglishEnglishSubclinical Hypothyroidism, High-Risk Individuals, Outpatient Department, History of cigarette smoking, Diabetes mellitus and obesityINTRODUCTION
Hypothyroidism is a common problem; it causes symptoms that reduce the functional status and quality of life. It is a common endocrine disorder in general practice. A textbook describes the classical hypothyroid state thus, the patient's face looks grotesquely swollen and eyelids may be so infiltrated that the skin beneath hangs in sacs. Movements and speech are grossly retarded. The tongue may fill the mouth. The voice is hoarse, almost a croak. Skin is thickened, cold, rough and dry. Hair tends to dry and become brittle and sparse. A slow pulse rate may be found. Nonpitting edema can be recorded in third to half of patients. The Achilles reflex is prolonged. The disease may progress slowly without the patient being aware that he/she is ill.1, 2 The history pertaining to thyroid is summarized by Rolleston1 according to which Galen in his De voce briefly described the gland. Vesalius added to the anatomy of the gland. He suggested that the gland was there to round out and beautify the neck. Hypothyroidism as a clinical syndrome was described for the first time in London in 1870. In 1873 Sir William Gull was the first to understand that the cause of myxoedema is atrophy of thyroid gland.3
Ord coined the term Myxedema in 1878 and published the definitive account of myxedema. Later it was accepted widespread that cretinism, myxedema and post-thyroidectomy changes all were a result of the loss of function of the thyroid body. In 1896 Baumann suggested that iodine deficiency caused the malfunctioning of the thyroid. Kendall isolated thyroxin (thyroxyindole) for the first time in 1914. Harrington synthesized it for the first time in 1926. However, synthesis of thyroxine was done in large scale in 1949; later it became a universally accepted therapy for hypothyroidism.4 In 1951 T3 was found to be metabolically active in the treatment of hypothyroidism.5
Subclinical hypothyroidism was a new clinical entity described in early 1970s after TSH estimation became routine. It represents a form of mild thyroid failure. Large epidemiological studies indicate that subclinical hypothyroidism is the most prevalent thyroid disease in the community.6
AIM
To study the magnitude and association of subclinical hypothyroidism in individuals having risk factors. (females with age more than 50 years old and family history of hypothyroidism). At the same time we will study the magnitude and association of subclinical hypothyroidism in subjects having following risk factors
a) Females more than 50 years old
b) Family history of hypothyroidism
c) History of cigarette smoking
d) Diabetes mellitus and obesity
METHOD
This is a Cross-sectional, observational hospital-based study design. The study was conducted in patients attending the medicine outpatient department in Krishna Hospital and Medical Research Centre, Karad. The study duration was from October 2018 to March 2020 (18 months). Ethical committee clearance: This study was approved by Institutional Ethics and Protocol Committee (Protocol number 0252/2018-2019). The Sample size was calculated by using the following formula
N=4×p×q/d2
With reference to previous studies, we found that prevalence of subclinical hypothyroidism was 9.4% constituted p in the above equation. Hence ‘q’ which is 100 - p became 90.6% (100-9.4). The ‘d’ is absolute allowable error taken as 5% (considering a confidence interval of 95%). Hence from the above equation, the estimated sample size for this study was 136.
Inclusion criteria
Subjects with high-risk factors for the development of hypothyroidism were included. We took the following high-risk factors for screening of subclinical hypothyroidism
1. Females more than 50 years old
2. Family history of hypothyroidism
3. History of cigarette smoking
4. Diabetes mellitus and obesity
Exclusion criteria
1. Subjects already diagnosed to have hypothyroidism
2. Cases of frank hypothyroidism
3. Critically ill patients
Method: Demographic information such as age, gender, past medical history, personal history and general examination findings such as weight, height, body mass index were recorded with the help of standard, pre-validated, semi-structured case record proforma.
RESULT
Subclinical hypothyroidism is defined as an elevated serum thyroid-stimulating hormone (TSH) level associated with normal total tetra-iodothyronine (T4) and tri-iodothyronine (T3) levels. This is a much more common disorder than overt hypothyroidism. After institutional ethical clearance, with informed consent and with inclusion and exclusion criteria 136 cases with known high-risk factors in medicine outpatient department were included in the study and were evaluated on the basis of thyroid hormone profile. The data was entered in the master sheet and analyzed statistically. The salient of features of studied criteria in study population are summarized below: In the present study majority of the study, subjects were females (69.11%) whereas 30.88% of the subjects were males. The majority of the study subjects were in the age group of 46 to 55 years (41.91%)
A family history of hypothyroidism was present among 26.47% of study subjects, and in 22% of the subject's history of diabetes mellitus was seen. It was found that 19.85% of subjects were smokers, whereas 12.5% of the subject of tobacco consumption (smokeless) and 16.91% subjects were having the habit of alcohol consumption37.50% study subjects had body mass index between 17.5 - 25 i.e normal, followed by 33.82% with BMI 25 – 30 and 28.68% subjects were obese with BMI between 30 -40The presence of subclinical hypothyroidism in this study was 24.26%, whereas overt hypothyroidism was observed among 11.76% of the subjects. Hyperthyroidism was noted among 3.68% of the subjects and 60.29 % of the subjects were having normal thyroid function status. Subclinical hypothyroidism was significantly observed more among subjects with type 2 diabetes mellitus (p < .05)
A significant association between smoking and subclinical hypothyroidism was found(p < .05). It was observed that a comparatively larger proportion of subjects who consumed tobacco (smokeless form) developed subclinical hypothyroidism, but the statistical significance could not be established (p > .05). Subclinical hypothyroidism was observed significantly more among the subjects with a body mass index of more than 25 kg/m2 (p < .05). Subclinical hypothyroidism in the present study was seen in 35.13% of females with more than 50 years of age (p < .05)In the present study risk factors associated with subclinical hypothyroidism were female subjects with age more than 50 years, family history of hypothyroidism, obesity (BMI >30kg/m2), smoking, history of type 2 diabetes mellitus.
DISCUSSION
Age and gender-wise distribution
In the present study the majority of the study subjects were females (69.11%) whereas 30.88% of the subjects were males. The M:F ratio observed in the present study was 1:2.23. In the present study the age distribution of the study subjects was assessed. It was observed that majority of the study subjects belonged to the age group of 46 to 55 years (41.91%), followed by 56 to 65 years (22.06%) then 36 to 45 years (20.59%) and more than 66 years (7.35%). The mean age of the study subjects was 50.68 ± 9.76 years. Similar to present study, studies were conducted by Thakur V et al. [n=678, M:F ratio=1.06:1, age 49.4 ± 12.5], Eidan et al.[ n=394, M:F ratio= 1:1.11, age 41 ± 12] and Wang J et al.[n=4256, M:F ratio=1.06:1, age [50.51 ± 14.2].7,8,9 The observation of these studies were comparable to present study.
Family history of hypothyroidism
In the present study, the family history of hypothyroidism of the study subjects was assessed. It was observed that the family history of hypothyroidism was present among 25.73% of study subjects and subclinical hypothyroidism was observed more among cases with a family history of hypothyroidism. [chi-square statistic is 11.6246. ‘p’-value is 0.0006. Odds ratio= 4.2. Relative risk = 2.63] Eidan et al. in their study observed the odds of developing subclinical hypothyroidism among the cases with a family history of hypothyroidism as 2.8. These findings are not comparable with our study which is due to the ethnicity of the study population.7
History of type 2 diabetes mellitus
In the present study, the history of type 2 diabetes mellitus among the study subjects was evaluated. It was found that in 22% of the subjects history of type 2 diabetes mellitus was present and subclinical hypothyroidism was significantly observed more among cases with type 2 diabetes mellitus. [chi-square statistic is 31.5842. The ‘p’-value is < 0.00001. Relative Risk = 3.85. Odds Ratio = 8.76] Thakur V et al in their study compared the presence of type 2 diabetes mellitus among subclinical hypothyroidism and euthyroid subjects. They observed 19.80% euthyroid subjects and 14.70% subclinical hypothyroidism subjects. The findings were not statistically significant. These findings were not consistent with our results due to the difference in duration of diabetes at the time of screening.9
CONCLUSION
Subclinical hypothyroidism is a common clinical problem and is associated with various high-risk factors. Thyroid disorders in such patients having these associated high-risk factors have significant morbidity if they are not treated and subsequently, these patients may develop clinical hypothyroidism. In the present study, the clinical presentation of the patients with subclinical hypothyroidism was mostly nonspecific, which were mostly undiagnosed compared to euthyroid; so, screening of these patients is required to find out subclinical hypothyroidism and early intervention can be done. The risk factors associated with increased risk of development of subclinical hypothyroidism in the present study population were female subjects with age more than 50 years, family history of hypothyroidism, obesity, smoking, history of diabetes mellitus. The present study provides valuable information regarding the presence of subclinical hypothyroidism insignificant proportion of subjects in context with the Indian population.
Conflict of Interest: There is no conflict of Interest
Source of Funding: No Source of Funding
Authors Contribution: This is a collaborative work among all authors. Dr. Anand D Bang, and Dr. Nitin N Jadhav performed the statistical analysis, wrote the protocol, and wrote the first draft of the manuscript. Dr. Virendra C Patil, Dr. Aparna P Patange managed the literature searches. All authors read and approved the final manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=4029http://ijcrr.com/article_html.php?did=40291. Surks MI, Ortiz E, Daniels GH, Sawin CT, Col NF, Cobin RH, et al. Subclinical thyroid disease scientific review and guidelines for diagnosis and management. J Ame Med Assoc. 2004; 291(2):228–238.
2. Gillett M. Subclinical hypothyroidism: subclinical thyroid disease: scientific review and guidelines for diagnosis and management. Clin Biochem Rev. 2004;25(3):191–94.
3. Hollowell JG, Staehling NW, Flanders WD, Hannon WH, Gunter EW, Spencer CA, Braverman LE et al. Serum TSH, T(4), and thyroid antibodies in the United States population (1988 to 1994): National Health and Nutrition Examination Survey (NHANES III). J Clin Endocrinol Metab. 2002;87(2):489–499.
4. Cooper DS. Subclinical hypothyroidism. N Engl J Med. 2001;345:260 – 64.
5. Garber JR, Cobin RH, Gharib H, Hennessey JV, Klein I, Mechanick JI, Pessah-Pollack R, Singer PA, Woeber KA, American Association Of Clinical E, American Thyroid Association Taskforce On Hypothyroidism In A 2012Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid. 2012; 22:1200–1235
6. White GH, Walmsley RN. Can the initial clinical assessment of thyroid function be improved? Lancet. 1978; 2: 933-935.
7. Al Eidan E, Ur Rahman S, Al Qahtani S, Al Farhan AI, Abdulmajeed I. Prevalence of subclinical hypothyroidism in adults visiting primary health-care setting in Riyadh. J Community Hosp Intern Med Perspect. 2018 Feb 6;8(1):11-15.
8. Wang J, Ma X, Qu S, et al. High prevalence of subclinical thyroid dysfunction and the relationship between thyrotropin levels and cardiovascular risk factors in residents of the coastal area of China. Exp Clin Cardiol. 2013;18(1):e16-e20.
9. Thakur V. Subclinical hypothyroidism in India: an imperative risk for coronary artery disease (CAD). Metab Int J. 2018;6(6):401- 403.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareMinimally Invasive Surgery for Pulmonary Spindle Cell Carcinoma - Uncommon Aggressive Variant
English109112Kuppan CTEnglish Balasubramanian VMEnglish Jagadesh CBEnglish Suhaildeen KMEnglishIntroduction and Importance: Spindle cell carcinoma (SpCC) of the lung is a rare type of lung malignancy with a poor prognosis. Only a limited number of cases have been reported worldwide and no established treatment protocol is available at present. Case Presentation: We report a case of a 71-year-old elderly lady, incidentally detected with a lung mass on routine medical evaluation. Preoperative biopsy was suggestive of non-small cell lung cancer, PET-CT was suggestive of localised disease with no mediastinal lymph node. The patient underwent modified uniportal VATS left lower lobectomy with systemic mediastinal lymph node dissection. Postoperative biopsy was suggestive of spindle cell carcinoma lung (pT3N0). At 6 months follow-up, the patient is doing well. Conclusion: We report the first case of successful modified uniportal VATS assisted surgical resection in this poor prognostic type of lung cancer.
EnglishLung cancer, Video-assisted thoracoscopy, Uniportal VATS, Non-small cell lung cancer, Spindle cell carcinoma, Minimal invasive surgeryIntroduction:
Pulmonary sarcomatoid carcinoma (PSC) is a very rare variant that accounts for less than 1% of all lung malignancies. Spindle cell carcinoma of the lung is a type of pulmonary sarcomatoid carcinoma.1 It is a very rare entity with only a limited number of cases have been reported worldwide. It presents with diagnostic difficulty and has an aggressive clinical course with no separate established treatment protocol.
Minimally invasive management of lung cancer has become the standard of care, whenever feasible. Uniportal Video-Assisted Thoracoscopic Surgery (VATS) is a minimally invasive modality, which has been increasingly used in the surgical management of lung cancer. Here we describe a case of an elderly female patient with the aggressive spindle cell carcinoma of the lung who was successfully managed surgically with modified Uniportal VATS (left lung lower lobectomy + systematic mediastinal lymph node dissection). This proves the efficacy of uniportal VATS surgery even in aggressive operable lung cancer. Surgical management is an appropriate treatment even for early-stage sarcomatoid variant lung cancer. A minimally invasive approach is a viable option even in this aggressive variant.
Case History:
A 71-year-old asymptomatic female, the non-smoker, was incidentally detected with a left lung lower lobe consolidation on routine health evaluation. The patient was a known hypertensive and diabetic with coronary artery disease. General physical examination was unremarkable. On systemic examination, there was decreased air entry on the left side. Chest radiograph revealed a homogenous left parenchymal mass (Fig. 1a). Contrast-Enhanced Computer Tomography (CECT) Thorax revealed a large 5 x 6.6 x 5.4 cm lesion in the apical segment of left lung lower lobe with adjacent focal consolidation. An image-guided core needle biopsy was suggestive of non-small cell lung cancer. Positron Emission Tomography (PET) showed a lesion of the lower lobe of left lung, with no mediastinal lymphadenopathy and distant metastasis (Fig. 1b, c).
After discussing in the Multidisciplinary Tumour board, the patient was taken up for Uniportal VATS Left lung lower lobectomy with an additional camera port. A single 4 cm long incision was given in the left lateral 5th intercostal space in the anterior axillary line at intercostal space. Skin incision deepened and the pleural cavity entered. A wound protector was used to keep the incision wide open and no rib spreading was done (Fig. 2a). An additional camera port was placed in 7th Intercostal space in the midaxillary line. No pleural deposits or effusion was seen. Tumor of 5 x 6 cm was found in the apical-basal segment of the lower lobe left lung. Pleura was released anteriorly and posteriorly. Inferior pulmonary ligament released and lymph node station 9 removed (Fig. 2b). Inferior pulmonary vein isolated and looped and divided using Endo GIA 45mm-2.5mm stapler (Covidien Articulating reload with Tri-state technology) (Fig. 2c). The branch of the pulmonary artery to the lower lobe was defined in the fissure and the same was looped and divided (Fig. 2d). Bronchus was isolated and clamped. Lung was inflated to check the aeration of the upper lobe of the lung. Bronchus divided using Endo GIA 45mm-4.5mm stapler (Covidien Articulating reload with Tri-state technology). Specimen removed using specimen bag. Lymph node stations 8,7 removed. Pleura over the arch of aorta opened superiorly and station 5, 6 lymph node cleared and sent separately. Hemostasis secured and drains placed. The postoperative stay was uneventful. On a postoperative day one - the patient started on a normal diet and mobilized out of bed. Postoperative day 3 antibiotics were stopped. On postoperative day 5, the intercostal drain was removed and discharged on postoperative day 6. Postoperative pain was scored on visual analog score (ranging from 0-10) and was scored 3 on the first postoperative day and 2 at the time of discharge. Postoperative biopsy was Spindle cell carcinoma of the lung pT3N0 [as per AJCC 8th edition],2 with margins free of tumor and no lymph nodal involvement. On immunohistochemistry, the tumor was positive for Vimentin and CK-7, focally for TTF1 and negative for CK 20, p63, Napsin A, Synaptophysin and Chromogranin (Fig. 3). The patient has advised chemotherapy but the patient was not willing. On follow up patient is asymptomatic, disease-free after 8 months disease-free interval.
Discussion:
Video-Assisted Thoracoscopic Surgery (VATS) has become the standard of care with its oncological efficacy proven compared to conventional thoracotomy. Uniportal VATS is a modification of the multiport VATS surgery introduced about a decade earlier by Diego.3 It involves the use of a single utility incision of ~4 cm length to perform the entire surgery. Instruments are introduced through this single incision along with the camera to perform the surgical procedure. It scores over the multiport vats because it causes lesser injury to the intercostal nerves and thus lesser postoperative pain. However, it is technically demanding to perform. The other advantage is the direct vision of the hilum, which enables the surgeon to take better control of the hilar structures. Many articles have been published confirming the safety and oncological outcomes of uniportal VATS.4 In our study, we also found the patient to have a low postoperative pain score on day one and at the time of discharge. Even with multiple comorbid conditions and elderly age, the patient had an uneventful recovery due to the minimally invasive nature of surgery.
Spindle cell carcinoma of lung, which accounts for only 0.2 - 0.3 % of all lung malignancies, occurs in the elderly age group with a male preponderance, associated more with smokers.5 Based on a PubMed search done on 18/8/2020 with the phrase “pulmonary”, “Spindle cell carcinoma” and “Lung” there were only 28 articles that have been reported so far.
Clinical presentation of Spindle cell carcinoma of the lung is similar to other types of lung cancer, with about 50% of presenting with Cough, hemoptysis, and dyspnoea.6 Preoperative histologic identification of these tumours remains difficult. It requires examination of the resected surgical specimen since these are highly heterogeneous group of tumors which requires a minimum sarcomatoid component of 10% for a positive diagnosis. In light of this mixed multicellularity and the variations in the percentages of the cell types, no preoperative technique permits accurate tumor diagnosis.7 The expression of cytokeratin and epithelial membrane antigen are needed for demonstrating epithelial differentiation of sarcomatoid components.8
Since these are very rare tumors, currently patients with spindle cell carcinoma are managed similarly to Non-small cell lung carcinoma (NSCLC). Patients with localized lesions are treated with surgical resection followed by adjuvant therapy based on the histopathological diagnosis. Chemotherapy is given for patients with advanced or metastatic SpCC. However, the efficacy is poor and the patient's survival is limited to 5 to 6 months.9 A Study done by Roesel C et al. showed an overall 1-, 3- year survival rates were 57.7 and 35.8% of all operated cases respectively which is comparatively lesser/poorer compared to other Non-small cell lung carcinoma.5 UVATS has been proven to be a feasible and optimal treatment approach for patients with early-stage NSCLC by achieving similar results compared to multiportal VATS in terms of oncological efficacy and also providing better postoperative outcomes providing better pulmonary function outcome and reducing postoperative pain by minimizing trauma caused by surgery leading to a lesser hospital stay and faster return to daily activities.10 Our patient had the whole surgery done with modified UVATS and this is to our knowledge is the first report of successful use of this approach in such an aggressive type of lung cancer.
Conclusions:
Pulmonary spindle cell carcinoma is a neoplasm with an unfavorable prognosis through clinical symptoms and imaging findings are similar to other lung cancers. Minimally invasive surgery using uniportal VATS is feasible and safe even for aggressive variants of lung tumors. Spindle cell carcinoma of lung is an aggressive variant of lung cancer that is difficult to diagnose histologically and has a comparatively poor prognosis even after multimodality treatment. As a highly malignant carcinoma, efforts should be made to avoid misdiagnosis. Hence expertise in histopathological diagnosis is required for diagnosis. Even in early-stage tumors, the prognosis is more reserved than in other NSCLC because of their greater aggressiveness, high metastatic potential, and chemoresistance.
Acknowledgment:
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 the editors of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Source of Funding:
Nil
Conflict of Interest:
Nil
Authors’ Contribution:
Kuppan C T – Data collection, Writing the manuscript, Study design.
V Balasubramanian – Data collection, Writing the manuscript, Study design, Final draft correction and review
S Jagadesh Chandra Bose– Study design, Final draft correction and review
K Suhaildeen –.Data collection, Writing the manuscript, Study design
Englishhttp://ijcrr.com/abstract.php?article_id=4030http://ijcrr.com/article_html.php?did=40301. Travis WD, Brambilla E, Nicholson AG, Yatabe Y, Austin JHM et al. The 2015 World Health Organization Classification of Lung Tumors: Impact of Genetic, Clinical and Radiologic Advances Since the 2004 Classification. J Thorac Oncol. 2015 Sep 1;10(9):1243–60.
2. Amin MB, Edge S, Greene F, Byrd DR, Brookland RK, et al. editors. AJCC Cancer Staging Manual [Internet]. 8th ed. Springer International Publishing; 2017 [cited 2020 Sep 12].
3. Gonzalez D, Delgado M, Paradela M, Fernandez R. Uni-incisional video-assisted thoracoscopic left lower lobectomy in a patient with an incomplete fissure. Innovations (Phila). 2011 Jan;6(1):45–7.
4. Bertolaccini L, Batirel H, Brunelli A, Gonzalez-Rivas D, Ismail M, et al. Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019 Aug 1;56(2):224–9.
5. Roesel C, Terjung S, Weinreich G, Hager T, Chalvatzoulis E, et al. Sarcomatoid carcinoma of the lung: a rare histological subtype of non-small cell lung cancer with a poor prognosis even at earlier tumour stages. Interact Cardiovasc Thorac Surg. 2017 Mar 1;24(3):407–13.
6. Higareda Basilio AE, Ceballos Zuñiga CO, Hernandez Rocha FI, Yaurima Ham SS. Pulmonary spindle cell carcinoma: case report and literature review. Pulm Respir Med Int J. 2019 Mar 12;2(1):1–3.
7. Venissac N, Pop D, Lassalle S, Berthier F, Hofman P, et al. Sarcomatoid lung cancer (spindle/giant cells): An aggressive disease? J Thorac Cardiovasc Surg. 2007 Sep 1;134(3):619–23.
8. Nakajima M, Kasai T, Hashimoto H, Iwata Y, Manabe H. Sarcomatoid carcinoma of the lung: a clinicopathologic study of 37 cases. Cancer. 1999 Aug 15;86(4):608–16.
9. Langer CJ, Gadgeel SM, Borghaei H, Papadimitrakopoulou VA, Patnaik A, et al. Carboplatin and pemetrexed with or without pembrolizumab for advanced, non-squamous non-small-cell lung cancer: a randomized, phase 2 cohort of the open-label KEYNOTE-021 study. Lancet Oncol. 2016 Nov;17(11):1497–508.
10. Park JS, Lee Y, Han J, Kim HK, Choi YS, et al. Clinicopathologic outcomes of curative resection for sarcomatoid carcinoma of the lung. Oncology. 2011;81(3–4):206–13. 3.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareA Review on Use of m-Health Interventions in Maternal Health
English113117Kaur ManpriyaEnglish Sheoran PoonamEnglish Sarin JyotiEnglishIntroduction: Effective maternal health care during pregnancy and after childbirth is a very crucial time for recognising and responding to obstetric complications. Most of the pregnancies result in normal birth but few may develop unpredicted complications. These complications can be prevented by using preventive strategies such as using m-Health interventions to educate the mothers on different aspects of antenatal care such as antenatal checkups, antenatal advice, birth preparedness and complication readiness, skilled birth attendant, early detection of risk, timely management of obstetrics complications and postnatal care. Methods: Peer-reviewed papers are included to assess the use of m-health applications that address maternal health issues. Randomised controlled trials, cluster-randomised trials, quantitative or mixed-methods papers which are published between January 2014 to May 2020 were included in this review. Peer-reviewed papers were identified using electronic databases via a combination of search terms. 11 relevant articles were identified. m-Health interventions were found useful, an effective and acceptable tools for pregnant/new mothers and community health care providers. Conclusion: m-Health intervention is an innovative strategy that may contribute to decreasing maternal and neonatal morbidities and mortalities and in developing countries, these strategies have proven to be more effective where resources are limited.
Englishm-health, Maternal health, Pregnancy, Mobile phone, m-Health interventions, Mobile healthINTRODUCTION
Mobile Health is defined by the World Health Organization as a public health tool that is based on wireless communication platforms such as Mobile phones, tablet computers, real-time patient monitoring devices and the use of Information and Communication Technologies.1
World Health Organization statistics showed that every day approximately 830 women die from pregnancy or childbirth-related complications globally. Approximately 303,000 women died during pregnancy and after childbirth and mostly the deaths were occurring in those settings where resources are limited.2 Data also revealed that the Maternal mortality ratio in developing countries in 2015 is higher 239/ 1 lakh live births as compared to 12/1 lakh live births in developed countries. Sample registration survey revealed that maternal mortality ratio in India is 130/1 lakh live births whereas in the states like Assam has maximum number of maternal deaths as Maternal Mortality Rate of 237/1 lakh live births, Uttar Pradesh has 201/1 lakh live births, Rajasthan has 199/1 lakh live births, Odisha has 180/1 lakh live births, Punjab state has 122/1 lakh live births, Haryana has 101 /1 lakh live births and least is in Kerala with 46/1 lakh live births.3
Deaths due to pregnancy and childbirth are common among women in the Reproductive age group. Globally, India being amongst the top fifth country accounts for more than one-fifth of all maternal deaths. 5 out of 1000 women who become pregnant die because of pregnancy-related causes and childbirth. The majority of maternal deaths are due to obstetric hemorrhage followed by anaemia, malaria, heart diseases, infections account for 15%, unsafe abortions 13% and around 8% of maternal deaths result due to prolonged or obstructed labour.4
Registration of pregnancy must be done as soon as the pregnancy is confirmed so that any medical complications can be easily identified or detected before they become life-threatening emergencies. Providing knowledge related to their health is a vital element, so as to aware the mothers regarding their own health status. There is huge evidence available that shows those women having adequate knowledge resulted in safe pregnancy and delivery outcomes.5 This is likely because if antenatal mother is equipped well with the knowledge, it will help her to take timely decisions about her health during pregnancy and childbirth.
The primary focus of modern obstetrical nursing is on the preventive care of pregnant women. If the mothers are well educated during antenatal period that can lead to safe childbirth. So, educating the primigravida mothers by using m-health technology is a strategy to improve her self-care practices during pregnancy and childbirth. This current review paper assesses the interventions targeted to increase antenatal care attendance, providing health education and studies evaluating other uses of m-Health. The present systematic review provides a more definitive picture of the state of evidence for m-Health interventions for maternal health.
AIMS AND OBJECTIVES The overall aim of this review is to identify, appraise, and synthesize quantitative research evidence on the use of m-health to improve maternal health care practices. This will allow us to identify the potential for using m-health strategies in national maternal health programs.
MATERIALS AND METHODS
Search Strategy: This review includes Peer-reviewed papers that assess use of any mobile phone application that addresses maternal health issues. The study limited to randomized controlled trials, cluster-randomized trials, quantitative or mixed-methods papers which are published from January 2014 to May 2020 and therefore excluded the qualitative research and oral presentations. The literature search was conducted in Bio Med Central, Google scholar and various other electronic databases via a combination of search terms. Table 1 showed the search strategy using search terms.
Study selection Study selections were depend on peer-reviewed original articles on m-health interventions for maternal health. Titles and abstracts of these articles were extracted from different database searches and then they were reviewed to ensure whether related to use of m-Health that addresses maternal health issues or not with the following inclusion and exclusion criteria. Our search identified 100 papers, in which we removed 10 duplicates and screened 90 titles and abstracts, of which 50 were excluded after initial screening. Full texts of 40 studies were assessed, 29 were excluded and 11 were included in this review. (Fig 1) All the included articles were reviewed twice by authors.
Outcome Measures
Primary Outcome
Number of Antenatal care visits, TT immunization, Early registration before 12 wks of gestation, Gain in weight and haemoglobin, Maternal knowledge regarding self care during pregnancy
Secondary Outcome
Maternal Outcomes- Institutional deliveries, maternal morbidities, early referral in case of identified complications, easy accessibility to skilled birth attendant for delivery
Infant outcomes-Decrease number of Low birth weight babies, preterm birth, still birth, Neonatal mortality
RESULTS
Three papers reported on interventions to improve antenatal attendance, 1 described use of m-health interventions for the purpose of Communication between health care facility, Community Health Worker, Pregnant women and new mothers, 2 papers reported use of m-health in the form of Health education and appointment reminders and 5 studies targeted antenatal mothers using mobile applications during pregnancy. Sample size range from 12-3000. Table 2 elaborated the characteristics of the papers included in the review.
Improving Antenatal care attendance. Three papers reported improving antenatal care attendance by using a mobile phone. A Randomized controlled trial was conducted among 1311 women in the intervention group and 1239 in the control group, who attended their first antenatal care visit at selected primary health care facilities and were followed until 42 days after delivery. The intervention involves sending mobile phone text-message on the antenatal mother’s phone along with distributing the voucher. Findings showed that the majority of the women received > four antenatal care visits in the intervention group as compared to the control group. Study recommended that mobile phone applications should be considered by policymakers as they may contribute towards improved maternal and newborn health.6
A similar study conducted for a period of 21 months on a sample of 204 registered antenatal women. The interventional group received mobile health support in addition to routine antenatal care and the control group received only routine antenatal care. The study findings revealed that the interventional group had maximum number of Antenatal Care visits, better correction of anemia, and only a few mothers were lost to follow-up.7
Another interventional study conducted among antenatal mothers using mobile phones was followed up to 28 days postpartum. 178 mothers and 206 antenatal mothers were included in the interventional and control group respectively. Results concluded that in the interventional group, there is an increase in antenatal attendance at the health facility, High risk pregnancies cases such as Hypertension, diabetes cases were detected earlier, increase in mean weight and hemoglobin was observed in the third trimester, more number of Institutional delivery and less prevalence of Low Birth Weight babies. Almost all the neonates in the interventional group were immunized with BCG and Oral Polio Vaccine within seven days compared to the control group.8
Communication between health care facility, Community Health Worker, Pregnant women and new mothers. In one study of provider to provider communication using a mobile Health tool that uses text messages to coordinate between health care facility, health worker, Pregnant women and new mothers. Results showed that all Community Health Workers agreed that this tool helped them easily tracking of pregnant woman. This study further recommended that incorporation of m-Health tools in Community maternal health programs will decrease the obstetric complications by improving the women adherence to Antenatal care and postnatal care. 9
Health education and appointment reminders. In a study conducted by Dalton showed similar findings of providing antenatal education for pregnant women through the Healthy e-baby App and sending appointment reminders to enhance Antenatal care visits.10 Another cluster Randomized Controlled Trial study was conducted in Bangladesh for 1 year period on sample size of 3000. Study interventional group i.e. 500 antenatal women received Mother and Child health Handbook along with text messages and 500 got health education through Maternal and child health book only. 1000 participants were in control group. This mobile phone-based intervention and handbook were more beneficial to improve maternal knowledge.11
Enhancing awareness regarding different aspects of pregnancy. A cross-sectional survey was conducted among 193 pregnant women to explore the use of pregnancy-related mobile applications. Findings suggested that more than half of the pregnant women were using mobile apps related to pregnancy, birth, or child care. There is a significant difference in the use of mobile App among Primigravida mothers. This study further recommended that there is a need of developing credible pregnancy care applications and its content must be prepared by experts in the field of health.12
Another study to evaluate the mobile usability of Amila Pregnancy app, a mobile assistive app for pregnant women and expectant mothers and the results showed that most of the participants like the mobile Amila Pregnancy app and found acceptable, usable and useful during pregnancy.13
Another similar study on mobile applications i.e. BenEssere Mamma App (Pregnancy App) had features of providing meditation and guided imagery exercises to the selected antenatal mothers. 12 study subjects were selected for a total of four weeks. This App was perceived very easy to use and guided imagery exercises were assessed as pleasant and quite effective.14 Another study was conducted on usage of Smartphone Apps. Pregnant and young mothers from various hospitals and scan centres were the study subjects. The researcher found that the women who were pregnant and new expecting mothers were more enthusiastic in knowing their health and infant development. The result of the study revealed that middle-class and lower-middle-class women uses a smartphone and its applications more frequently during their pregnancy period as compared to the women in the upper-middle class and higher-income women.15 Another study project was donefor pregnant women to develop an Android application on self-care management to control gestational weight gain. This Android application enhances self-care practices and awareness and brings convenience to pregnant women in order to maintain a healthy weight gain during their pregnancy stages.16
DISCUSSION The current review showed that m health interventions have been widely used in maternal health in order to improve the maternal and neonatal outcomes. Review studies showed that m-health interventions provide promising findings such as health education, appointment reminders, sending text messages to improve Antenatal care visits and better communication strategy between health care facility, Community health workers and pregnant mothers. m-Health strategy is very effective in tracking and timely referring the high risk-pregnancies. In survey results, 94% of pregnant women reported that smartphones had changed their life in many ways such as the availability of information related to pregnancy anytime-anywhere.17 Even this service can be accessed from rural areas where transportation and medical services are limited. Easy availability and affordable prices of mobile phones makes huge contribution towards the development in the field of m-Health.
m-health applications helps pregnant and new mothers to reduce the time of traveling to health facility, free of access to information and hence, it overcomes the issues of inadequate financing, poor access to information and limited resources. m-Health is an effective educational communication tool between pregnant/ new mothers and community health care providers.7Antenatal mothers m-health registration should be done early in first trimester to avoid less number of Antenatal care visits. However, there were barriers associated with the engagement of antenatal mothers in using m-health such as free wi-fi was not available at the time of registration so they were not able to download the application on their mobiles. Another factor is difficult to understand the user interface/ language could impact the usage of m-Health interventions.10 In order to overcome the barriers adequate training to community health workers about m-Health application usage is necessary and if the application is provided in their local language then it will be easy for the antenatal mother to understand various aspects of antenatal care such as antenatal advices, exercises, about diet in pregnancy, minor ailments of pregnancy, birthing process and breastfeeding. The present review agreed with other reviews that there is a need of higher-quality studies which are focussing on m-health interventions addressing maternal health issues. But still there is a need to review full text of large number of papers to know more about the m-health interventions. There is a need for comprehensive review as the new papers on m-health are publishing very fast. Currently the number of women accessing the complete antenatal care package (to monitor the foetal development and to know about maternal well-being) is quite low which results in delay in reaching the health facility and ultimately increases the risk of complications to both mother and baby.
CONCLUSION To fulfil the needs of pregnant mothers, pregnancy-related credible m-health applications should be developed in local language and managed by qualified health professionals, so that there will be quick provision of credible professional information for pregnant mothers. Policy makers must ensure to include m-health services in the national health programs to achieve Sustainable Developmental Goals of reducing maternal and newborn mortality and morbidity rates. Future researchers must conduct more studies on m-health to prove its role in delivering maternal and new born health care.
ACKNOWLEDGEMENT Authors acknowledge the immense help received from scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Ethical clearance: None
Informed consent: NA
Source of funding: None
Conflict of interest: NIL
Author’s Contribution:
Conceptualization: MK,PS,JS Methodology: MK,PS,JS Results: MK,PS Writing-Original draft preparation: MK Writing- review and editing: MK,PS,JS Supervision: PS,JS
Englishhttp://ijcrr.com/abstract.php?article_id=4031http://ijcrr.com/article_html.php?did=4031
WHO Global Observatory. mHealth: new horizons for health through mobile technologies: second global survey on eHealth. Switzerland[Internet]. World Health Organization; 2011[cited 2021 Jan 8]. 14p. Available from: https://www.who.int/goe/publications/goe_mhealth_web.pdf
Maternal Mortality. [Online].; 2021 [cited 2021 Jan 8]. Available from: http://www.who-int/news-room/fact-sheets/detail/material-mortality
National Institute of Transforming India.[Online] [cited 2021 Jan 8]. Available from: Maternal Mortality Ratio (MMR) (per 100000 live births) | NITI Aayog.
World Health Organization. [Online].; 2021 [cited 2021 Jan 8]. Available from: https://www.who.int/healthinfo/global_burden_disease/estimates_child_cod_2000 _2012/en/
Zohra S L, Mansoor T, Rehana A S, Das J K, Bhutta ZA. Essential pre-pregnancy and pregnancy interventions for improved maternal, newborn and child health. Reproductive Health 2. 2014; 11(1):1-19
Stine L, Birgitte BN, Maryam H, Ida MB, Azzah S, Khadija SM, Makungu H et al. Mobile phones improve antenatal care attendance in Zanzibar: a cluster randomized controlled trial. BMC Pregnancy and Childbirth. 2014; 14(29):14-29.
Basavanapalli M, Vasundhara K, Vijaya SM. The role of m-health in providing antenatal care in rural areas. International Journal of Reproduction, Contraception, Obstetrics and Gynecology. 2017 Sep; 6(9):4059-4064.
Mudey DA, Khapre DM, Mudey DG,Goyal DR. An Innovative Approach of Mobile E-Health Intervention in Tracking Antenatal Mothers & Neonates in Selected Rural Areas of a District in Central India: An Ice Breaking Footstep for Revolution. Int. J. Epidemiol.2015 Sep; 44(1):95-96.
Ivy M, Chibulu L, Casey IH, Yanis BA. Evaluation of the impact of a mobile health system on adherence to antenatal and postnatal care and prevention of mother-to-child transmission of HIV programs in Kenya. BMC Public Health. 2015 Feb; 15(102):1-16
Julia AD, Dianne R , Michael W , Sal H, Andrew S , Claire TR et al. The Health-e Babies App for antenatal education: Feasibility for socially disadvantaged women. PLoS ONE. 2018 May; 13(5):1-18.
Ruoyan GT, Syed EH, Kiyoko I, Rintaro M. Mobile-health tool to improve maternal and neonatal health care in Bangladesh:a cluster randomized controlled trial. BMC Pregnancy and Childbirth. 2018; 18(102):1-7.
Yeonkyu L, Mikyung M. Utilization and Content Evaluation of Mobile Applications for Pregnancy, Birth, and Child Care. Healthcare Informatics Research. 2016 April; 22(2): 73-80.
Hussain A, Emmanuel M, Najdawati MF, Norhasizasuriati MH. The UX of amila pregnancy on mobile device. In The 2nd International Conference on Applied Science and Technology; 2017: AIP Publishing.
Carissoli C, Villani D, Triberti S, Riva G. User experience of BenEssere Mamma, a pregnancy app for women wellbeing. Annual Review of CyberTherapy and Telemedicine. 2016; 14(1):195-98.
Jayaseelan R, Pichandy C, Rushandramani D. Usage of Smartphone Apps by Women on their Maternal Life. Journal of Rawalpindi Medical College. 2015; 5(7):1-6.
Saw YC. My pregnancy care mobile health monitoring application system Malaysia: Universiti Teknikal Malaysia Melaka, 2014.
Pradhan N. Use of Mobile health applications in obstetric care: A review. BMC Pregnancy and childbirth 2017:18-46
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareElectrocardiographic and Echocardiographic Evaluation of Subjects with Atrial Fibrillation
English118122Gharge Sushilkumar SunilEnglish Vivek E. RedkarEnglishEnglishAtrial fibrillation, Hypertension, Coronary artery disease, Diabetes mellitusINTRODUCTION
Atrial fibrillation (AF) is one of the most commonly sustained arrhythmias and an important cause of morbidity, mortality, and health care expenditure.1, 2 Currently there are 2.3 million people in the US who have AF and this is expected to rise to 5.6 million by 2050. In persons aged 60-65, the prevalence is around 1%, but in those > 80 years of age, the prevalence is 8-10%. It is present in 6 - 10% of patients older than 70 years.2 The prevalence is also higher in men than women and in whites than black ethnicity.2 It is also associated with a 5-fold risk for stroke and 2 fold risk for all-cause mortality.3, 4 It is described as an irregular and often rapid heart rhythm. The symptoms of AF may vary from person to person. In many people, AF may cause symptoms but doesn‘t do any harm and many have no symptoms at all. Palpitations are the most common symptom with intermittent AF, anxiety and irregular fluttering are others.5 In patients with an uncontrolled ventricular response exercise intolerance and Dyspnoea may also develop which is mostly related to congestive heart failure (CHF). Thromboembolism is the most threatening complication of AF.
AF can be present in a structurally normal heart (lone AF) but usually, it is associated with many predisposing factors like an underlying cardiovascular disease. The most notable is rheumatic mitral stenosis. Hypertension (HTN) and coronary artery disease (CAD) are the most common risk factors in the developed world. Other risk factors are - Diabetes Mellitus (DM), congestive heart failure (CHF), valvular Heart diseases (VHD), and previous myocardial infarction (MI). Clinical hyperthyroidism is also associated with new-onset AF but, prevalence is low. In developing countries, Rheumatic VHD, HTN, and congenital heart disease (CHD) are important causes.6
Rheumatic heart disease:
One of the most common complications is AF. Historically rheumatic MS has been proven to be closely related to AF.7 The incidence of AF in RHD is about 40%. Devil et al reported the incidence of AF to be clearly related to age. AF was uncommon in young patients, but increased in frequency each decade and occurred in the majority of patients after the 4thdecade.8
William Kennel et al reported an incidence rate of 10.2% and 26.5% among men and women respectively for RHD among their AF patients.2 Adell Cullen et al, reported 19% incidence of RHD among their AF patients.9 Aberg et al, reported RHD among 11% of patients with AF.10 Eugene Rich et al observed RHD in 10% of patients with AF.11 The prevalence of RHD in India is high. In a study conducted by T.K.Raman et al, RHD was observed in 58% of the cases of AF studied by them.12
Hypertensive heart disease:
It is designated if a subject is hypertensive and had either LVH by ECG, cardiac enlargement by X-ray, increased LV mass index (>131 g/m in men and >110 g/m2 in women) or a cardiac failure.13The incidence of AF in HTN varies and the frequency of fibrillation is directly related to the chronicity, severity and associated complications of HTN. Studies on the precursors of AF have reported hypertensive heart disease to be the one most commonly associated with AF. William Kennel et al, reported that hypertensive HD accounted for 45.7% in men and 51.2% among women of the cases of AF.2 De Carvalho Filho et al, observed 51% of hypertensive HD among their patients with AF.14Adell Cullel et al reported hypertensive HD in 34% of the series 1 of AF patients studied by them.10 Leclercq et al. in their study on PAF had HTN as the only disorder in most of their cases.15
AIM
To evaluate the electrocardiographic and echocardiographic findings in patients with atrial fibrillation patients admitted in Krishna hospital and Medical Research Centre, Karad.
Objectives
1. To assess the frequency of underlying heart disease in patients with atrial fibrillation.
2. To study various clinical presentations of atrial fibrillation.
3. To evaluate the electrocardiographic and echocardiographic findings in patients with atrial fibrillation.
METHOD
Type of study:
This was a cross-sectional, observational, non-interventional, study. The study was conducted in the Department of General Medicine of Krishna Institute of Medical Sciences and Research Center, Karad, in patients of inpatient department of tertiary care, teaching institute during the period of October 2018 to March 2020.
Sample Size:
According to, ?Clinical and etiological study of atrial fibrillation in upper Assam?, Kotokey RK et al, the prevalence of RHD in patients of AF was 43.5 %.16
Hence, we chose p=43.5 %, q= 1-p i.e. 56.5 %. Using the formula for cross-sectional studies, with a relative precision of 20% at 95% confidence interval (e=20% of 43.5), and p=43.5%, the minimum sample size comes up to 127 patients which was rounded off to 130 patients.
Hematology
1. Hemoglobin by fully automated 3 part cell analyzer
2. Total leukocyte count by fully automated 3 part cell analyzer
3. Platelet count by fully automated 3 part cell analyzer All CBC parameters were performed in an automated 3 part analyzer by Nihon Kohden (Model number MEK 6420P)
4. Prothrombin time (PT/INR) by Stag analyzer (Model number- BT3305B301)
Biochemistry
1. Blood urea by Urease-GLDH (Glutamate dehydrogenase) method
2. Serum Creatinine by Modified Japanese Female Facial Expression (JAFFE’S) method
3. Serum Sodium by ISE (ion-selective electrode) based method
4. Serum Potassium by ISE (ion-selective electrode) based method
5. Random blood sugar by Hexokinase-mediated reaction
6. Serum Calcium by Arsenazo method
7. Serum Magnesium by Xylidyl blue method
8. Serum Phosphorus by UV Molybdate method
9. Liver function tests by Calorimetric
10. Serum T3, T4, TSH by immune-unsymmetric assay (automated) on TOSOH
Machine.
All biochemistry parameters analyzed in EM 360 analyzer by Transasia
RESULT
The mean age of patients in our study was 64.42 ± 14.66 years (Range 21-95 years). The majority of the patients were seen in the age group of 61-80 years (75 patients, 57.7%), followed by 41-60 years (30 patients, 23.1%), >81 years (13 patients, 10%) and 20-40 years (12 patients, 9.2%). The majority of the participants were males (55.4%) and rest were females (44.6%). The male: female ratio was 1: 0.80 Ischemic heart disease (IHD) (40.76%) was the most common antecedent cause for AF, followed by RHD, MS (both 33.84%) and HTN (31.53%).Other causes are MR (6.92%), Hyperthyroidism (3.84%) , ASD, PHT, TR (all 1.5%) , AS, AR and COPD (0.8%).There was no significant difference in the distribution of etiology among both sexes.( chi sq. value = 33.575 , p-value = 0.117) Dyspnoea (97.7%) was the most common presenting symptom , followed by pedal edema ( 64.6%) , palpitations (61.5%), chest pain (60.8%) , cough (13.1%) , hepatomegaly (3.8%) , hemoptysis (2.3%) , abdominal pain (1.5%) and syncopal attacks (0.8%).All patients had an irregularly irregular pulse. The average pulse rate was 119.34± 17.54 bpm. The range was 66-168 bpm. The pulse rate was >110 bpm (67.7%) in the majority of the patients followed by 90-110 bpm ( 26.2%) and 10 in 87 patients i.e. 66.9% and ≤ 10 in 43 patients (33.1%).
The mean Spontaneous bacterial peritonitis (SBP) was 142.38 ± 17.38 mmHg (Range 90-170). The mean Diastolic blood pressure (DBP) was 86.46± 10.11mmHg (Range 60-110). The mean random blood sugar (RBS) was 149.83 ± 51.09 mg/dl (Range 74-364). The mean Urea was 37.00 ±18.84 mg/dl (Range 14- 142). The mean Creatinine level was 1.26 ± 0.57 mg/dl (Range 0.6-4.5). The mean Sodium levels were 139.08 ± 5.55 mEq/l (Range 123.0-149.0). The mean Potassium levels were 4.09 ± 0.45 mEq/l (Range 3-5). Jugular venous pulse (JVP) was raised in 80 (61.5%) patients. Chest X-ray was normal in 71 (54.6%) patients. Cardiomegaly was seen in 58 (44.6%) patients. One patient (0.8%) had features of Chronic obstructive pulmonary disease (COPD). ECG was done using a 12-lead electrocardiogram. The rate varied from 74- 180 bpm and in the majority of the patients i.e 45%, the rate was 90-110bpm. The rhythm was irregularly irregular in all patients. P -waves were absent in all patients. QRS complexes were normal, but irregular in time and varied in amplitude.
DISCUSSION
AF is one of the most commonly sustained arrhythmia and an important cause of morbidity, mortality, and health care expenditure.1,2AF is identified and treated early, risk of serious or life-threatening problems are minimal. This study was conducted on 130 patients of AF to assess the presenting symptoms, underlying predisposing factors, electrocardiographic and echocardiographic findings in patients with AF.
In our study, the mean age of patients in our study was 64.42 ± 14.66 years (Range 21-95 years). The majority of the patients were seen in the age group of 61-80 years (75 patients, 57.7%), followed by 41-60 years (30 patients,23.1%), >81 years (13 patients, 10%) and 20-40 years (12 patients, 9.2%). These results are similar to previous Indian studies. In a study by Vivek GC et al, the mean age of the patients was 54.84 ± 17.49 years (Range 30-80) and majority belonged to 60-79 age group i.e. 30%.45 In another study by Sharma et al, and Gurpal Singh et al47 the mean age was 40.0 ± 7.0 years and 57.33 years respectively. Kulkarni et al reported the mean age for AF as 59.6years.18,19,20 The Framingham heart study provides the single best evidence for chronic AF and proves that the incidence rises with increasing age.13The prevalence of AF was 0.5% in 50-59 years and rises to 8.8% in 80-89 years.49 A study by Prakash SK and Chugh SK reported that all cases of AF due to CAD were above 50 years.22
Few studies in western countries, where the major cardiac precursors of AF are HTN and CAD also found a higher incidence of AF in increasing age groups.23,29,24 In the Indian population, the major cardiac precursors of AF is RHD.
The symptoms of AF may vary from person to person. In many people, AF may cause symptoms but doesn‘t do any harm and many have no symptoms at all. Palpitations are the most common symptom with intermittent AF, anxiety and irregular fluttering are others.5 In our study , Dyspnoea (97.7%) was the most common presenting symptom , followed by pedal edema ( 64.6%) , palpitations (61.5%), chest pain (60.8%), cough (13.1%), hepatomegaly(3.8%), hemoptysis (2.3%), abdominal pain (1.5%) and syncopal attacks (0.8%).Similarly, Vivek GC et al, reported that, 82% cases had dyspnoea followed by palpitations(78%), edema (66%), chest pain(36%), abdominal pain (18%), hemoptysis(10%) and syncopal attacks (4%).17 Similar symptoms were observed by Gurpal Singh et al47 too.19 Table 1 given below indicates the comparison baseline characteristics in AF patients.
AF can be present in a structurally normal heart (lone AF) but usually, it is associated with many predisposing factors like an underlying cardiovascular disease. In India, the incidence of RHD is around 35-45% of all cardiac cases.25 It is the most common antecedent disease for atrial fibrillation. In our study, IHD (40.76%) was the most common antecedent cause for AF, followed by RHD, MS (both 33.84%) and HTN (31.53%). Other causes are MR (6.92%), Hyperthyroidism (3.84%), ASD, PHT, TR (all 1.5%), AS, AR and COPD (0.8%). There was no significant difference in the distribution of etiology among both genders. Vivek GC et al, reported that RHD (50%) was the most common cause for AF, followed by IHD and HTN (12%) cases, only HTN (12%), IHD alone(8%), ASD (4%), cardiomyopathy (6%)cases, COPD (6%), and Thyrotoxicosis (2%).17 Gurpal Singh et al47 reported the etiology of AF to be RHD (26%) , DCM (23%), HTN (14.06%) , MVP, thyrotoxicosis (9.37% each),IHD (3.1%), ASD (1.5%), digitalis toxicity(1.5%) and lone fibrillation (1.5%).Similar results were reported by Prakash SK and Chugh SK et al, reported that 91.61% of AF was secondary to chronic RHD, 5.94% due to CAD.22 The Framingham heart study reported that, RHD and cardiac failure were most predictive precursor of AF. 24Davidson et al, in their study of 704 cases of AF, reported atherosclerotic CVD (55%) including MI, hypertensive heart disease and CAD as the most frequent cause associated with AF. Chronic RHD (22.8%), COPD (2.8%), WPW syndrome (2.6%) and thyrotoxicosis (2.6%),cardiomyopathy (0.9%),MVP (0.9%), sick sinus syndrome (0.7%),myocarditis (0.6%), pulmonary embolism (0.3%) and ASD (0.3%)were among others. 55 In two studies by Levy S et al, it was reported that RHD is present about 20-23% of AF patients and ASD is the most common congenital heart disease reported to cause AF.They also reported a case of thyrotoxicosis.26,27 The Framingham heart study reported hypertensive heart disease as the most common cardiac precursor for AF.13
CCF was the most common complication seen in 90 patients (69.3%). Of these, 3.07%patients died and one patient had associated DCM. No complications were seen in 30.8%. Similarly, Vivek GC et al. reported that 80% cases developed CCF.17 The ALFA study by Levy et al, showed 38% of patients had CCF and a study by Sharma et al, reported CCF was present in 30%.26,18 Other complications like stroke,cor-pulmonale and superior mesenteric ischemia were also reported in few other studies.13,17,28
CONCLUSION
Atrial fibrillation is the most common form of arrhythmia encountered during the regular clinical practice. In consideration to the present study, dyspnoea and palpitations were the commonly observed presenting complains in patients. There was no specific gender predominance found in the patient distribution. Ischemic heart disease and rheumatic heart disease were the leading etiological factors. The electrocardiographic evaluation of the subjects revealed the ischemic heart disease as the most common finding. Followed by echocardiographic evaluation showed left atrial enlargement and mitral stenosis.
Conflict of Interest: There is no conflict of Interest
Source of Funding: No Source of Funding
Authors Contribution: This is a collaborative work among all authors. Dr. Gharge Sushil Kumar Sunil, Dr. Vivek E. Redkar performed the statistical analysis, wrote the protocol, and wrote the first draft of the manuscript. Dr. Gharge Sushilkumar Sunil, Dr. Vivek E. Redkar managed the literature searches. All authors read and approved the final manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=4032http://ijcrr.com/article_html.php?did=40321. Floria M, Tanase MD. Multimodality Echocardiographic Assessment of Patients Undergoing Atrial Fibrillation Ablation. Echocard Heart Fail Card Electrophy. 2016; 10(3):19:65.
2. Kannel WB, Benjamin EJ. Current perceptions of the epidemiology of atrial fibrillation. Card Clin. 2009 Feb 1;27(1):13-24.
3. Hart RG, Benavente O, McBride R, Pearce LA. Antithrombotic therapy to prevent stroke in patients with atrial fibrillation: a meta-analysis. Ann. Intern. Med. 1999 Oct 5;131(7):492-501.
4. Benjamin EJ, Wolf PA, D‘Agostino RB, Silbershatz H, Kannel WB, Levy D. Impact of atrial fibrillation on the risk of death: the Framingham Heart Study. Circulation. 1998 Sep 8;98(10):946-952.
5. Armstrong WF, Ryan T. Feigenbaum‘s Echocardiography. 8th ed. Philadelphia: Wolters Kluwer -- Medknow Publications; 2019.
6. Makwana A, Shrivastava S, Trivedi AH. Clinical Profile of Atrial Fibrillation. Ind J Appl Res. 2015;5(October):537–540.
7. Lip GY, Beevers DG. ABC of atrial fibrillation: history, epidemiology, and importance of atrial fibrillation. Bri Med J. 1995 Nov 18;311(7016):1361.
8. Cullell TA, Samaniego FS, Beistegui CC, Pijuan NM, Olona JF, García EJ. Total Arrhythmia Due to Atrial Fibrillation. Primary Care Approach. Atencion primaria. 1993 Apr 30;11(7):333-336.
9. Aberg H. Atrial fibrillation: I. A study of atrial thrombosis and systemic embolism in a necropsy material. Acta Medica Scandinavica. 1969 Jan 12;185(1?6):373-379.
10. Rich EC, Siebold C, Campion B. Alcohol-related acute atrial fibrillation: A case-control study and review of 40 patients. Archives of Internal Medicine. 1985 May 1;145(5):830-833.
11. Raman T. Auricular Fibrillation. Ind Hear J. 1951;39:289–91.
12. Braunwald E. Heart disease. A Textb. Cardiovasc. Med. 4th ed., 1992, p. 1245; 1683–1684.
13. Koskinen PE, Kupari MA, Leinonen HA, Luomanmäki K. Alcohol and new onset atrial fibrillation: a case-control study of a current series. Heart. 1987 May 1;57(5):468-73.
14. Leclercq JF, Attuel P. Paroxysmal atrial fibrillation. J Cardiogr Suppl. 1993.43(12).1515- 21
15. Ohkawa S, Inoue J, Sugiura M. A clinicopathologic study of dilated cardiomyopathy in the aged. J Cardiogr Suppl. 1986.9.35-47
16. Chandrashekar V, Gadwalkar, SrikantRBasavareddy A, Basavareddy R. A clinical, electrocardiography and echocardiography study of atrial fibrillation in a tertiary care teaching hospital. J Transl Intern Med. 2014;2(4):168.
17. Sharma S, Joshi S, Gupta A. Prospective study of atrial fibrillation in a large industrial hospital: Therapeutic implications. Ind Heart J. 2002;23:109–13.
18. Gurpal S, Nayar S. Study of left atrial size in atrial fibrillation. Ind Heart J. 2002;36:276–81.
19. Kulkarni A, Mulay D, Jilla P. A study of the relation between left atrial size and atrial fibrillation. J Assoc Phys Ind. 2002;50:1555.
20. Zimmerman MC, Lazartigues E, Sharma RV, Davisson RL. Hypertension caused by angiotensin II infusion involves increased superoxide production in the central nervous system. Circul Res. 2004 Jul 23;95(2):210-6.
21. Prakash S, Chugh S. Atrial fibrillation in women. J App Phy. 1973;(21):953– 5.
22. Kitchin AH, Milne JS. Longitudinal survey of ischaemic heart disease in a randomly selected sample of the older population. Heart. 1977 Aug 1;39(8):889-93.
23. Rose GP, Baxter PJ, Reid DD, McCartney P. Prevalence and prognosis of electrocardiographic findings in middle-aged men. Heart. 1978 Jun 1;40(6):636-43.
24. Manyari DE, Patterson C, Johnson D, Melendez L, Kostuk WJ, Cape RD. Atrial and ventricular arrhythmias in asymptomatic active elderly subjects: correlation with left atrial size and left ventricular mass. Amer Hear J. 1990 May 1;119(5):1069-1076.
25. Singh B. Nonvalvular atrial fibrillation in India—time to pause, think, and change. Ind Heart J. 2018 Nov;70(6):767.
26. Levy S. Atrial fibrillation, the arrhythmia of the elderly, causes and associated conditions. Anadolu Kardiyol Derg. 2002 Mar;2(1):55-60
27. Wolf PA, Abbott RD, Kannel WB. Atrial Fibrillation: A Major Contributor to Stroke in the Elderly: The Framingham Study. Arch Intern Med. 1987;147(9):1561–1564
28. Henry WL, Morganroth J, Pearlman AS, Clark CE, Redwood DR, Itscoitz SB, Epstein SE. Relation between echocardiographically determined left atrial size and atrial fibrillation. Circ. 1976 Feb;53(2):273-9
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareAssessment of Psychiatric Illness Among Patients with Dermatological Disorders Attending a Tertiary Care Hospital of Rajnandgaon District (C.G), India
English123128Pooja PandeyEnglish Sharad M ManoreEnglish Prabhat PandeyEnglish Neeraj DokaniaEnglishEnglishAnxiety, Depression, Acne, Fungal infection, Dermatological disorder, Psychological problemINTRODUCTION -
Skin plays a major role in social and sexual communication. Healthy normal skin is essential for a person’s physical and mental well-being and sense of self-confidence.1The relation between psychiatry and skin diseases can be evaluated from two aspects: On one hand, psychiatric co-morbidity influences the development and course of dermatologic diseases via the effects of stress, depression, and anxiety.2 On the other hand, cosmetically disfiguring dermatologic diseases may cause significant psychosocial distress for patients.3 Co-morbid mental illness plays a substantial role in the course, severity, response to therapy and therefore the psychosocial well-being of the dermatologic patients. It seems that co-morbid mental illness and its consequences on patients' quality of life have been underappreciated. Therefore, understanding the prevalence of psychiatric co-morbidity and its potential effects on patients' lives may lead to changes in management approaches and ultimately to improve the patients' outcome.
As per available previous studies, strong association is found between dermatological condition and psychological problems.4Approximately 30% and 40% incidence of psychiatric disorders among dermatological patients was observed.5
When assessing dermatological patients, it is best to adopt a multidimensional, biopsychosocial approach, which allows for relative contributions of biological, psychiatric and psychosocial factors, because it may not be possible clearly to determine whether a psychiatric syndrome is primary or entirely secondary to the dermatological condition.6Acne, tineacorporis, vitiligo, scabies, melasma, STIs etc are some commonly occurring disorders and can be psychologically devastating to patients with darker skin type. It can lead to cosmetic disfigurement and affect psychosocial and psychosexual identity. Research have shown that resolution of all these disorders can improve the quality of life. Improvements have been seen in the areas of feeling self-conscious about the skin or being scrutinized by others, feeling unattractive, using cosmetics to cover up the disease and limiting social or leisure activities because of appearance of the skin.7As per available previous research, visible dermatologic skin conditions were significantly affecting the quality of life and psychosocial functioning.8-11
In the present study the aim is to find out the magnitude of anxiety and depression in common dermatological patients and its association with dermatological diagnosis.
MATERIAL AND METHODS-
This cross-sectional study with consecutive sampling was conducted at BRLSABVM Medical College and hospital, Rajnandgaon (C G), India. A total of 170 patients participated in the study during the period July 2020 to December 2020.
Patients suffering from dermatologic diseases who gave informed consent to participate in the study were included in study population regardless of their age, sex, education level and marital status. Subjects were evaluated on a brief semi-structured Performa for collecting demographic and clinical information. Performa was converted in the local language for their convenience. Ethical consideration was made through institutional ethical committee (No./13/GMC/I.E.C./2017. Rajnandgaon)
The questionnaire consists of two parts. In the first part, the demographic characteristics and its related information were collected; and in the second part, five other areas questionnaires were used: DLQI, PHQ-9, HAM-D and GAD-7, PHQ-15. 12-16
Inclusion criteria- Patients suffering from dermatological problem attended OPD.
Exclusion criteria-
Patients having chronic diseases other than dermatological problem.
Past history of psychological illness.
Apparent life stress other than skin disease.
Those who were younger than 15 years of age and who did not give informed consent.
Data was recorded in MS Excel and checked for its completeness and correctness then it was analyzed by using suitable statistical software and p-value < 0.05 was considered as statistically significant.
RESULTS-
Majority of the patients 60% belongs to the age group of 16 to 25 years. Out of the total 170 study subjects, 47.1% were males and 52.9% were females. 34.1% of the study subjects were married and 65.9% were single. Most of study patients were Hindu by religion and out of 170 patients 90 were from urban and 80 were from rural background. 65.9% of the study subjects were unemployed and 34.1% were employed. Majority of the study subjects 43.5% studied up to higher secondary and only 6.5% were post-graduate.TABLE.1
Out of 170 patients, Acne with scar is the common diagnosis i.e., 61 (35.9%) followed by fungal infection 45 (26.5%) and Pigmentary disorder 25 (14.7%). TABLE.2
Among the patients with Acne, the quality of life of most of the patients was severely affected, indicating a poor quality of life. Most of them with Bacterial infection also scored high in the DLQI score and were mild, moderately and severely affected. The majority with Papulo-squamous disease were mild, moderately and severely affected. There was a significant association between quality of life and Dermatological Disorder. TABLE.3
On assessing the severity of depression using PHQ-9, Only 2 patients had severe depression due to STD/VD and Psychiatric disorder and the majority of the subjects had mild and moderate depression due to Acne with scar. Diagnosed depression and grade severity of symptoms in general medical and mental health was found statistically significantly associated with Dermatological Disorder. TABLE.4
Thirty patients with acne had clinical depression followed by 34 patients with mild, moderate and severe depression due to bacterial infection and Papulo-squamous disease.Dermatological Disorder were found to be associated to depression.TABLE.5
Out of total 170 subjects, Majority of them had mild, moderate and severe anxiety due to Acne with scar. There was no significant association found between Dermatological Disorder and anxiety. TABLE.6
On assessing the somatic symptom subscale using PHQ-9, 13 patients had mild and 4 patients had moderate somatic disorder due to Acne. Only 4 patients had severe somatic disorder Papulo-squamous disease. Somatic disorder was found statistically significantly associated with Dermatological Disorder.TABLE.7
DISCUSSION-
Dermatological problems varies from region to region all over the world and also vary depending on different socio-demographic, socio-economic and climatic factors. In the present study, relatively more females (n = 90) attended the OPD than males (n = 80). A similar pattern female to male proportion was found in the study by Kosaraju S.K et al. and Kuruvilla et al. in South India. The more male patient proportion was found in the study conducted by Kar et al. in a Tertiary Care Centre.17-19Most of the patients were from below Englishhttp://ijcrr.com/abstract.php?article_id=4033http://ijcrr.com/article_html.php?did=4033
Aktan S, Ozmen E, Sanli B. Psychiatric disorders in patients attending a Dermatology outpatient clinic. Dermatology 1998; 197: 230-4.
Schultz HY. Society for Investigative Dermatology Skin Disease Comorbidities Project Launch Conference Proceedings. J Invest Dermatol 2009; 129: 525–528.
Gupta MA. Psychiatric comorbidity in dermatologic disorders. In: walker C ,papadoulos L, eds. Psychodermatology. Cambridge: Cambridge University Press; 2005.
Shenoi SD, Prabhu S, Nirmal B, Petrolwala S. Our experience in a psychodermatology liaison clinic at Manipal, India. Indian J Dermatol.2013;58:53-5.
Ghosh S, Behere RV, Sharma P, Sreejayan K. Psychiatric evaluation in dermatology: An overview. Indian J Dermatol. 2013;58:39–43.
Gupta MA, Gupta AK, Ellis CN, Koblenzer CS. J CosmetDermatol. Psychiatric evaluation of the dermatology patient. 2008 Sep;7(3):164-8.
Taylor A, Pawaskar M, Taylor SL, Balkrishnan R, Feldman SR. Prevalence of pigmentary disorders and their impact on quality of life: a prospective cohort study.
Langley RG et al. Ustekinumab signi?cantly improves symptoms of anxiety, depression, and skin-related quality of life in patients with moderate-to-severe psoriasis: results from a randomized, double-blind, placebo-controlled phase III trial. J Am AcadDermatol. 2010;63:457–65.
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Linnet J, Jemec GB. An assessment of anxiety and dermatology life quality in patients with atopic dermatitis. Br J Dermatol. 1999;140:268–72.
Kurd SK, Troxel AB, Crits-Christoph P, Gelfand JM. The risk of depression, anxietyand suicidality in patients with psoriasis: a population-based cohort study. Arch Dermatol. 2010;146:891–5.
Aghaei S, Sodaifi M, Jafari P, Mazharinia N, Finlay AY. DLQI scores in vitiligo: reliability and validity of the Persian version. BMC Dermatol2004 ; 4 : 8.
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Kuruvilla M, Sridhar KS, Kumar P, Rao GS. Pattern of skin diseases in BantwalTaluq, Dakshina Kannada. Indian J DermatolVenereolLeprol 2000;66:247?8.
Kar C, Das S, Roy AK. Pattern of skin diseases in a tertiary institution in Kolkata. Indian J Dermatol 2014;59:209.
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Dalgard F, Holm J, Svensson A, Kumar B, Sundby J. Self-reported skin morbidity and ethnicity: a population-based study in a western community. B M C Dermatology, June 2007,7:4
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Yazici K, Baz K, Yezici AE. Disease specific quality of life is associated with anxiety and depression in patients with acne. J EurAcadDermatolVenereol 2004; 18: 435-9.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareA Questionnaire Study on Assessing Newer Concepts and Diagnosis of Root Resorption Among Orthodontists and General Dentists- Knowledge, Awareness, Practice Survey
English129137Arvind PrasannaEnglish Ramasamy NavaneethanEnglishIntroduction: Upcoming research necessitates a quantitative assessment of root resorption with trends pointing towards increased evidence of iatrogenic root resorption. Aims: This questionnaire survey aimed to assess the knowledge and working principles on the latest protocols of root resorption among orthodontists and general dentists Methodology: A total of 11 questions on root resorption were circulated through Google Forms. The questions evaluated participant’s knowledge and grasp on the topic of root resorption along with awareness about the latest protocols for management. 188 responses were recorded of which 73 were orthodontists and 115 were general dentists. Results: Overwhelming majority noted root resorption with 80% of participants having observed root resorption at some point in time. Nearly 55% believe root resorption can be prevented from further progression if treated at the right time (pEnglishRoot resorption, Diagnosis and treatment planning, Orthodontics, Apical resorption, External resorptionINTRODUCTION
External apical root resorption (EARR) is an acknowledged sequelae of fixed appliance therapy. Force concentration at the root apex during tooth movement is a mechanical effect that seems to trigger biologic events associated with root resorption especially in aberrant root shapes.1 Increased force levels can cause more destruction of cementoblasts by compression of cells and periodontal vessels, increasing root vulnerability to resorption.2 In extracted teeth analysed histologically, it has been found in up to 100% of orthodontically treated teeth but less often in teeth examined by panoramic or intraoral radiographs.3
Numerous investigators have reported that routine orthodontic treatment is associated with a risk of apical root resorption.4, 5 There is general agreement, however, that the presence of preexisting root absorption increases the risk factor and speculations prevail as to the involvement of a genetic predisposition. It is necessary to upgrade pre-existing information on current protocols regarding root resorption and improve diagnostic aids necessary for its prompt treatment.6The standard protocols for observing and monitoring OIRR include periodic periapical radiographs taken during orthodontic treatment.7However, 2D radiographs may not be sufficient to highlight all the surfaces of the tooth in question. Moreover, reproducibility of the radiographs is always questionable due to the difficulty in magnification standardization and angulation errors.8 Hence, the newer modalities of diagnosing root resorption such as cone-beam computed tomography (CBCT), Histological analysis have arrived.9,10 This survey aims to assess the awareness among orthodontists and general dentists regarding the key elements of root resorption.
Newer modes of diagnosis, research protocols have all started to focus on the effect of root resorption. Despite the absence of serious clinical effects, it is necessary for the operating dentist to adhere to the first rule of any treatment, which is to do no harm. Concepts of root resorption are constantly evolving with focused research avoiding confounding factors. Root resorption which is traditionally assessed with respect to only the apical area of the tooth has gradually started changing with researchers focusing on volumetric assessments including the cervical and middle-third of the tooth as well.11 This survey aims to assess the awareness among orthodontists and general dentists regarding the key elements of root resorption, its more recent methods of diagnosis and latest protocols on treatment of root resorption.
MATERIALS AND METHODOLOGY
This study was a knowledge, awareness, practice survey assessing the awareness of orthodontists and general dentists towards the newer advances and protocols followed in root resorption. The survey was prepared using Google forms and sent to the participants through mail or the web link of the survey.
188 participants responded to the survey. Out of this, 73 participants were orthodontists and 115 participants were general dentists. 11 questions were asked in the survey, and all needed to be answered compulsorily. The study participants were from different geographical areas of India and hence their racial characteristics, prevalence all could increase the diversity of the knowledge. The participant’s opinions regarding root resorption were recorded and subjected to statistical analysis.
Statistical Analysis
The data obtained through Google sheets was statistically analysed using IBM SPSS Software Version 20.0. Chi-square tests were used to determine association between orthodontists and general dentists regarding concepts. The pEnglishhttp://ijcrr.com/abstract.php?article_id=4034http://ijcrr.com/article_html.php?did=40341. Aryal N, Jing M. Root Resorption in Orthodontic Treatment: Scoping Review. Orthod J Nepal. 2017 Dec 31; 7(2):47-51.
2. Weltman B, Vig KW, Fields HW, Shanker S, Kaizar EE. Root resorption associated with orthodontic tooth movement: a systematic review. Am J Orthod Dentofacial Orthop. 2010 Apr 1; 137(4):462-76.
3. Abass SK, Hartsfield Jr JK. Orthodontics and external apical root resorption. Semin Orthod 2007 Dec 1 (Vol. 13, No. 4, pp. 246-256)
4. Linge L, Linge BO. Patient characteristics and treatment variables associated with apical root resorption during orthodontic treatment. Am J Orthod Dentofacial Orthop. 1991 Jan; 99(1):35–43.
5. Turkkahraman H, Yuan X, Salmon B, Chen C-H, Brunski JB, Helms JA. Root resorption and ensuing cementum repair by Wnt/β-catenin dependent mechanism. Am J Orthod Dentofacial Orthop. 2020 Jul; 158(1):16–27.
6. Consolaro A. Extensive orthodontically induced dental resorption: What to do? Dental Press J Orthod. 2020 Mar; 25(2):18–23.
7. Apajalahti S, Peltola JS. Apical root resorption after orthodontic treatment—a retrospective study. Eur J Orthod. 2007 Aug 1; 29(4):408–12.
8. Sameshima GT, Sinclair PM. Predicting and preventing root resorption: Part I. Diagnostic factors. Am J Orthod Dentofacial Orthop. 2001 May; 119(5):505–10.
9. Dudic A, Giannopoulou C, Leuzinger M, Kiliaridis S. Detection of apical root resorption after orthodontic treatment by using panoramic radiography and cone-beam computed tomography of super-high resolution. Am J Orthod Dentofacial Orthop. 2009 Apr; 135(4):434–7.
10. Samandara A, Papageorgiou SN, Ioannidou-Marathiotou I, Kavvadia-Tsatala S, Papadopoulos MA. Evaluation of orthodontically induced external root resorption following orthodontic treatment using cone-beam computed tomography (CBCT): a systematic review and meta-analysis. Eur J Orthod. 2019; 41(1):67–79.
11. Kapila SD, Nervina JM. CBCT in orthodontics: assessment of treatment outcomes and indications for its use. Dentomaxillofac Radiol. 2015 Jan; 44(1):20140282.
12. Li X, Xu J, Yin Y, Liu T, Chang L, Tang Z, et al. Association between root resorption and tooth development: A quantitative clinical study. Am J Orthod Dentofacial Orthop. 2020 May; 157(5):602–10.
13. Leach HA, Ireland AJ, Whaites EJ. Radiographic diagnosis of root resorption in relation to orthodontics. Br Dent J. 2001 Jan 13; 190(1):16–22.
14. Graber LW, Vanarsdall RL, Vig KWL, Huang GJ. Orthodontics - E-Book: Current Principles and Techniques. Elsevier Health Sciences; 2016. Jul 15.
15. Segal GR, Schiffman PH, Tuncay OC. Meta-analysis of the treatment-related factors of external apical root resorption. Orthod Craniofac Res. 2004; 7(2):71–8.
16. Lund H, Gröndahl K, Hansen K, Gröndahl H-G. Apical root resorption during orthodontic treatment. A prospective study using cone-beam CT. Angle Orthod. 2012 May 1; 82(3):480–7.
17. Marques LS, Junior P, Jorge M, Paiva SM. Root resorption in orthodontics: An evidence-based approach. Orthodontics-Basic Aspects and Clinical Considerations. 1th ed. InTech: Shangai. 2012 Mar 9:429-46.
18. Kunimatsu R, Kimura A, Tsuka Y, Horie K, Yoshimi Y, Awada T, et al. Baicalin inhibits root resorption during tooth movement in a rodent model. Arch Oral Biol. 2020 Aug; 116:104770.
19. Janson GR, De Luca Canto G, Martins DR, Henriques JF, De Freitas MR. A radiographic comparison of apical root resorption after orthodontic treatment with 3 different fixed appliance techniques. Am J Orthod Dentofacial Orthop. 2000 Sep; 118(3):262–73.
20. Vineet RV. Root resorption: Pathophysiology & Management. diplom.de; 2015. Dec 23.
21. Brezniak N, Wasserstein A. Defining and framing orthodontitis: a new term in orthodontics. Angle Orthod. 2014 May; 84(3):568–9.
22. Kjaer I. Root resorption: Focus on signs and symptoms of importance for avoiding root resorption during orthodontic treatment. Dental Hypotheses. 2014 Apr 1; 5(2):47.
23. Al-Qawasmi RA, Hartsfield JK Jr, Everett ET, Flury L, Liu L, Foroud TM, et al. Genetic predisposition to external apical root resorption. Am J Orthod Dentofacial Orthop. 2003 Mar; 123(3):242–52.
24. Lopatiene K, Dumbravaite A. Risk factors of root resorption after orthodontic treatment. Stomatologija. 2008; 10(3):89–95.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareDepression and Stress Induced Infertility: A Review in Unisex
English138143Gnanaraj VDPEnglish Manohar SSEnglish Dharmaseelan SEEnglish Kandhasamy KEnglishToday, infertility has become more common among young adults due to various reasons which are not easy to determine. The prevalence varies significantly in different parts of the world, ranging sparingly from less than 5% to over 30%. The recent trending cause estimated is the depression and stress due to occupational work. Infertility caused by depression and stress may further cause depression which again worsens the condition. This being the social problem, mass attention has to be achieved in terms of research for resolving it. Many researchers explained the neurophysiology of stress-induced infertility and its probable treatment whereas the exact reason and solution is still a question. In this review, we focus on the neurophysiology, infertility experienced by different occupational workers and the management of stress-induced infertility. A structured and orderly means were undertaken as a key aspect for the systematic literature review.
EnglishInfertility, Stress, depression, Anxiety, Occupation, HormonesIntroduction
Infertility is a common term that resonates in every part and parcel of the world. To define infertility in the terms of the World Health Organization (WHO),it, specifically, is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse.1 In the year 2002, the WHO estimated that infertility affects approximately 80 million people all over the world.2 Bovin et al., in 2007, suggested that nearly 72.4 million couples experience fertility problems.3 This crucial problem is estimated to affect 10-15% of couples in the course of their lifetime.4,5 The prevalence varies significantly in different parts of the world, ranging sparingly from less than 5% to over 30%.3 The major breathtaking estimation is announced by the WHO, that approximately One in every ten couples has primary or secondary infertility. It is essential to identify the clear relationship between age and infertility. The Centre for Disease Control and Prevention (CDCP) reports that in the United States, infertility affects married women, independently from race and ethnicity, approximately with these percentages: 11% of women aged 15-29 years, 17% of women aged 30-34, 23% of women aged 35-39 and 27% of women ages 40-44.6 Moreover, few authors have deliberately come forward to report that the probability of conception decline with age.4,5,6Apart from all these studies, the causal role of psychological disturbances in the development of infertility is still a matter of debate for ages. Anxiety in infertile couples was considerably higher than the general public, with 8%–28% of infertile couples showing substantial clinical anxiety.7
Discussion
Neurophysiology of stress-induced infertility
Intriguingly, neurotransmitters and nuclei within the hypothalamus control stress and reproduction. Gonadotropin-releasing hormone (GnRH) neuron recruitment and activity is regulated by a balance between stimulation, suppression and permissiveness controlled by noradrenaline (NA), neuropeptide Y (NP-Y) and serotonin (5-HT) from the brain stem, impact from glutamate in the medial preoptic area and NP-Y in the arcuate nucleus (AN), in opposition to the restraining influences of Gamma-amino benzoic acid (GABA) within the medial preoptic area and opioids from the AN. Also, Stress activates NP-Yperikarya in the AN and brain stem NA neurons. The latter project indirectly, via the medial preoptic area, or directly to the paraventricular nucleus (PVN) to release corticotrophin-releasing hormone (CRH) and arginine vasopressin (AVP). Stimulation of CRH neurons in the PVN also activates GABA and opioid neurons in the medial preoptic area and reduces GnRH cell recruitment, thereby decreasing GnRH pulse frequency. Oestradiol enhances stress-induced NA suppression of luteinizing hormone(LH) pulse frequency but when applied in the PVN nucleus or brain stem, and not in the medial preoptic area or AN. Another stress-activated pathway involves the amygdala and bed of the nucleus striaterminalis, which contain CRH neurons and accumulate GABA during stress.8 Although both adrenocorticotropic hormone(ACTH) and glucocorticoids (GCs) are elevated in stress, there is little evidence that these hormones directly affect gonadotropin (Gn) secretion or ovulation.9
In normal intact animals, estradiol activation of GnRH–LH surge secretion involves an initial stimulatory oestradiol signal but restraining modulation is mediated by NA and opioid regulation of suppressive GABA neurons. During the later transmission phase in which oestradiol concentrations are higher, a gradual removal of opioid influence may mediate the uncoupling of NA restraint on GABA cells, resulting in a (now oestradiol-independent) more positive NA influence on GnRH–LH release. At the end of the transmission phase, neurotransmitters control the recruitment of more GnRH neurons, culminating in coordinated hyperpolarization and massive outpouring of GnRH into the portal capillaries to cause secretion of the prepared stores of LH. Several reproductive situations involve suppression of GnRH–LH pulsatility mediated by increased sensitivity to oestradiol in different parts of the hypothalamus and brain stem. 8
Effect of occupational stress on infertility
Industrial chemist
In today’s economically fast-moving world, with an increasing number of women entering the work force worldwide, women are exposed to various reproductive toxins. An increasing body of evidence shows a correlation between environmental and occupational exposures and reproductive adverse effects. Eventually, studies have examined the adverse effects of exposures to cigarette smoke,10,11caffeine12 pesticides,13,14 air pollution,15,16 organic solvents,17-22 and occupational stress.23 The National Institute for Occupational Safety and Health estimated that 9.8 million workers in the United States were occupationally exposed to solvents. Organic solvents identified as potential reproductive toxins include benzene,17,18,24 toluene,19,20,21 and related compounds.22 Studies have begun to suggest that even low level occupational exposure to organic solvents is linked to a broad range of adverse reproductive outcomes which is shocking.24,25 There is growing evidence that many environmental and occupational factors are associated with reduced birth weight.26,27 As it is evident, benzene is known to produce several toxic metabolites that affect rapidly growing cells such as bone marrow, cause oxidative damage in the cells, and suppress cell growth.28,29 Likewise, benzene and other organic aromatic solvents were repeatedly shown to be fetotoxic in animal studies, leading to delayed fetal growth and decreased birth weight.30,31 The mechanism by which maternal stress affects birth outcome was thought to be through stress dependent hormones or immunological pathways.32
One notion that is least bothered is that the critical period prior to conception and during pregnancy is an important period for adverse influence on fertility and pregnancy outcome, and that environmental tobacco smoke, and exposures from video display terminals (VDT) and indoor air quality, are the most common concerns of women in their places of work. Benzo[a]pyrene from pulmonary arterial hypertension (PAH) in tobacco smoke and diesel exhaust cause meiotic maturation of oocytes and deoxyribonucleic acid (DNA) adducts in sperm, oocytes and embryos of IVF patients. Polychlorinated biphenyl (PCB)from oils, electric coolant causes impaired response to ovulation induction, reduced parity, impaired lactation, and potential reduced fecundability. Further, dioxins and polychlorinated dibenzofurans (PCDF) from incineration of plastics, automobile exhaust, and pesticide manufacturing cause potential for change in sex ratio and increased risk of endometriosis. Pesticides, usually from herbicides used in combination, cause no apparent effects alone, but decrease in semen content and fecundity, spontaneous abortion, preterm birth, and low in mixtures for gestational age. Also Dichlorophenyl(tri/di)chloroethylene (DDT/DDE) a causes reduced parity, impaired lactation, decreased semen quality, impaired fertility, and small-for-gestational-age babies. Decreased sperm counts & infertility are evidently caused by Dibromochloropropane. Even lead and various metals cause decreased semen quality, increased time to pregnancy, and spontaneous abortion.33
Another important factor is physical load and heavy physical work (high energy expenditure) which cause spontaneous abortion, low birth weight. And frequent heavy lifting cause pre-term birth, spontaneous abortion. Prolonged standing results in low birth weight, pre-term birth, spontaneous abortion. Physical factors like ionizing radiation induces spontaneous abortion, congenital defects and reduced sperm count azoospermia. Similarly noise (0.90 dBA)can also cause spontaneous abortion, low birth weight, pre-term birth.34
Oncopharmacist
While infertility was reported as an effect of chemotherapy for some cancer patients, there was no investigation into the connection of infertility with occupational exposure. Self-reported infertility is consequently associated with occupational handling of chemotherapeutic drugs prior to onset of infertility. Most importantly, prevention of chemotherapy side effects by use of available protection is preferable to risking infertility.35
Flight attendant
In the case of flight attendants, cosmic radiation and circadian disruption are potential reproductive hazards.36 Miscarriage was associated with flight attendants who work during sleep hours and people who work under high physical job demands and who are associated with work under cosmic radiation exposure.37,38,39 and menstrual irregularities.40 Workplace exposures of concern include cosmic ionizing radiation[41] and circadian rhythm disruption.42 Galactic cosmic radiation generates secondary and tertiary radiation at aircraft altitudes,43 including neutrons and energetic photons (International Agency for Research on Cancer (IARC)-known human [group 1] carcinogens).One should note that the solar particle events (transient solar surface eruptions) are also another source of cosmic radiation exposure. To put together, flying across time zones or working during normal sleep hours can affect reproductive hormones with circadian regulation.44
Nurses
Shifts in circadian rhythms may play a role in regulating the reproductive hormones which control the menstrual cycle, either through sleep disturbances or through altered melatonin development. Shift work is even more prevalent among nurses, 24–28% of whom work in the evenings, nights, or rotating shifts. Most studies examining the relationship between shift work and menstrual cycle characteristics support an association between working at night and menstrual function. So night work, long hours, and physically demanding work might clearly relate to menstrual disturbances. The sober thing is that the menstrual cycle is a marker of general reproductive health.45
Inhalation anesthetist
Inhalation anesthetics are commonly administered to veterinary patients. Some of these agents can enter the operating room atmosphere, exposing veterinary personnel to potential risks from chronic exposure to inhalation anesthetic gas concentrations. Epidemiological studies of humans and laboratory studies of animals have suggested that chronic exposure to trace levels of anesthetics may constitute health hazards including fetal death, spontaneous abortion, birth defects and cancer. Significant difference is noted in reproductive risk for women working in veterinary anesthesia when compared to women working in veterinary critical care.46
Military personnel
A person of military is often subjected to work-related stress or life event stress which result in alterations in their menstrual function. Study suggests that women in the military report less day-to-day job stress but more atypical life events, including those related to their jobs, and that these life events in the long run are associated with adverse menstrual consequences.47
Psychological distress in the workplace
Psychological distress has long been suspected as having an important impact on infertility.48-53 In both sexes, psychological factors were found to be predictors of the couple’s fertility status.50-53 However, it is not yet well known if psychological stress is part of the etiology of infertility as a causal factor or occurs as a consequence of the overall question of infertility. While other aspects of work, primarily exposure to chemicals, radiation, etc., have been studied, the effect of working conditions and psychological distress in the workplace on female infertility is a significant but less researched aspect of infertility. It is likely that occupational stress serves as an etiological factor among the male population, although it may be an advice in women. The social responsibility for reproduction and treatment falls even more on women's shoulders than on men. On the other hand, it is possible that choosing a career delays conception and thus recognition of their infertility occurs only at an older age.54
Effect of stress on semen quality
Reports affirm that mental stress causes abnormality of spermiogram parameters. Nitric oxide (NO) is a highly reactive free radical gas that has been demonstrated to have an exceptional range of biological functions.50 NOS has been found in the male reproductive system.56 Being both a cytotoxic and necessary molecule for normal sperm production, NO has a dual function. Under physiological conditions, NO plays an important role in normal sperm production and motility. Evidently, low NO concentrations have been shown to enhance sperm motility,57whereas high NO concentrations reduce it.58Extrahepaticarginase may play a role in reactions other than those of the urea cycle.59 Since arginase is an arginine-depleting enzyme, it is an important part of the cellular arginine regulatory system affecting NOS activity.60 Psychological stress causes an increase of NO level and a decrease of arginase activity in the L-arginine-NO pathway. In addition, poor quality of the sperm may be due to excessive NO production under psychological stress. Thus the arginine-NO pathway, together with arginase and NO synthase, are involved in semen quality under stress conditions.
Stress-induced effects also tend to include meiotic and structural changes in the sperm cells. The spermatogenic process was enhanced after a period of Modulating Radiance Therapy (CRM therapy) conveyor suggesting stress is an important risk factor for idiopathic infertility.61 Identifying the psychosocial risk factors such as stress for poor semen quality is important for improving fecundity and fertility, and may also have implications for life course and intergenerational health.62 In studies examining life stress, one prospective study found no association,63 and another study found positive results for only one particular stressful life event (death of a family member),64 and others were inconsistent with the semen parameter which found an association.64-67 Similarly, a detailed analysis of stress at work found an inverse correlation with semen quality,68 yet two others have not.63, 64
Management
Oxidative stress is thought to have an impact on male fertility and on normal embryonic development in the male germ line. Fertility specialists are therefore actively investigating the treatment of such stress in spermatozoa and evaluating the potential use of antioxidants to relieve this disorder. The antioxidant efficacy of vitamin-C alone on sperm oxidative stress was first demonstrated69 in a small number of smokers. Vitamin-E, on the other hand, was found to effectively reduce ROS concentration and improve fertilization or pregnancy rates. The positive effects of zinc on semen parameters have been known for some time and documented in at least five clinical studies.70-74 A research recently showed the antioxidant efficacy of zinc in reducing multiple oxidant stress measures and increasing motility in asthenospermic patients.75 Thus, the quest to identify novel antioxidants and combinations that are optimized for safety and efficacy is likely to continue. On theoretical grounds, an appropriate combination of antioxidants should be more effective than any single antioxidant since oxidative stress is a non-localized heterogeneous phenomenon. For example, vitamin-C, carnitines, zinc and NAC are all highly hydrophilic molecules; conversely, vitamin-E and carotenoids such as astaxanthin are highly lipophilic structures. Each of these naturally occurring antioxidants with their own unique pharmacodynamic profile for the male reproductive tract is likely to neutralize at least some of the nearby ROS, therefore it transpires collectively to a more effective management of sperm oxidative stress.76
Owing to hormone disorders, auricular acupuncture appears to offer useful alternative treatment for female infertility. As Cindy Margolis puts it, "Infertility is a massive roller coaster of emotions." Psychological intervention is not only necessary to alleviate negative psychological symptoms, to escape anxiety, depression and phobia, but also to improve physical health and a healthy pregnancy. Psychosocial counseling should be offered frequently at any stage of infertility treatment, and not only when treatment fails.77 High glucose level in the blood lead to hormone disruption as there is weight gain and insulin resistance in the body. Hormonal imbalance cause ovary dysfunction which may further cause depression and hence glucose level has to be maintained. 78
Conclusion
Infertility being a global problem everyone as an individual should show attention in resolving the problem. The risk factors explained above should be considered and lifestyle changes should be adopted with respect to the occupation.
Acknowledgement
We acknowledge the suggestions and guidance from management and faculties of all departments and other employees for completing this study.
Source of Funding
Nil.
Conflict of Interest
There are no conflicts of interest.
Authors’ Contribution
DPG Vimala has helped develop the concepts, acquire knowledge and analyse data. In the literary quest, SM Sharumathi contributed. Ebenezer D Sam helped prepare the manuscript. The manuscript was examined by K Krishnaveni and revised.
Englishhttp://ijcrr.com/abstract.php?article_id=4035http://ijcrr.com/article_html.php?did=4035
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareEffectiveness of Assertive Training Program on Knowledge Regarding Prevention of Abuse among Adolescents
English144150Sharma JigyashaEnglish Kaur RavneetEnglish Kaur KawaljitEnglishIntroduction: Abuse is the use of some bad words or treating someone other with harmful treatment that includes mental, physical, sexual, verbal or intellectual maltreatment. Adolescence is the transition age group that includes major changes in life such as social, mental, physical and emotional changes. Thus, the girls are more prone to such conditions and need to be assertive in those particular situations. Assertive training is the procedure of acquiring skills within self and standing for the rights of one’s own. The assertiveness training program should be used and taught to adolescent girls as it can help in improving their social skills, self-esteem and concept. Objective: The primary objective of the study was to assess the effectiveness of assertive training programs on knowledge regarding the prevention of abuse among adolescent girls. Methodology: The study setting was MHR DAV Institute of Nursing, Jalandhar, Punjab. A one-group pre-test post-test design was employed to get data collected. The study sample comprised of 100 adolescent girls who are selected through a purposive sampling technique from the selected nursing institution. A self-structured knowledge questionnaire was used to evaluate the knowledge regarding the prevention of abuse among adolescent girls. Assertive Training Program was prepared and administered to the adolescent girls. Results: The findings of the study revealed that after the administration of the Assertive Training Program majority of the adolescent girls 67 (67%) were having average knowledge regarding prevention of abuse among adolescent girls. The mean difference between pre-test and post-test knowledge was 6.06 and the calculated value (11.23) was found to be statistically significant. Conclusion: The study concluded that after the administration of the Assertive Training Program highly significant difference was found between pre-test and post-test knowledge scores regarding prevention of abuse among adolescent girls which was evaluated by a self-structured knowledge questionnaire.
English Assertive Training Program, Abuse, Effectiveness, Prevention of Abuse, Knowledge, Adolescent girls
Introduction
Abuse is inappropriate behaviour and harmful treatment that influences many populations throughout the world. It is the inappropriate use or treating of the person who is often done by the abuser to unwarranted or inappropriate profit. It classified abuse in many types, such as physical maltreatment, verbal maltreatment, assault, violation, rape, or eve-teasing. A great deal of maltreatment is unavoidable and only can be escaped once they take place. Eve-teasing and sexual abuse are two types of abuse.1 Eve-teasing is the making of unwanted sexual remarks in public places 2 and sexual abuse is sexual behaviour acted upon without consent 3 Assertive training is the program that is used to modulate the behaviour of the person and stand for their rights in the right way. It helps in empowering themselves, interacts equally with every person in society, and creates a positive sense of one. It also increases the respect for self and others. The principal aim of assertiveness training is to teach the person about using social skills in social gathering and recognizing the needs and outcomes for the communication.4
The world health organization estimates that according to worldwide health statistics, 879,000 adolescents have experiences with sexual abuse.5 According to a census, in the world, the maximum number of adolescents i.e. 375 million are living in India and these are covering 40% of India’s total population. Out of this 40% of the population, 69% of adolescents are the victim of different abuse like physical, emotional, and sexual abuse.5 According to a report released in 2016 on criminal offenses in New Delhi, India presented by the former Home Minister of India Rajnath Singh, 1,06,958 cases were reported about the crimes for adolescents in the year 2016. Out of these, 36,022 cases were reported for sexual abuse and the reason was neglect and unable to discuss. 6According to a study conducted on sexual abuse, One-third of the total sample collected had experienced anyone type of abuse sexual abuse. The study also reported gender differences in preferences of sexual abuse.7
Objectives
To assess the pre-test knowledge regarding prevention of abuse among adolescent girls.
To plan and implement the assertive training program regarding the prevention of abuse among adolescent girls.
To assess the post-test knowledge regarding prevention of abuse among adolescent girls.
To compare the pre-test and post-test knowledge regarding prevention of abuse among adolescent girls.
To determine the association of knowledge regarding prevention of abuse among adolescent girls with their selected socio-demographical variables.
Related work:
Patel V et al. conducted a research study in Goa, India on adolescents on sexual abuse and risk behaviours among adolescents. The study was conducted among 12-17 years of adolescents. A total of 811 adolescents were selected and among them 53% were males and 47% were females. The findings revealed that one-third i.e. 266 adolescents had experienced some type of sexual abuse. Out of those 266 adolescents, 47% of adolescents had experienced sexual abuse more than a single time. Gender contrasting was also seen in the types of sexual abuse recorded in the study. There are also differences found in the risk behaviours’ of urban-rural school students. The risk behaviours were found for the students from older students or friends was maximum i.e. 53%, 8% for relatives, 4% of teachers and miscellaneous were 27%. The final findings showed that increased rates of sexual abuse are because of low awareness. 7
Anderson J et al. conducted a research study to find out the prevalence of sexual abuse among children and the nature of sexual abuse in childhood. The research design was used using a two-stage design in which one is with the help of a questionnaire and the other is the face-to-face interview. The sample provided general information on different aspects like prevalence rates, types of abuse, age of the victim, and relation of the abuser with victim and cohort effects. The results revealed that one-third of women in the study i.e. a woman in every three women having one or more times undesirable or forced sexual experiences. The results also revealed that a total of 70% were involved in genital intercourse or other more severe abuse, 12% of them were having sexual intercourse. The results also showed that the majority of the offenders were young men. The prevalence rates also showed that there are no urban or rural differences among samples with their age groups. 8
Kathleen B et al. carried out a research study in the United States on childhood sexual abuse by family members. The study aimed to assess that if a woman is sexually abused as a child in her own family had also experienced more childhood abuses in other forms like physical abuse as compared to the women who had experienced physical abuse. The sample includes 60 females who were not sexually abused and 89 females who were sexually abused in their own families. The study showed that the sexual abuse-related factors and violence in the family members of the victim must be contemplated for the individuals and strategies to stop the potential crimes by experienced individuals. 9
Carry PD et al. conducted a cross-sectional study in South Africa on risk indicators and psychopathology in traumatized children and adolescents with any history of sexual abuse. The study sample showed the results about risk indicators in traumatized children and the most prevalent psychological after-effects of trauma. The total sample selected was 94 and those were selected as who are exposed to any trauma in their life. The final results of the study showed that increased rates in child sexual abuse are indicating higher rates of post-traumatic stress disorders in the selected traumatized samples. 10
Nwadinobi V conducted a study for assessing the role of assertiveness training programs for the prevention of non-consensual sexual experiences and abuse. The total study sample in the research study was 50 girls. The study indicated that 6 sessions were administered among 50 girls. The findings revealed that there is a significant improvement in the knowledge that non-consensual sexual abuse is a legal issue. 11
Abraham S conducted a quasi-experimental study of the management of sexual harassment through assertiveness skills. The study consisted of 150 adolescent girls. The findings revealed that the majority of adolescent girls have some form of sexual harassment experience. There is a slight change in assertiveness level after intervention as well as a change in management of sexual harassment skills.12
Lobo L conducted a research study on the relationship of sexual abuse knowledge with assertiveness skills and self-confidence among young adolescent girls. The study consisted of the four selected high schools in Mangalore city. The sample size was 100 respondents i.e. 25 girls of age group 13-15 years from each school. The research study concluded that nearly half of the girls were having poor knowledge. The findings also revealed that there is a significant increase in the knowledge of the girls with increasing assertiveness scores.13
Dzimadi R had undertaken a study to evaluate the knowledge of sexual abuse among female adolescents in Malawi. A total of 219 samples were selected from systematic random sampling. The results showed that 41% of sexual abuse was prevalent in the selected sample, 55.6% reported the sexual abuse, 44.4% of the total sample were silent about their experiences. 27.8% of the total sample had told about sexual abuse to their friends, 16.7% of them had told to their mothers, 7.8% of them told to other family members including sisters, aunt’s etc.14
Amole K ascertained a study to know the impact of assertive training programs among nurses. The study findings revealed that a highly significant difference was noticed between before and after training programs regarding the practice of communication skills, assertiveness and self-esteem. 15
Makinde OB et al. undertook a study to evaluate the effects of assertiveness training on self-esteem in Lagos secondary schools. The sample selected was a total of 96 adolescents i.e. 48 males and 48 females from schools. The research design was quasi-experimental with a pre-test post-test control group method was undertaken. Two tools are used to find the final results for the study. The findings concluded that assertiveness training and mentoring were quite effective for increasing self-efficiency. The study also concluded that there was no association between religion and the educational status of parents with assertiveness training and mentoring. 16
Material and methods
Ethical clearance was taken before conducting the study from the ethical committee of MHR D.A.V Institute of Nursing, Jalandhar. The reference number of the ethical committee approval letter is 8A/39.
This pre-experimental research design was conducted at MHR DAV Institute of Nursing, Jalandhar, Punjab. The sample was adolescent girls studying in B.Sc. (N) 1st and 2nd year and those who are interested to attend the data collection procedure.
Research approach: Quantitative research approach was contemplated and found appropriate for the study.
Study design: Pre-experimental research design with one group pre-test post-test method was used in the study.
Study Location: The study was carried out in a nursing institute based in Jalandhar, Punjab at MHR DAV Institute of Nursing.
The sample size was 100 adolescent girls studying in B.Sc. (N) 1st and 2nd year.
Sampling technique: The technique to draw the sample used was Non-probability purposive sampling.
Methodology
Development of tool:
Part I: - Socio-demographic variables: The variables to find out the personal information of subjects on aspects like age, residential area, currently residing in, type of family, father and mother’s education and occupation and previous source of knowledge regarding prevention of abuse.
Part II: - Self-structured knowledge questionnaire to evaluate the knowledge regarding prevention of abuse.
Data collection procedure
Final data were collected after getting administrative acquiescence. The aim of the research was described to the sample and was assured regarding anonymity and confidentiality of the data given by them, and informed consent was obtained to engage in the investigation.
Pre-test: Pre-test was administered to adolescent girls in the form of a structured knowledge questionnaire on the prevention of abuse.
Implementation of Assertive Training Program: The assertive training program was administered (Figure 1) on the same day of the pre-test to adolescent girls.
Post-test: Post-test was carried out on the 3rd day of pre-test with the same set of structured knowledge questionnaires on prevention of abuse.
Statistical analysis
Data were analyzed using inferential and descriptive interpretation. Interpretation and evaluation of data were performed employing percentage, mean, and mean percentage, standard deviation, chi-square and paired t-test. Paired t-test was performed to ascertain the significant differences between mean pre-test and mean post-test values. Chi-square was employed to know the association of knowledge with selected socio-demographic variables.
Results
Description of socio-demographic variables
Most of the adolescent girls i.e. 68% are in the age group of 19-20 years, 47% of adolescent girls are residing in urban areas, majority of adolescent girls i.e.75% are currently residing in a hostel, 78% of adolescent girls are belonging to the nuclear family, 62% of adolescent girls are having previous knowledge about prevention of abuse from media, 38% of adolescent girl’s fathers are having education up to 11th to 12th, 36% of adolescent girl’s mothers are having education of graduate or above, 36% of adolescent girl’s fathers are a government employee and 82% of adolescent girl’s mothers are home-maker.
Maximum score = 30 ***Significant at 0.001 level
Minimum score = 00 df=99
The mean pre-test knowledge score was 13.90 (±4.56) and mean of post-test knowledge score was 19.96 (±3.26) (Figure 2). The findings revealed that mean difference between pre-test and post-test knowledge was 6.06. The calculated‘t’ value (11.23) was found to be statistically significant at 0.001 level of significance (Table 1). Hence, it revealed that the difference in the mean pre-test and mean post-test knowledge score regarding prevention of abuse was a true difference not by chance.
df = 99 * = Significant at 0.05 level
*** = Significant at 0.001 level NS= Non-Significant
The findings indicate the mean pre-test and post-test knowledge scores of different areas regarding prevention of abuse among adolescent girls.
It showed the total gain in the knowledge after an assertive training program in the concept of eve-teasing (0.49), causes and impact of eve-teasing (1.13), the concept of sexual abuse (0.61), acts involved in sexual abuse (1.08) and prevention of abuse through assertiveness (2.63) (Table 2) (Figure 3).
The calculated t-test for the concept of abuse and eve-teasing is 1.26 which is not found significant, concept and impact of eve-teasing is 2.04 which is significant at the level of 0.05, the concept of sexual abuse is 1.90 which is found significant at 0.05 level, acts involved in the sexual abuse is 1.98 which is also significant at 0.05 level and prevention of abuse through an assertive training program is 4.66 which is highly significant at 0.001 level (Table 2)
It is concluded from the association scores with pre-test knowledge that socio-demographic variables like the previous source of knowledge and father’s education influenced the knowledge of adolescent girls on prevention of abuse. (Table 3)
Discussion:
Assessment of the pre-test knowledge:
The analysis of the first objective showed that in the present study, the mean pre-test knowledge score was 13.90. As per the level of knowledge more than half of the adolescent girls i.e. 53 (53%) were having below-average knowledge regarding prevention of abuse. These same findings are found in the study that the maximum number of adolescent girls were having below-average knowledge regarding prevention abuse before intervention17.
Assessment of the post-test knowledge:
The analysis of the objective showed the major findings of the mean post-test knowledge score was 19.96. As per the level of knowledge most of the 67 (67%) adolescent girls were having average knowledge regarding prevention of abuse. The study of other investigators revealed the same findings17. The research was conducted on 207 student nurses from four different grades. The study findings revealed that 60.4% of students were having increased post-test scores.
Compare the pre-test and post-test knowledge:
The analysis of the objective showed that after the administration of the Assertive Training Program there was a significant increase in post-test knowledge scores among adolescent girls, which was statistically significant at 0.001 levels. The findings are similar to the study conducted in Nigeria in high school with 174 high school girls18. Two different sets of questionnaires were used, one on self-efficacy and the other on sexual assertiveness. The outcome was found that there was a significant increase in sexual assertiveness scores. The investigator found that the program was effective for the sexual assertiveness of high school girls.
Association of socio-demographic variables with knowledge scores:
The findings in the objective revealed that the association of pre-test knowledge score with their selected socio-demographic variables i.e. previous source of knowledge regarding prevention of abuse (13.41) and father’s education (18.46) was statistically significant at pEnglishhttp://ijcrr.com/abstract.php?article_id=4036http://ijcrr.com/article_html.php?did=4036
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Abraham S. Management of sexual harassment through assertiveness skills. J social work edu pract Int Peer Rev J. 2016; I(I):81-97. https://www.jswep.in/uploads/3/1/7/2/31729069/management_of_sexual_harassment_through_assertiveness_skills.pdf
Lobo L. Sexual abuse knowledge and its relationship with self-confidence and assertiveness skills among young adolescent girls. Int J Sci. Study 2018 Sep;7(9):42-6.
Dzimadi R, Klopper H. Knowledge of sexual abuse amongst female students in Malawi. Curation. 2007 Sep;30(3):23-30.
Kanade A. The effects of an assertiveness training program on nurses. Indian J Psych. 2018; 15(2):19-23.
Makinde OB, Akinteye AJ. Effects of Mentoring and Assertiveness Training on Adolescents’ Self-Esteem in Lagos State Secondary Schools. Int J Soc Sci Res. 2014 Jun;2(3):78-88.
Slater J. Effecting personal effectiveness: assertiveness training for nurses. J Adv Nurs. 1990 Mar;15(3):337-56.
Agbakwuru C. Effect of assertiveness training on resilience among early-adolescents. Euro Sci J. 2010 May;8(10):69-84
Kaur Sumanpreet. Effectiveness of structured teaching program on knowledge regarding sexual abuse. Int J Nur Edu. 2017; 5(1):33-43.
Correlation between Mental Well-Being and Decision Making Competency (Dmc) Among Early Adults. Eur J Mol Clin Med. 2021; 8(2):892-902.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareEmotional Intelligence Using Ability Model in Context of Nursing and its Impact on End-Stage Renal Disease Patients: A Narrative Review
English151158Kogila SupramanianEnglish Rashidah ShahruddinEnglish Mahendran SekarEnglish Background: Emotional intelligence (EI) using an ability model that contributes to the precise appraisal and emotional expression by oneself and also for others. Regulation of emotion in an effective way enhances motivation, planning and gaining achievement for one’s life. Objective: The present review aimed to provide comprehensive information on the ability or branch model of EIin the context of nursing and its impact on chronic disease patients which focuses on haemodialysis patient’s decisions on their treatment. Methods: To complete this review, relevant literature was collected from several scientific databases including Science Direct, Google Scholar, Scopus and PubMed. After the complete screening, the obtained information has been summarized and included in the present review. Results: The detailed information about the concept of EI in the context of nursing, EI for end-stage renal disease (ESRD) patients and strength of ability model were discussed. The ability model and components using Meyer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) were also highlighted in this review. Conclusions: EI is needed to handle situations where emotions are an important role apart from other domains in life which include physical and mental wellbeing. The treatment decision needs an emotional approach that can lead patients with chronic illness to have better decisions to increase their quality of life.
EnglishEmotional intelligence, Ability model, Patient-nurse therapeutic relationship, Quality of life, Chronic kidney failure, End stage renal diseaseINTRODUCTION
A person’s ability to express and control their own emotion is essential, but so is their own ability to understand, interpret and respond to the emotions of others. Psychologist refer this ability as emotional intelligence (EI), and some experts even suggest that this can be more important than intelligence quotient (IQ) in overall success of a person. An ability to perceive can also be referred as EI, control and overcome emotions. Some studies suggest that EI can be adopted, learned and fortified, while some entitled it as an inborn characteristic. One of the leading researchers on EI had defined as it is an ability to monitor own feelings and emotions.1 It has been a guide to discriminate among them and the information’s is used for the purpose of thinking and action. EI has an empirical effect on different aspects of our lives and thus EI has become an important mantra for present-day organisations. Problem-solving for an individual has been classified into four areas of branches.2 They have divided the mind into three different component known as cognitive which is the knowledge, affective which is to rationalize and motivation for self and others.
Excitement is a short, severe and general reaction of an organism to an unexpected emotional state. Some of the problems in the field of EI are an integral part of the life of an individual and play an important role in our actions and understanding our and others' enthusiasm, managing momentary impulses, sympathising with others, and using excitement in thought and understanding. EI is an issue that can direct someone’s life and make him/her better adapt to a new situation. Features of EI are completely consistent with the nursing profession. The nurse's job requires them to learn self-knowledge, interpersonal and intrapersonal skills, control of enthusiasm, and the extension of sympathy and therapeutic relationships between patients and nurses. In their interactions with colleagues and patients, nurses use the functionality of EI. EI offers a conceptual framework for understanding how effectively individuals identify, process and regulate emotions in themselves and others.3EI has been hypothesized to have a protective effect on individuals facing health challenges through mechanism related to stress processing and regulation.4 According to Mayer and Salovey4,EI leads to someone’s ability to perceive, express, understand, use and manage emotion for own self and others. Based on the literature we have found that person’s EI is high if they can able to understand and control their emotions. Therefore, the present review aimed to provide comprehensive information on ability or branch model of EI in context of nursing and the effect for end-stage renal disease (ESRD) patients which focus on haemodialysis patient’s decision on their treatment.
METHODS
To complete this review, relevant literature was collected from several scientific databases including ScienceDirect, Google Scholar, Scopus and PubMed. The categories of keywords used for searching are “Emotional Intelligence” AND “Ability Model” OR “Context of Nursing” OR “Renal Disease Patients” OR “Quality of Life” OR “Chronic Kidney Failure”. After the complete screening, the obtained information has been summarized and included in the present review.
RESULTS
I. Attributes of Emotional Intelligence
EI research first appeared in academic articles that began in the early 1990s. The theory had gained substantial popularity by the mid-decade and powerful claims were made about its importance in predicting performance. Until now, many investigators have thought of EI in much the same way, and there is a much greater understanding of what EI is, how it can be measured, and what is expected than there was even a decade ago. Although the word EI is used alternately, it is more likely to refer to a set of different positive characteristics and abilities, not all related to emotions, intelligence or their intersection.5
Through the field of cognition and affect, the study of EI developed, looking at how emotion influenced thought. Emotion was originally believed to have a negative effect, which can also be considered to be adaptive to thought and to balance each other.6 Mayer and Salovey has developed their first theory of EI, which was popularized by Goleman.7Goleman also suggested that EI was central to the success of life. Since then, multiple hypotheses have arisen of contradictory viewpoints, and consequently, measured differently.
II. Concept of EI
According to Bar-on8, EI is not a new concept and it is becoming notifiable and very much useful in the context of psychology. It is present from the Vedic times. A numbers of texts are available in these about it. In modern concept Alfred Binet who was one of the pioneers of intelligence test believed that general intelligence might not be the only factor important for social intelligence whereas EI also can be viewed as a subset of social intelligence that has been explained by many psychologists.9 EI has been discussed in work of various psychologists and other workers in this field like in Howard Gardener’s theory of multiple intelligences and the association can be seen between EI and interpersonal intelligence and intrapersonal intelligence.10
Though, EI was established by Salovey & Mayer1, and in 1995 by Goleman has published a book on EI.11 Since then the practice of EI is widely known. Goleman11further elaborated the concept of EI and divided into five basic emotional and social competencies-self-awareness, self-regulation, motivation, empathy and social skills. In General, the models of EI have classified it as individual intelligence and social intelligence. Salovey and Mayer1, revealed EI as understanding and also to manage owns and others emotion. EI can be divided into five attributes namely current environment for example daily life hassle and stressful situations, emotional literacy for example self-awareness, emotional awareness, emotional expression and emotional awareness of others.
Other than that the EI competencies such as intentionality, creativity, resilience, interpersonal connections and constructive discontent, EI values and attitudes that include a person’s outlook, compassion, intuition, trust radius, personal power and integrated EI outcomes such as general health, quality of life, relationship quotient and optimal performance. EI also referred as “an array of non-cognitive capabilities, competencies and skills which influence one’s ability to succeed in coping with environmental demands and pressures”, it can be improved by training and lack of which can lead to emotional problems and failure.12
III. Emotional Intelligence in the Context of Nursing
As stated by Petrides13, research for EI in the nursing could be more effective if it is well developed and well utilized for the conceptual peculiarity of EI model were adopted and applied in nursing research. Ability EI is considered a cognitive ability related to judgemental and problem solving in the domain of emotion.14 Researchers need to study not only the structural characteristics of nurses such as education and staffing levels, but also the interpersonal and extra-personal characteristics in view of the nature of the nurse-patient relationship. This will offer a fuller understanding of the influence that nurses have on the patient outcomes such that strategies might be developed in order to improve patients care and their quality of life.
The first element of self-compassion, common humanity, refers to the shared human experience. Stressful situation is experienced by every human. Mostly this occurs due to the external factors, such as culture, genetics, and environmental conditions impact behaviors and relationships with others. The integral recognition of our common humanity by a person and the ability to recognize the external factors that make us unique can enable one to be non-judgmental and understanding. Self-kindness requires self-understanding when we are struggling or feeling inadequate without being self-critical. When one accepts painful experiences with self-kindness, one is more apt to experience that pain calmly and rationally, rather than with anger and frustration. The third element of self-compassion is mindfulness, a mind state whereby one can observe feelings and events without exaggerating, denying or suppressing them. Mindfulness allows for a larger perspective on the situation. Being attentive implies a balanced approach to negative emotions.
Well-being, self-control, emotionality and sociability are four factors that are important to in EI. The factor self-control contains the components of emotion regulation, stress management and low impulsiveness. Another of the four factors, emotionality involves emotional awareness of self and others, communication of emotion, abilities in relationships and empathy. People who perceive themselves as emotionally high performers are able to be clearer about their own emotions and communication. They are able to take another’s perspective and might have more fulfilling relationships. The last element, social abilities, the ability to manage emotions and assertiveness.
IV. Emotional Intelligence for ESRD Patients
Haemodialysis is a life-sustaining procedure for ESRD patients, although this procedure is needed to sustain patient’s life an accepted consequence of haemodialysis. Mental and social health of haemodialysis patients depends on the amount of stress and mental pressure whereby emotionally they have disturbance and can lead to isolating self.15Chronic kidney failure (CKF) patients that are treated according to the illness, however their mental and social wellbeing affect them which can affect their quality of life.16
While haemodialysis increases life span of patients, it affects all aspects of natural life and creates many problems for patient, including hypotension, nausea and vomiting, sweating, seizures and air embolism which may cause entry of air into the patient’s vascular systems. Other complications of haemodialysis include restlessness, lack of control over the treatment process, limited activity due to changes in diet, sleep disturbances, changes in body image, inability to communicate with friends and family, mood changes, loss of social security, creating dependence on others changes, and change in quality of life.17
People with chronic diseases may experience more problems including low self-esteem, emotional and behavioural problems that CKF is not an exception in this regard. The incidence of CKF and treatment procedures, including haemodialysis, can create some complications for the patient. Eventually leading to lifestyle changes, health status and is role in society and changes in quality of life.18 Mental and social health of haemodialysis patients depends largely on the amount of stress which cause them to have poor mental status and mental problems and social isolations. CKF patients are treated to provide their health, while several physical, mental and social stressors affect them overshadowing the quality of life for dialysis patients. Therefore, studying the concept of quality of life haemodialysis patients by a nurse is a very important issue.19In contrast with other healthcare workers, nurses are the caregivers in hospitals who appear to stand out. To ensure an ideal atmosphere for the well-being of their patients, they are constantly on the front lines of the battle.
V. Emotional Intelligence Using Ability Model
The most initial model was formed by Salovey and Mayer.1 Their initial conception presented EI as a complex construct consisting of three abilities namely 1) the identification and expression of emotions 2) the regulation emotions of emotions 3) Application of emotional information to thinking and action 3) Application of emotional information to thinking and action. It included only cognitive abilities associated with the processing of emotional information. Daniel Goleman popularized this concept in 1997, through his book and the attention to Corporate America was turned towards EI.
It has been described by Mayer and Salovey2, that perception, appraisal and emotional expression through dimension as a person’s ability to recognise and differentiate emotion in oneself and others. This process takes place in a person’s feeling, body arousal and thoughts. Once a person experience emotions, they will consequently the emotions can be captured and recognized. With that a person can distinguish between a real and inaccurate expression of feelings, as well as differentiate the honest and dishonest expression of feeling. Intelligence can also be referred as ability by giving a situation to a person to solve and from there we evaluate the result patterns of correct answers.19 It can be seen that the models of EI are based on different conceptualizations and hence lead to an interesting mixture of confusions and controversies regarding the best model, which represent EI.
The ability model views EI as a traditional intelligence, made up of a set of specific, interrelated abilities. This model states that emotions are evolved signal systems and each emotion conveys a specific meaning. For example, fear conveys meaning that one in under attack and will need to escape.2 The ability model also states that EI can be learned and it develops with age. According to ability model, EI can be divided into four branches, which are explained below. The ability to perceive emotions involves non-verbal expression through face, voice and other communication channels and perception of emotions, and the capacity to recognize emotions in other’s faces and postural expressions.
Ability to use emotion to facilitate thought deals with the ability of emotions to assist in thinking. Part of intelligence involves ability to build a knowledge base of previous emotional experiences, from which we can draw information for thinking. An individual can use their own emotion in reasoning, critical thinking, problem-solving and interpersonal communication.2 A person’s judgmental and intense emotion will help in rationalizing and also for memory process. Therefore, emotionally intelligent person able to make decision which can be useful in their critical condition. Understanding emotions of own self and others involves the capacity to analyse emotions, appreciate their probable trends overtime and understand their outcomes. A difference between emotion and identifying it can be referred as understanding emotions. A feeling of pleasure is a feeling of being happy and satisfied whereas a feeling gloomy can make a person to shed tears of sadness.
Managing emotions is ability to regulate emotions, according to an individual’s environment, self-awareness and social awareness. For example, to control anger, we ask someone to count from 1 to 10, before reacting.2 This is to enhance a person to have cognitive and emotional growth of an individual. A relevant thinking process will guide thinking process to plan. If a person has effective regulation of emotion, they can tend to accept feeling of pleasant and unpleasant. The four branch model uses the Meyer-Salovey-Caruso Emotional Intelligence Test (MSCEIT) to measure EI. The MSCEIT is the most recent version and measures the four branches in eight tasks (two in each branch). MSCEIT uses both expert and consensus scoring approaches and is available commercially with Multi Health Systems, Canada.
Human intelligence is among the most frequently studied construct in the field of individual differences. The theoretical foundation empirically demonstrated in the useful of cognitive ability tests.20 However, some researchers argue that the IQ is a rather narrow concept. Therefore, cognitive intelligence is a potential predictor of educational and professional success, it is nonetheless an imperfect predictor of successful functioning relies not simply on cognitive intelligence but rather on the relatively new construct of EI. Historically, at least part of this suggestion may be traced to Goleman.11He has viewed that EI is much more important than cognitive intelligence and personality. These models can be classified into two fairly distinct groups that is ability models and mixed models.
With the exception of Mayer & Salovey’s ability model, existing conceptualizations of EI are mixed, and so expand the meaning of this construct by explicitly incorporating a wide range of personality characteristics. However, ability versus mixed models of EI not only vary considerably regarding the scope of conceptualizations but also with respect to the proposed instruments used to measure EI. Mayer and Salovey2, presented their revised and refined conceptualization of EI that strictly constrain EI to mental ability concept and separates it from classical social-emotional personality traits. EI as collection of emotional abilities can be divided into four classes or branches. The best model of EI is the ability model whereby it follows a very common definition known as managing emotion of owns elf and others.21
Mayer et al.22 claimed that only psychometric performance tests of the proposed emotion-related abilities, enabling discrimination between correct and incorrect responses, can demonstrate and prove the existence of EI. Mayer has developed Multifactor Emotional Intelligence Scale (MEIS) that consists of 12 performance tasks designed to measure the four branches. Hence, Robert et al. has revealed that MEIS had problem related to measurement and scoring. To resolve some of the problem, and as well to improve the psychometric qualities of the MEIS, Mayer and colleagues developed the MSCEIT. Mayer and Salovey2, has argued that EI is based on ability of a person and not a trait which has been supported by Goleman11, in which it will increase by age and teaching a person. The instrument used to assess EI by Mayer and Salovey is the best can be used to differentiate ability.23
Figure 1 indicates on the branches of ability model of EI. The four branches that explained are used in the context of mental abilities, and in the EI area, some research focuses on specific abilities related to emotional intelligence, and other research examines many abilities together. Specific ability models examine a particular realm of EI in depth. The integrative approach to EI can provide a reasonable first overview of an area because it draws together examples of the specific areas that make up reasoning about emotions and emotional information.
VI. Strength of Ability Model
In the course of the last two decades, EI researchers have developed three major models and they are the ability, mixed and trait EI models. The main difference in these three categories is whether author’s model perceives their EI as an innate human trait or competence that can be systematically developed over time. Thus, measuring EI differs per model varying from strict ability testing with right and wrong answers to subjective self-report types of measurement. Ability models regard EI as a pure form of mental ability and thus a pure intelligence.
In contrast mixed models of EI combine mental ability with personality characteristics such as optimism and well-being. Wherein, trait models of EI refer to an individual’s self-perceptions of their emotional abilities. The ability model of EI is proposed by John Mayer and Peter Salovey.6 John Mayer and Peter Salovey first coined the term “emotional intelligence” in 1990 and have continued to conduct research on the significance of the constructs.6 Their pure theory of EI integrates key ideas from the field of intelligence and emotion. They further, mentioned that EI is based on a model of intelligence. It implies that EI consists of two areas: the ability to perceive, react and manipulate emotional information without necessarily knowing it, and the ability to understand and control emotions without necessarily perceiving feelings well or experiencing them entirely. He had developed four branches for this model that has been discussed earlier.6 Conception of EI strives to define EI within standard criteria for a new intelligence. Therefore, the ability based model views emotions as useful source of information that helps one to work in social environment.
The measurement of Mayer & Salovey’s model of EI is the MSCEIT which was formed on a sample of 5000 men and women. It has been designed for individuals 17 years of age or older and aims to measure the four abilities outlined in Salovey & Meyer’s model of EI with 141 items. Each ability that is the perception, facilitation of thought, understanding and regulation of emotions is measured by using specific tasks. Perception of emotions is measured by rating the extendtype of emotion expressed on different types of pictures. Thinking facilitation is calculated by basking individuals to draw comparisons, such as light, colour and temperature, as well as emotions and feelings, between emotions and physical sensations. Understanding is assessed by asking the subject to explain how emotions can blend from other emotions, such as how emotions, such as anger and rage, can shift from one to another. Regulation of emotions is measured by people having chosen effective self and other management techniques.
DISCUSSION
A new concept that fascinates the world of academia, business and health care is known as Emotional Intelligence. While their appeal seems almost intuitive, people have only started to appreciate the relevance of this concept by understanding the very nature of relationships and our effectiveness in working with others. In a study stated that many different ways can be used to conceptualize the ability and the most significant is facial expression.24 Some individuals have argued that when making decisions and taking actions, emotions are just as important as rational, intellectual thought. In nursing profession emotions are useful when facing life-and-death decisions, all data, including data obtained from emotions, can be considered critical. Improving in decision making and problem-solving is one reason for identifying EI as a feature of effective nursing performance.
Many other explanations have been identified why EI can be linked to a successful performance.25, 27 One such reason is that emotions are essential to creating and maintaining a caring environment.28 The nurse’s ability to establish a rapport with patients, manage their own emotions, and empathize with patient is essential to providing quality care. Improving EI skills can help nurses deal with the healthcare environment’s emotional demand, which can be stressful and exhausting and potentially lead to burnout. Whitley-Hunter29 revealed the relationship between EI and nursing performance in clinical staff nurse and reported that there is a significant correlation between these two variables in 27 clinical staff nurses in the United States. However, the relationship between EI and nursing performance has not been established in undergraduate and graduate nursing students.
Many researchers understand that EI awareness is a key factor.30 A lack of self-awareness of one's emotional relationships and friendships.11 EI can also be understood and interpreted as the ability to combine emotion with intellect and use emotions as a tool for problem solving and decision making that allows someone to fulfil life from both an empirical and a theoretical perspective EI is an important topic of relevance to nursing. The increasing frequency of published empirical studies the growing interest in this area of research around the world. In 2000, the number of EI related article published began to rise, with a major peak in 2004.
The findings of EI enhance several aspect of professional nursing importance. The true view point in nursing is linked to basic human needs in relation to wellbeing and suffering experiences. Nurses need to have emotional emphatic and understand the insecurity of patients while at the same time being able to contrast between their own needs of the patient and prevent isolating themselves from the way they think and behave as professional nurse. The ability to emphasize and communicate productively is a major requirement in nursing, as it emphasizes human relationships while non-verbal communication may reveal a lifetime a lifetime of emotions. EI plays a meaningful role in both the perception of the moral dimension and insensitivity in clinical practice.
EI may also have consequences in nursing for the advancement of wellbeing and the quality of working life. EI has the potential to enable nurses to cope better with stressful situation and therefore contribute positively to the maintenance of physical and mental health together with career pathway. Positive emotional wellbeing seems to be affected by one’s ability to actively control feelings and build impulses that are aligned with core value or personal beliefs. Several EI research studies have shown proof of a strong correlation between measured EI and efficient leadership results in many professional disciplines, including nursing. There are empirical findings within the nursing discipline that provide proof of the value of EI as a characteristic for nurse leaders. In one Meta-Analysis performed, EI performance research studies revealed a constructive correlation between EI and measures of performance. In times of transition, these results include leader performance, retention, positive fiscal results, customer loyalty, and organisational resilience.
In nursing, these findings are particularly important as the whole health care sector is entering a time of dramatic change. Evidence also shows that EI has a positive relationship with the development of leadership in small groups. In addition, there is evidence that in both nurse leaders and leaders in other careers, peer coaching techniques can be effective in improving EI. In nursing, EI capacity has an important position, where compassion and care are two pillars of the profession. Nurses must be able to recognize, use, control, and appreciate feelings not only in themselves, but also in relation to others, in order to provide compassionate treatment. EI capacity to think in lectures is not to be considered and must be improved by active listening, interaction and involvement.
A handful of methods for improving EI skills are supported by studies. Most of the study incorporates EI and leadership development together; the use of coaching is also included in other studies. One of the first studies examining EI development showed that, relative to a group that received no training or education, EI scores increased with education and training in small groups. The study also showed that, six months after the intervention, improved EI scores continued to increase. Some recent evidence is also available to support the use of peer coaching to improve EI. This study showed that the participants strengthened their understanding and knowledge of their EI skills by using peer coaching.
Emotion has historically been seen as an obstacle to rational thinking and professionalism, generating the impression that emotions should be regulated. However, EI can be termed as motivating factor as well.31 At present, theorist and researchers generally describe many models of EI as general intelligence, a set of mental skills related to accurate EI process, a set of mental skills that relate to accurate processing of emotion-relevant intelligence.6
A few previous studies have been discussed about the importance of emotional states on physical health.32 Negative emotional conditions were believed to be correlated with unhealthy patterns of physiology functioning, whereas positive emotional conditions were associated with healthier patterns of cardiovascular activity and immune system response.33
Individuals who can control emotional states are healthier because they can recognise and assess emotional states correctly, have the capacity to know the appropriate time and purpose to communicate their emotions, and can regulate their mood states affectively.32 According to Taylor34, people with high EI levels can better deal with life's difficulties and have the ability to control feelings that are both good for psychological and physical health. In addition, it was also reported that EI individuals would be healthier than those with lower EI, who are able to express, understand, and control feelings, and who are able to cope with stress.35
In addition, EI was found to be positively associated with certain psychological well-being measure that included life satisfaction and happiness, but negatively correlated with depression, stress and loneliness.36 EI was thought to be a dynamic construct that involved emotion, personal and social skills as part of self-assessment of emotion on oneself and another, establishing and sustaining relationships with others, ability to convey emotion, regulation of emotions, self-control, and solving effective problems.37
CONCLUSIONS
The ability model suggested that EI can be referred as operationalized also as mental ability by using the MSCEIT which is reliable measurement tool that can predict significant psychological and behavioral outcomes. Chronic illness patients such as CKF and ESRD patients that have depression and relationship problems can be assessed for EI for further management. The treatment decision will need emotional approach that can lead those patients with chronic illness to have better decision in order to increase their quality of life. However, preliminary and more studies will be needed to test the validity of MSCEIT. The future research may reveal more on individuals with the level of EI and by using the MSCEIT the ability according to the branches need to be identified. EI is needed in order to handle situations where emotions are an important role apart from other domains in life which include physical and mental wellbeing.
ACKNOWLEDGMENT
The authors also would like to thank University Kuala Lumpur Royal College of Medicine Perak, Malaysia for providing the necessary facilities and resources to complete the study.
CONFLICT OF INTEREST
The authors declare that they have no known conflicts of interest.
FUNDING
There is no significant financial support for the work that could have influenced its outcome.
AUTHORS CONTRIBUTIONS
K.S. conceived the idea, designed, collected the literature, interpreted the data, analyzed the data, drafted and revised the manuscript. All the authors have made noteworthy contributions to the study design, data collection, review and interpretation; have engaged in the drafting or revision of the article; have agreed to submit to the current journal; have given final approval of the version to be published; and have agreed to be responsible for all aspects of the work.
Englishhttp://ijcrr.com/abstract.php?article_id=4037http://ijcrr.com/article_html.php?did=4037
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Saklofske DH, Austin EJ, Galloway J, Davidson K.Individual difference correlates of health-related behaviors: Preliminary evidence for links between emotional intelligence and coping. PersIndividDiff2007;42(3):491-502.
Pourmohamadreza-Tajrishi M, Ashori M, Jalilabkenar SS.The Effectiveness of emotional intelligence training on the mental health of male deaf students. Iranian J Public Health2013;42(10):1174-1180.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareModified Sphygmomanometer as “Biofeedback Tool” in Retraining Quadriceps Function among Individuals with Unilateral Tibio-femoral Osteoarthritis - A Case Series
English159163Renuka KEnglish Shristhudhi DEnglish Sankarmani BEnglish Seetharaman VSEnglish Jagadevan MEnglish Mohanakrishnan BEnglish Prabakaran REnglishEnglishModified sphygmomanometer, Isometric quadriceps strength, Unilateral tibiofemoral osteoarthritis, Pain, DisabilityIntroduction:
Osteoarthritis (OA) of knee is a prevalent musculoskeletal impairment among geriatric population, it is estimated that, the prevalence was found to be 22% to 39% of the total population.1 OA is common in women and the prevalence increases with age. OA knee is accompanied with pain, quadriceps weakness, altered functional abilities and progressive deformity.2 Quadriceps weakness is one of the early clinical observation which is found to emerge before limiting the functional abilities of these individuals and may play a crucial role in disease manifestations.3 Hence, it is imperative for physical therapist to succor the patient in relearning the quadriceps muscle activation at an early stage.4 The strength deficits of quadriceps in the OA knee individuals ranges from 15 to 18% prior to secondary changes to 24% in individuals with Kellgren & Lawrence (K/L) grade II OA and to as high as 38% in individuals with K/L grade IV knee OA.5
Quadriceps has a multiple role at the knee joint in routine activities and reduces impulsive load on to the intra-articular structures.6 Off late, quadriceps weakness is found to be a risk factor for knee pain and is associated with alterations in balance and postural control in individuals with knee OA.7, 8 Evidence from the past shows that quadriceps weakness is analogous with inferior outcome measures which can prognosticate the depreciation in physical ability levels over a period of time in individuals with knee OA.9 Quadriceps weakness can be attributed to multiple factors which can be mechanical or physiological. Despite, pain is identified as the important cause for quadriceps atrophy, it has been observed4 quadriceps weakness is prevalent in individuals with knee OA despite the absence of pain which suggests that pain is not the only factor which instigates the onset of weakness in quadriceps. This gives us an insight of other attributing factors in the incidence of quadriceps weakness. Of which, one of the major cause for quadriceps weakness is Quadriceps Activation Failure (QAF), which is due to impaired neural facilitators effects. These individuals have higher QAF than with their age and sex matched asymptomatic individuals4 QAF is found to be inversely related to the impairment in quadriceps with reduced maximum voluntary isometric contraction (MVIC) and lower physical performance and self?report measures in individuals with knee OA (Fitzgerald GK). The findings of Hurley et al highlights a cascade of events initiated by the mechanical alterations from the degenerated joint structures leading to altered sensory information from mechanoreceptors which results in reduced activation levels of quadriceps muscles.10
Reduced MVIC in individual’s knee OA can reversed by voluntary activation of quadriceps, which is regarded as an appropriate and a reliable approach to improve the strength.11, 12In older individuals with knee OA isometric activation of quadriceps has been found to facilitate the MVIC of the quadriceps with much ease.8, 13, 14 A modified sphygmomanometer is used as a pressure biofeedback in this study in training the strength of the quadriceps. This conventional sphygmomanometer was found to be an affordable and useful alternative in monitoring and maintaining the isometric quadriceps strength during acute phase of post?Anterior cruciate ligament (ACL) reconstruction rehabilitation.15 The objective of this study is to observe the influence of an objective training program by using a modified sphygmomanometer as visual biofeedback tool to facilitate quadriceps activation which can also be cost effective tool.
Methodology:
A case series was performed to observe the influence of a modified sphygmomanometer as a visual biofeedback in isometric quadriceps strengthening in patients with unilateral tibio-femoral Osteoarthritis. Out of 23 patients diagnosed with knee Osteoarthritis, 13 patients who fulfilled the selection criteria were included for the study. During the course of the treatment, there were 2 dropouts and the posttest evaluations were done for 10 patients and in total, females were higher than the male (Table: 1). Written consent was taken from every patient. Approval for this study was obtained from the Institutional Ethics Committee of Sri Ramakrishna Institute of Paramedical Sciences (IEC NO: SRIPMS/COPT/007/03). The inclusion criteria were, both male and female patients aged between 35- 65 years who had mild to moderate unilateral tibio-femoral osteoarthritis. The exclusion criteria were knee deformity, symptomatic patella-femoral arthritis, visual impairment, recurrent dislocation of patella, knee surgeries, recent fractures in lower limb, cardiac patients and ligament injuries. The treatment duration was for about 1 month, where initial assessment was taken on the first day and follow up assessments were taken every week. The assessment tools used are VAS scale, manual muscle testing for quadriceps strength and Lysholm’s knee scoring scale. A brief idea about the treatment and objectives were explained to the patients. Quadriceps muscle strength was assessed using a modified sphygmomanometer.
Apparatus setting
Patient was positioned in long sitting and the cuff of the conventional sphygmomanometer was placed below the knee joint which was inflated up to 100 mm/Hg. The knee joint which has to be treated was flexed to 10 – 15 degrees and supported with a rolled towel. The patient was encouraged to visualize the movement and the apparatus for a better visual feedback to enhance learning.
Procedure:
The patients were instructed to perform an isometric quadriceps contraction, observe the same with the change in mercury levels and hold the same for about 5 to 8 secs. The basal pressure was fixed at 100 mmHg10 and the pressure difference15was noted as gain in isometric quadriceps strength. The patient was instructed to observe the values which served as a visual biofeedback.
They were instructed to perform six times/ week, two sessions/ day with two to three sets/ session. Every set had 10 repetitions with a hold time of 3-5 seconds for the isometric contractions. Adequate rest periods were ensured in between every contractions and every sets. Initially for a week patients were supervised to avoid potential compensations such as pelvic hiking, excessive hamstring and gluteal muscle activity. Later home based exercises program (HEP) with the apparatus was advised for three weeks.
Statistical analysis
Non Parametric tests were performed and the data were expressed as mean and standard deviation. Wilcoxon signed rank test was performed to observe the impact of biofeedback based on the pre and post analysis.
Results:
The present study involved 10 individuals between the age group of 35-65 years. The mean age of participants was 42 ± 7 while females were slightly higher than males. The study results showed that there was a statistically significant difference between the pre and post scores of outcome measures of quadriceps isometric strength, pain and functional ability (Graph: 1) with less than 0.01 level of significance (Table: 1).
Discussion:
Biofeedback is considered as a “psychophysiological mirror” which allows the patients to observe and learn from the psychological signals created from the soma. Sphygmomanometer used as a modified biofeedback uses sensors that are entirely non – invasive and helps achieving threshold activation in osteoarthritis knee which may not be possible volitionally in muscles with quadriceps activation failure.16 To gain the strength of a muscle, training programs should impart 30-50% of maximum voluntary effort to impart the overload principle.17 This type of biofeedback device creates a self- awareness and control over the persons own physiological response. As self- awareness increases, the person may achieve insight and control over this action. Concurrently, the therapist utilizes the signal information to monitor and facilitate the particular effort of activation and subsequent strengthening.
Evidence from the past validates that strength and QAF can be improvised by progressive strength training.18In older adults, Henwood and Taaffe et al demonstrated a 17% improvement in strength following retraining exercise. Similarly, individuals demonstrated improvements in both muscle strength and functional performance following progressive strength training.19 Thus, it becomes necessary on the part of the therapist to ensure threshold stimulus for effective activation of quadriceps muscle.
Learning to control brain activity is resulted by the contingent feedback and reward, potential verbal instructions and mental strategies. It is a resultant concurrent occurrence of a strong presynaptic and postsynaptic activity and dopamine release. According to Hebb et alif the activity in the presynaptic neuron led to the firing of the post synaptic neuron, an enduring alteration of the synaptic structure follows, such that subsequent activity of the presynaptic neuron has a high probability to excite the post synaptic neuron. Thus in this type of learning, the synaptic transmission is strengthened only in those neurons that simultaneously receive input coding some aspect of event in the environment and dopaminergic input20. In a clinical stand point, the neuro feedback remains in early development i.e, stimulating the quadriceps muscle in the early stage of quadriceps failure or reflex inhibition, accurate learning helps in maintaining the strength of the muscle and thereby preventing further worsening of the functional status. The improvements in muscle strength occurs as a result of patients learning to activate the quadriceps muscle to a threshold level thereby minimizing the effects of neural arthrogenic inhibition.21
In the study by Raeissadot et al has shown that, there occurs a significant improvement in VAS score on treating patients with Electromyography (EMG) biofeedback.22This is in accordance with this study which could be due to the psychological effects of modified biofeedback. On the other hand, Anwar et al in 2011, evaluated the effects of EMG biofeedback in quadriceps strength in knee OA and found that the maximal voluntary contraction of quadriceps to be significantly greater in biofeedback group.23 The use of modified pressure biofeedback device employed instead of EMG or Neuromuscular Electrical Stimulation (NMES) helps in gaining similar effects and also acts as a cost – effective and a simple acting tool.
There are numerous studies that endorsed that this method is a safe and effective method to treat and evaluate the muscle activation in cervical pathologies, hand grip strength, and low back pain. Thus, sphygmomanometer used as a pressure biofeedback can be an effective alternative in training muscle activation and is also a safe and cost effective tool.
Conclusion
Based on the outcome of this study it may be concluded that a simple “modified sphygmomanometer” may be used as an objective tool in individuals with unilateral tibio-femoral osteoarthritis. Since the study involved limited samples further studies are recommended with structured methodology and with adequate samples.
Acknowledgement:
We are grateful to the patients who volunteered to participate in this study.
Conflict of interest:
No conflict of interest.
Source of funding: Self
Individual Author’s contribution:
K Renuka–Methodology, Data Collection
Shristhudhi Deepika . S – Writing and Redrafting.
Prof. B Sankarmani – Conceptualization
Prof. V. S Seetharaman – Original Draft Preparation
MohanakrishnanJagadevan – Redrafting, Statistics
BhanumathyMohanakrishnan – Redrafting
R. Prabakaram- Writing.
APPENDIX
INFORMED CONSENT
Adequate information about the research should be given in simple, easily understandable, unambiguous language in the Participant/ Patient Information Sheet.
Title of the project:
Modified sphygmomanometer as “biofeedback tool” in retraining quadriceps function among individuals with unilateral tibio-femoral osteoarthritis – A case series
Name of the Principle Investigator:
Description of the Study:
Nature and purpose of study stating it as research:
The purpose of the study is to find out the effectiveness of exercise program in in retraining quadriceps function among individuals with unilateral tibio-femoral osteoarthritis
Voluntary participation :
Participation in this study is completely voluntary and your consent is required before you can participate in the study.
Duration of participation with number of participants:
1 month duration.
Procedures to be followed:
The patients will undergo physical examination. Patients with unilateral osteoarthritis underwent quadriceps retraining using a modified sphygmomanometer along with home based exercise program. The assessment tools used are VAS scale, manual muscle testing for quadriceps strength and Lysholm’s knee scoring scale. Quadriceps muscle strength was assessed using a modified sphygmomanometer.
Ethical Clearance Number: SRIPMS/COPT/007/03
Investigations, if any, to be performed: Nil
Any alternative procedures or courses of treatment that might be as advantageous to the participant as the procedure or treatment to which she is being subjected: Nil
Storage period of biological sample and related data with choice offered to participant regarding future use of sample, refusal for storage and receipt of its results: Nil
Possible Risks to the participant: Nil
Cost and Payments to the participant: There is no cost for participation in this study. Participation is completely voluntary and no payment will be provided.
Confidentiality: Information obtained in this study is strictly confidential. Your name will not be used in reporting of information in publications or conference presentations.
Participants’ right to withdraw from the study: You have the right to refuse to participate in this study, the right to withdraw from the study and the right to have your data destroyed at any point during or after the study, without penalty.
Voluntary consent by the participant: participation in this study is completely voluntary, and your consent is required before you can participate in this study.
I have read this consent form (or it has been read to me) and I fully understand the contents of this document and voluntarily consent to participate in the study. All of my questions concerning this study have been answered. If I have any questions in the future about this study they will be answered by the investigators listed below. I understand that this consent ends at the conclusion of this study.
Englishhttp://ijcrr.com/abstract.php?article_id=4038http://ijcrr.com/article_html.php?did=4038
Pal CP, Singh P, Chaturvedi S, Pruthi KK, Vij A. Epidemiology of knee osteoarthritis in India and related factors. Indian journal of orthopaedics. 2016 Oct;50:518-22.
Punnett L, Wegman DH. Work-related musculoskeletal disorders: the epidemiologic evidence and the debate. Journal of electromyography and kinesiology. 2004 Feb 1;14(1):13-23.
Petterson SC, Barrance P, Buchanan T, Binder-Macleod S, Snyder-Mackler L. Mechanisms underlying quadriceps weakness in knee osteoarthritis. Medicine and science in sports and exercise. 2008 Mar;40(3):422.
Slemenda C, Brandt KD, Heilman DK, Quadriceps weakness and osteoarthritis of the knee. Ann Intern Med. 1997;127:97–104.
Mizner RL, Petterson SC, Stevens JE, Axe MJ, Snyder-Mackder L. Preoperative quadriceps strength predicts functional ability one year after total knee arthroplasty. J Rheumatol. 2005;32:1533–9.
Hurley MV. The role of muscle weakness in the pathogenesis of osteoarthritis. Rheum Dis Clin North Am 1999; 25: 283– 98.
Messier SP, Royer TD, Craven TE, O'Toole ML, Burns R, Ettinger WH Jr. Long?term exercise and its effect on balance in older, osteoarthritic adults: results from the Fitness, Arthritis, and Seniors Trial (FAST). J Am GeriatrSoc 2000; 48: 131– 8.
Fisher NM, Pendergast DR, Gresham GE, Calkins E. Muscle rehabilitation: its effect on muscular and functional performance of patients with knee osteoarthritis. Arch Phys Med Rehabil 1991; 72: 367– 74.
Miller ME, Rejeski WJ, Messier SP, Loeser RF. Modifiers of change in physical functioning in older adults with knee pain: the Observational Arthritis Study in Seniors (OASIS). Arthritis Rheum 2001; 45: 331– 9
Hurley MV, Scott DL, Rees J, Newham DJ. Sensorimotor changes and functional performance in patients with knee osteoarthritis. Annals of rheumatic diseases. 1997 Nov 1;56(11):641-8.
Pietrosimone BG, Saliba SA. Changes in voluntary quadriceps activation predict changes in quadriceps strength after therapeutic exercise in patients with knee osteoarthritis. The Knee. 2012 Dec 1;19(6):939-43.
Kim HH, Chang HS. Comparison of the VMO/VL EMG ratio and onset timing of VMO relative to VL in subjects with and without patellofemoral pain syndrome. J PhysTherSci, 2012, 24: 1315–1317.
Anwer S, Alghadir A. Effect of isometric quadriceps exercise on muscle strength, pain, and function in patients with knee osteoarthritis: a randomized controlled study. J PhysTherSci, 2014, 26: 745–748.
Marks R. The effects of 16 months of angle-specific isometric strengthening exercises in midrange on torque of the knee extensor muscles in osteoarthritis of the knee: a case study. J Orthop Sports Phys Ther, 1994, 20: 103–109.
Mohanakrishnan J, Mohanakrishnan B, Salaja R, Balaji GG. Sphygmomanometer as biofeedback in acute anterior cruciate ligament reconstruction rehabilitation: A cost?effective technique. International Journal of Clinical and Experimental Physiology. 2016 Apr 30;3(2):100-4.
Peper E, Harvey R, Takebayashi N. Biofeedback an evidence-based approach in clinical practice. Japanese Journal of Biofeedback Research. 2009 Apr 25;36(1):3-10.
Henwood TR, Taaffe DR. Detraining and retraining in older adults following long-term muscle power or muscle strength specific training. J Gerontol A BiolSci Med Sci. 2008 Jul;63(7):751–8.
Kawakami Y, Akima H, Kubo K, Muraoka Y, Hasegawa H, Kouzaki M, Imai M, Suzuki Y, Gunji A, Kanehisa H, Fukunaga T. Changes in muscle size, architecture, and neural activation after 20 days of bed rest with and without resistance exercise. Eur J Appl Physiol. 2001 Jan-Feb;84(1–2):7–12. ]
Skelton DA, Greig CA, Davies JM, Young A. Strength, power and related functional ability of healthy people aged 65–89 years. Age Ageing. 1994 Sep;23(5):371–7.
Sitaram R, Ros T, Stoeckel L, Haller S, Scharnowski F, Lewis-Peacock J, Weiskopf N, Blefari ML, Rana M, Oblak E, Birbaumer N. Closed-loop brain training: the science of neurofeedback. Nature Reviews Neuroscience. 2017 Feb;18(2):86-100.
Dunn TG, Gillig SE, Ponsor SE, Weil N, Utz SW. The learning process in biofeedback: is it feed-forward or feedback?. Biofeedback and self-regulation. 1986 Jun 1;11(2):143-56.
Raeissadat SA, Rayegani SM, Sedighipour L, Bossaghzade Z, Abdollahzadeh MH, Nikray R, Mollayi F. The efficacy of electromyographic biofeedback on pain, function, and maximal thickness of vastusmedialis oblique muscle in patients with knee osteoarthritis: a randomized clinical trial. Journal of pain research. 2018;11:2781.
Anwar S, Quddus N, Miraj M. Efficacy of Electromyographic Biofeedback Training on pain and functional status in Osteoarthritis of Knee. Indian Journal of Physiotherapy & Occupational Therapy. 2011 Apr 1;5(2).
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareArtificial Intelligence in Medicine and Understanding its Potential for Newer Applications
English164169Pathak AEnglish Athavale HEnglish Pathak TEnglish Athavale SAEnglishIntroduction: Advancements in the performance and efficiency of computers have led to the development of Artificial Intelligence since the advent of the 1950s. The medical field was one of the firsts to seize the opportunity to incorporate these techno-logical advancements into its system. Artificially intelligent technologies were very skilfully added into everyday medical practice enhancing diagnostics and radiological capabilities, bolstering pharmaceutical processes, and revamping several other spheres of medicine. During the chaotic period of the pandemic too, it has proved to be an essential tool. Aim: For identifying sources of literature, initially google scholar database was used using broad research terms that were aligned to the topic and research question. More focussed terms were identified and were utilised with the ‘and’ command to perform a database search in Pubmed and Science direct. Cross-references were identified from the articles. Articles were scrutinized for content and summarized to discuss the utility of this technology in specific areas of medicine and its potential for the future. Conclusion: Artificial Intelligence has already been forayed into the field of medicine. It has exhibited immense potential in interpreting large amounts of data, deriving breathtaking algorithms, offering pragmatic and cost-effective approaches for prevention, diagnosis and treatment in almost all fields of medicine.
EnglishChatbots, COVID19, Deep learning, Machine learning, Neural networksINTRODUCTION:
Artificial Intelligence, commonly known as machine intelligence is the ability of a machine to analyze the task assigned which subsequently enhances the ability of the machine to successfully achieve its goals.1 Artificial intelligence can also be regarded as an oxymoronic term (when coupled with machine learning) which suggests the ability of machines to demonstrate qualities of higher living beings such as flawless cognitive brain function, learning and problem solving which is most often associated with the human brain.2 Modern machinery has embodied artificial intelligence to the extent of them being able to understand human speech, autonomously operate motor vehicles, prove to be a valuable screening tool for disease detection, etc.3,4 This is possible due to recent progress in extensive digital data acquisition and the wonders of machine learning.4 Machine learning, a subdivision of artificial intelligence deals with the understanding and inference of patterns in a data set. This helps to derive algorithms that are specific to the training data.5 Deep learning, a subset of machine learning can understand multiple hidden layers of the training data and thus helps to generate very high accuracy predictive outputs.6
Machine learning is divided into three types: Unsupervised, Supervised, and reinforcement. Supervised learning generates algorithms using a known dataset (which is labeled beforehand) which is then used to predict the desired outcome. Unsupervised learning comprises of unearthing hidden patterns from unknown data sets thereby aiding in identifying novel disease mechanisms, genotypes, or phenotypes; the objective ultimately being able to find appropriate solutions without human intervention. Reinforcement learning can be seen as a hybrid between supervised and unsupervised machine learning.7
Since the advent of artificial intelligence in the mid-1950s, much progress has been made.8 The application of artificial intelligence and machine learning is highly sought after in the field of medicine. The primary goal with respect to health-related AI applications is to analyse the working relationship between prevention, screening, and treatment techniques which is then tallied with patient prognosis and clinical outcome.9 Currently, immense potentials are being explored in the diagnostic processes, enhanced treatment protocols, drug development in pharmaceutical firms, patient monitoring, and care.10
For identifying sources of literature, initially google scholar database was used using broad research terms that were aligned to the topic and research question. The terms used were: Artificial Intelligence, AI in Medicine, History of AI, Machine learning, Deep learning, Neural Networks, AI in Diagnostics, AI in Cardiology, AI in radiology and imaging, AI in genetics, Chat-bots, Big data public health, AI in Radiology, AI in pharmacology, COVID-19, AI in COVID-19, Drug Design, AI in oncology, Newer applications of AI. More focussed terms were identified from the articles searched in google scholar and were utilised with ‘and’ command to perform a database search in Pubmed and science direct. Cross references were identified from the articles. These articles were analysed using the following criteria for inclusion.
1. The source article should be aligned with the purpose of review
2. The article should be published in a peer-reviewed journal.
3. Effort was made to include recently published articles.
Articles were scrutinized for content and summarized to discuss the utility of this technology in specific areas of medicine and its potential for future.
ARTIFICIAL INTELLIGENCE INTERWOVEN WITH DIAGNOSTIC MEDICINE:
Diagnostic medicine is a field that encompasses medical techniques designed to detect infections, conditions, and diseases. The institute of medicine at the National Academics of Science, Engineering, and Medicine reports that diagnostic errors contribute to approximately 10% of patient deaths, and also account for 6-17% of hospital complications.11 These mishaps and short falls prompted the integration of artificial intelligence into the world of medicine. The first use of artificial intelligence was in the form of chatbots. Chatbots analyse the symptoms put forward by the user which is then cross-referenced against a database of diseases. In response, the machine will recommend a course of action which is most suitable to the patient's history and patient circumstances. In addition to the prior chatbot technologies, these techniques have now been upgraded to monitor and record vitals such as heart rate and cholesterol level.12 AI being used in the field of oncology where early detection is key to the prognosis of the patient.13 It has achieved commendable accuracy for breast cancer screening.14 Deep neural networks - which are a recognized subset technology of machine learning - have been able to scan for and successfully locate enlarged lymph nodes or colonic polyps in computed tomography (CT) images.15,16 A breakthrough has also been achieved in the medical application of whole slide imaging which has resulted in the formulations of histopathological diagnoses17 Deep learning is also in the process of being able to decipher the molecular status of a tumour such as assessment of tumour marker proteins, namely, HER2 from pathological data.18 Moreover, artificial intelligence is being used in cancer genomics wherein a supercomputer is able to analyse and identify up-to 100,000 genomic mutations and provide precision care for each tumour sample.19 This development has revolutionised cancer treatment due to computers capable of employing gold standard treatment options specifically based on the expression of molecular markers and tumour cell mutations and characteristics.20 Extending from the field of oncology, artificial intelligence has established a strong foothold in the field of cardiology as well.21 These techniques play a critical role in improving precision of cardiovascular medicine by forming functional phenotypes like electrocardiography, echocardiograms, demographics, haemodynamics, and imaging data.22,23,24 Also, molecular profiles from large collections of data and medical records of patients comprising of laboratory test results, physician notes and other relevant information of disease, treatment, and epidemiology may be mined for analyzing association and building predictive models on prognosis and learning drug responses. A recent example of an exemplary use of machine learning in cardiology has been demonstrated by Shah (2017) which predicts the prognosis of the patients with heart failure and preserved ejection fraction (EF). This is an example of unsupervised machine learning which used 46 different data points to identify intrinsic structures among patients with this particular type of heart failure.25 Furthermore, AI has been used in cardiac imaging with great success too. 3D echo data sets acquisition has been fed to computational systems which automatically have been able to identify the heart's anatomy and suitably modify it further for optimal standard views of presentation.22 Not surprisingly, the use of artificial intelligence has been interwoven with mainstream medical practice. A machine learns and applies diagnostic tools by understanding patterns and formulating algorithms similar to how a doctor approaches diagnostic challenges.26 AI and machine learning have proved to be successful in analysing and diagnosing skin lesions (including melanoma) as precisely as expert dermatologists.27 This software could be added to smartphones whose reach is significantly farther than expert dermatologists. Other fields of medicine that are worth mentioning under the umbrella of fields using machine learning are pulmonary medicine, rheumatology, ophthalmology, otorhinolaryngology, head and neck surgery, etc.
ARTIFICIAL INTELLIGENCE INTERWOVEN WITH RADIOLOGY AND RADIOTHERAPY
Another major field of medicine that has seen significant advances in the use of artificial intelligence in the field of radiology. Radiology, as a branch, deals with the detection, characterization, and subsequent monitoring of disease. Detection in radiology involves manual expertise to identify abnormalities and cognitive skills to reach a diagnosis. Characterization involves the process of segmentation, diagnosis and staging of the disease. Lastly, monitoring encompasses the evaluation of the treatment response.28 Radiology is a branch that is heavily dependent on machines. The first use of computer programs and artificial intelligence was in the form of magnetic resonance imaging (MRI) and positron emission tomography (PET) scans which facilitated improvement in the diagnostic capabilities of physicians and hence their treatment modalities.29 But identification and analysis of such scans required expert intervention. Due to the lack of sufficient trained radiologists, enhanced AI systems have been seamlessly integrated within the branch which would increase efficacy, minimize errors and achieve targets with nominal manual input which would provide radiologists with labeled and identified images for faster diagnosis.30 Furthermore, deep learning algorithms can learn feature representations from data without human intervention. Deep learning can thus quantify phenotypic characteristics of human tissues, improving diagnosis and clinical care. For example, deep learning can extract predefined features and accurate segmentation of diseased tissues which falls under the pretext of detection.31 Further, via the use of carefully laid algorithms and deep learning, the machine can characterise the lesion which helps in the formulation of a diagnosis and its staging, if it involves neoplastic growth and/or cancers.32 In the long run, deep learning also aids in the monitoring of the patient which reduces significant work pressure over the health-care professional and expert radiologists.
ARTIFICIAL INTELLIGENCE INTERWOVEN WITH PHARMACEUTICALS AND DRUG TRIAL RESEARCHES:
From the ideation of using artificial intelligence for improving prescribing techniques to the evolution of personalised medicine, the pharmaceutical industry has integrated itself with artificial intelligence.33,34 In particular, the pharmaceutical industry has been known to use AI in improving its drug manufacturing processes.35 AI has been used to shorten design time, reduce wastage of raw materials, and much more. Human intervention has also been significantly reduced since the use of AI. Concurrently, AI has also aided the industry in drug discovery and design formulations by interpreting and integrating large amounts of patient data and comparing it with randomised controlled trials to judge its efficacy.36 Interestingly, AI has also aided in biomedical and clinical data processing which helps them to assess the efficacy of products launched by pharmaceutical companies. More recently, pharmaceutical companies have devised software that aid in tackling rare diseases and developing personalised medicines based on individual patients' test results, reactions to past medications, and their progress of the disease.37,38 This data collected is used to predict treatment results that have huge time & cost-saving applications. This shows that the addition of artificial intelligence has been a boon to the industry.
ARTIFICIAL INTELLIGENCE INTERWOVEN WITH SMART ELECTRONIC HEALTH RECORDS:
Electronic health records (by themselves) are large collections of medical data like patient demographics, medical images, medical notes and prescriptions which are often viewed by people as huge, monolithic and tedious to use. Due to the labor-intensive nature of the use of EHR, they have limited generalisability across databases.39 When integrated with artificial intelligence and machine learning, electronic health records can be very easily accessible.40 It has changed the data analytic modelling framework from human driven to data driven construction. The core reason for the integration of AI and machine learning into the field of EHR is the presence of large and complex datasets in healthcare that require stringent monitoring which is most efficiently managed by AI algorithms.39 It is a fact that the AI applications in electronic health records are narrow and premature, but currently, they include data extraction from free text, diagnostic and predictive algorithms facilitating the development of predictive models which warn physicians of high-risk conditions such as heart failure and sepsis, facilitate clinical documentation and data entry, strengthen clinical decision support consisting of computer algorithms which recommend treatment strategies, etc.39,41,42
ARTIFICIAL INTELLIGENCE INTERWOVEN WITH PUBLIC HEALTH:
Apart from the use of AI in diagnostics, screening and risk prediction, it has also transformed the conventional public health care systems to make superior healthcare accessible to all members of the community. One of the most important uses of AI in the public health setting is increasing patient adherence and access to treatment.9 AI algorithms are used to identify patterns in population clusters, specially comprising of women, infants and people below the poverty line helping them to make sure that they diligently follow their treatment regimes which has massive implications in the control and eradication of a particular disease.43 AI has also boosted patient adherence by providing valuable data by running predictive analysis algorithms which aid in improving the outreach of nationally run treatment programmers. Lately, AI has also been used to track the progress of grass root level health care workers who operate in geographies with dense and unmonitored populations. AI aids in actively forming algorithms which streamline data collection in the field and analyse on ground conditions on whether appropriate healthcare efforts are being channelized to the welfare of the community. Interestingly, it has also been used in prediction and containment of epidemics. By using machine learning, particularly the unsupervised variant, algorithms are formulated so as to monitor information from the news, official health care reports and even the social media in several languages around the world, red flagging where high priority diseases are mentioned.44 These trends are then monitored by algorithms which then alerts the authorities once it identifies a significant threat level in the community.
ARTIFICIAL INTELLIGENCE INTERWOVEN WITH DIAGNOSTICS AND THERAPEUTICS OF COVID-19:
The pandemic of 2020 wherein the causative agent was the SARS-nCoV19 virus caused havoc and lead to the disruption of the world order.45 This lead to the search for novel diagnostic and therapeutic methods which warranted the use of artificial intelligence.46,47 It is known that artificial Intelligence and machine learning (specifically models trained using unsupervised learning) with its strong pattern detection capabilities are great tools for early detection of viruses and diagnosis diseases. Recent applications focus on predicting mutations before the occurrence of a new strain by applying rough set theory as a processing tool for imprecise information.48 In addition to prediction of mutations, AI can help with cost and time effective methods for detection of covid-19 by using algorithmic structures like random forests, decision trees and support vector machines.49 Moreover, AI aids in developing vaccines and treatments at a significantly faster rate compared to regular clinical trials by virtue of powerful optimisation techniques of contemporary machine learning models.50 With internet and GPS enabled mobile devices being even more accessible to large populations, contact tracing has been made easier than ever with the help of ML-fueled data visualisation and analytics.51
NEWER APPLICATIONS OF ARTIFICIAL INTELLIGENCE AND MACHINE LEARNING IN MEDICINE:
Till date, newer strides are being made in the field of artificial intelligence and its application in the field of medicine. Some prodigious advancement has been made wherein a plausible concept has been put forward where the health status, ccomprising of the estimation of hormone levels and physiological state of a person are assessed by deciphering speech samples including but not limited to the vocal consonants (VC), consonant-vowel (CV), environment formants of the utterance, speech quality of the utterance, pitch of the utterance etc.52,53 The system consists of a processor and a memory paired with the processor. The processor executes programmed instruction for isolating one or more phonation segments which are analysed and cross-matched by the processing unit to provide corresponding hormone levels of the person based on different speech features.52,53 Significant strides have been made in the field of robotic surgery too, where raven robots and PR2 robots are being used in the suture automation, deep learning for the comprehensive evaluation of surgical skills and techniques, and machine learning for enhancing surgical robotic materials which improve the dexterity of surgeries requiring immense precision.54 The use of AI in the field of surgery has significantly improved pre and post-operative experience for the patient.55 Owing to the diverse applicability of AI systems, automated diagnoses or computer-aided diagnosis (CAD) are being devised which train using huge amounts of patient data, physiological signals and images based on meticulous use and analysis whose application is being noted in the field of neurology, neurosurgery, radiology, and others.56 Lastly, the newest breakthrough has been noted in the sub-set of artificial intelligence termed as computer vision.57 Computer Vision in the field of artificial intelligence that trains the computer to interpret and understand the visual world. Data from images are extracted by various information retrieval algorithms by analysing information from individual pixels and transforming them into computer-readable and manipulatable data. This transformed data can then be used as any regular data set to train/test machine learning models and deploy them for real-world applications.58 Some applications including but not limited to can be, monitoring heart rate by using high definition video samples from the neck region detecting & classifying bone fractures, tumours, and soft tissue conditions by leveraging machine learning models generated by huge amounts of historical data are being noted.59,60,61
CONCLUSION:
The evolution of the use of artificial intelligence and machine learning technology has revolutionised how the world of medicine is perceived and understood. It has brought forward breathtaking algorithms that are capable of interpreting large amounts of data and provide the most pragmatic and useful treatment or production options which ultimately benefits mankind which is the ultimate goal of the pursuit of the practice of medicine. Hence, AI technology should be welcomed in the field of medicine with open arms.
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 and 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
AUTHORS CONTRIBUTION :
Pathak A - Conceptualisation, Literature search, Manuscript writing
Athavale H – Literature search and review, Manuscript writing
Pathak T - Literature search and review, Manuscript writing
Athavale SA – Conceptualisation, Review, Final editing of manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=4039http://ijcrr.com/article_html.php?did=4039
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareRegional Pattern of Health Services through Health Personnel in Sonitpur District of Assam
English170174Baruah SameerEnglishIntroduction: Health workers or health personnel attains a great significance in the field of Medical Science, and the followers of medical science are interested to study the health personnel as it deals with the availability of doctors, nurses, pharmacists, radiographers, lab technicians and other health workers in a particular region. They make important contributions and are critical to the functioning of most health systems. Patient safety strategies are the main focus of health care personnel. The availability of these health workers reflects the status of health services in a specific region. Aims & Objectives: The main objective of the study is to examine the role and importance of health workers in the field of medical science in the Sonitpur District of Assam. The study is also undertaken to analyze the distribution of different health personnel in different health blocks of the district. Methodology: The whole study is mainly based on secondary data. In few cases, internet links are also taken into consideration for detail analytical study. The study will explain the role and distribution of health personnel in the district. Moreover, an analysis of the existing health personnel will give an idea about the availability and adequacy or otherwise of the same in the district. Results: The health blocks with less number of Health Workers are characterized by heavy population pressure on Health Personnel whereas, the health blocks where higher number of health workers exist are characterized by less population pressure on Health Workers. Conclusion: The entire study has given an idea about the distribution pattern of health workers in different health blocks of the region. The study also reflects the adequacy as well as deficiency of the same in the study area. The study will help the medical and other health experts to take crucial steps for better health planning in the region.
English Health Workers, Role, Services, Distribution, Deficiency, SonitpurIntroduction:
Medical Science deals with the study of the distribution of diseases as well as health care institutions along with the spatial distribution or availability of health personnel in a particular area. The study of health workers or health personnel attains a great significance, and medical experts are interested to study the health personnel in the field of Medical Science as it deals with the availability of doctor, nurse, pharmacist, radiographer, lab technician and other health workers in a particular region. They make important contributions and are critical to the functioning of most health systems.5 Patient safety strategies are the main focus of health care personnel. The availability of these health workers reflects the status of health services in a specific region. Rais Akhtar and Learmonth also have stated in their book ‘ Geographical Aspects of Health and Diseases in India: “ Political and economic factors play a dominant role in the shaping of the health services of the community, for instance and the degree to which the health services are to be available and accessible to the population”.7
Good health care personnel are considered to be good communicators. Community Health Workers are effective in improving public health.8 They are generally able to listen to their respective patients, and provide information about diagnosis. They often service as coaches to improve clients’ healthy lifestyle behaviors.9 They also provide required treatment in such a way that patients will easily understand. In other words, good health personnel are always ready to put their patients’ need first. Moreover, good health workers usually have strong sense of service, willing to help people feel better.
Health care is fundamentally associated with the promotion, maintenance, monitoring and restoration of the health of individuals or communities by agents of health services.3 Health Personnel or Health Care Personnel are defined as all paid and unpaid persons working in a health institution. They have the potential for exposure to patients and/or to infectious materials including body substances, contaminated medical supplies and equipment etc. Health workers are people whose job it is to protect and improve the health of their communities. Together these health workers, in all their diversity, make up the global health workforce.5
According to World Health Organization (WHO), “Health workers are people whose job is to protect and improve the health of their communities. Together these health workers, in all their diversity, make up the global health workforce.” The WHO defines health workers to be all people engaged in actions whose primary intent is to enhance health. Health Personnel are sometimes defined as all people engaged in the promotion, protection or improvement of the health of the population.1 Health Personnel are commonly referred as Community Health Workers (CHW) who works either for pay or as volunteers in association with the local health care system in both urban and rural environment. They usually share ethnicity, language, socio-economic status and life experiences with community members they serve. They offer interpretation and translation services, provide culturally appropriate health education and information, help people get the care they need, give informal counseling and guidance on health behaviors, advocate for community and individual health needs, and provide some direct services such as first aid and blood pressure screening.6
Materials & Methods:
In the study only secondary data are used. In order to collect relevant data many sources have been taken into consideration. Data concerned with spatial distribution of various diseases in the study area have been collected from the Office of the Health & Family Welfare (IDSP i.e. Integrated Disease Surveillance Project), Sonitpur District, Assam. Data pertaining to the distribution of health care facilities or health institutions in the study area have been collected from National Health Mission (NHM) office, Sonitpur District, Assam. Moreover, books as well as journals related to Medical Geography are also taken for detail analytical study. In few cases, internet links have also been taken into consideration for further study.
In the study spatial distribution of some selected diseases along with the distribution of health care facilities are proposed to be analyzed at the block level of the Sonitpur District. The study is carried out by taking seven health blocks with certain specific diseases. Analysis has been done with absolute data of incidence of diseases. The collected data have been systematically tabulated to show the temporal as well as spatial variation of the incidence of diseases in all the health blocks of the district. Taking into consideration of the above methods, the proposed study has been done in a proper way.
Results
Spatial Distribution of Health Personnel in Sonitpur District
In Sonitpur district health personnel or health workers play an important role in the field of Medical Science. Health personnel in the study area mainly include Medical Officers, GNM (General Nursing & Midwifery), ANM (Auxiliary Nurse Midwifery), Pharmacist, Lab Technician, Radiographer etc. Moreover, recently ASHA (Accredited Social Health Activists) workers as well as ASHA Supervisors are playing their vital role in the concerned field. There is a great variation in their distribution among the health blocks of the district. Some health blocks contain sufficient portion of health personnel, while some others have less portion of the same. An attempt has been made here to analyze and understand the spatial distribution of health personnel or health workers in the study area.
Distribution of Medical Officer
Medical officer normally refers to a doctor in charge of the health services of a civilian or military authority or other organizations. It may include all types of doctor, e.g. allopathic doctor, Ayurveda doctor, homeopathic doctor etc. Generally the post of Medical Officer is held by a physician who serves to advise and lead a team of public health professionals such as environmental health and public health nurses on matters of public health importance. Medical Officers generally serve as advisors on the issues of health and control of disease. They provide medical support and investigate health related problems. They analyze records, reports as well as examine data to help patient’s conditions. They will order extra test, if needed, and consult it with other physicians on the patient’s previous healthcare professionals.
In the district the total numbers of Medical officers are 164, of which 92 are working on regular mode and 72 are working under NHM (National Health Mission). The average density of Medical Officer per lakh population in the district is about 9. This total number of Medical Officer is unevenly distributed among the health blocks of the district (Table-1). Some health blocks contain more Medical Officer while some others are characterized by fewer portions of the same.
Distribution of GNM (General Nursing & Midwifery)
GNM usually stands for General Nursing & Midwifery which generally emphasized on educating nursing students on the matter of general health care and midwifery. They generally work in both the public as well as private health care sector. They may also operate in hospitals, nursing homes, the armed forces, medical colleges and other health care settings. The main tasks of GNM are basically to prepare nurses with good educational program in nursing to enable them to work as efficient members of the concerned health team. They also help nurses to develop their ability to co-operate with other members of the health team in the prevention of disease, recovery of health etc.
In the study area, GNMs are seen to be in good number compared to Medical Officers. In Sonitpur district the total number of GNM is 173, of which 69 are working on regular basis, while 104 are working under NHM (National Health Mission). The average density of GNM per lakh population in the study area is very close to 9, which is same as average of Medical Officers. This total number of GNM in the district is unevenly distributed among the health blocks of the study area (Table-1).
Distribution of ANM (Auxiliary Nurse Midwifery)
ANM usually stands for Auxiliary Nurse Midwifery, which is generally a village-level female health worker in India. They are known to be the first contact person between the community and the health services. ANM generally works at health sub-centres which provide primary health care to the people or community.
In the study area, the number of ANM is found to be quite good than GNM. In Sonitpur the total number of ANM is 590, of which 297 are working on regular mode and 293 are working under NHM (National Health Mission). The average density of ANM per lakh population in the district is about 31, which is much higher than the average of GNM. This total number of ANM is unevenly distributed among the health blocks of the study area (Table-1).
Distribution of Pharmacists
Pharmacists are considered as vital health care professionals who practice in pharmacy and focuses on safe and effective use of medication. They are seen to be directly involved with patient care. The basic role of pharmacists is to provide drugs to physicians or doctors for medication which is prescribed to patients. Their main role may include clinical medication management, monitoring the state of disease, compounding medicines, supervising pharmacy technicians and other staff, providing patients with health monitoring and advice including treatment of common diseases etc.
In the study area, number of pharmacist is seen to be very less compared to GNM and ANM. The total number of pharmacist in the study area is only 89, of which 61 are working on regular basis and 28 are working under NHM (National Health Mission). The average density of pharmacist per lakh population in the study area is almost 5, which is very low. The total number of pharmacist is unevenly distributed among the health blocks of the study area (Table-1).
Distribution of ASHA and ASHA Supervisor
The term ‘ASHA’ normally stands for Accredited Social Health Activists who is generally a community health worker. ASHA is generally a local village woman who trained under NRHM (National Rural Health Mission) for 28 days in health, water and sanitation, and also trained in maternal and child health issues. They generally support ANM (Auxiliary Nurse Midwifery) in health care system, and each ANM is supported by four or five ASHAs. ANMs are considered as Supervisor of ASHA. ASHA supervisor are generally the educated men and women who characterized with experience and understanding of working in the health system. They identify and encourage the strengths and correct the weaknesses of ASHAs. ASHA supervisors support in organizing maternal and child health related training for the ASHAs and made ASHAs to build a good rapport with ANM. They keep records and submit the same to the concerned authorities.
In the study area both ASHA and ASHA Supervisors play their vital role in their respective fields. In Sonitpur district there are 1659 numbers of ASHA workers and 162 numbers of ASHA supervisors distributed in different health blocks of the study area (Table-1). The average density of ASHA per lakh population in the district is about 88, which is far greater than any other health personnel’s average in the study area. On the other hand, the average number of ASHA Supervisor per hundred ASHA workers is about 10, and 1 per ten ASHA workers.
Discussion
The study undertaken here, mainly deals with the health personnel or health workers in different health institutions in the district of Sonitpur. The entire study is based on regional pattern of few health personnel namely Medical Officer, GNM (General Nursing & Midwifery), ANM (Auxiliary Nurse Midwifery), Pharmacists, ASHA (Accredited Social Health Activists) Supervisor and ASHA Workers in seven health blocks of the district.
The study found that there is great regional variation of Health Personnel in different regions of the district. Among the health personnel, ASHA Workers and ANM (Auxiliary Nurse Midwifery) are the one that exist in large numbers in the district. On the other hand, Pharmacists and GNM (General Nursing & Midwifery) exist in less numbers in comparison to rest of the health personnel. Almost all the health blocks of the study area are deprived of the health services. Gohpur BPHC is the only health block that is well-served by medical health personnel.
Conclusion
Health Personnel or health workers as the backbone of health system is essential to sustainable development.4 In any health system, improving health service coverage and health outcomes depends on the availability, accessibility, and capacity of health workers to deliver quality services.2 Without them, proper functioning of health institutions would not be possible. Hence, any health institution must contain sufficient numbers of health workers. In the study area, Medical Officers are found to be less. Number of GNM (General Nursing & Midwifery) compared to ANM (Auxiliary Nurse Midwifery) also found to be less. What is needed for health blocks in which number of health workers is found to be less is proper and careful health planning. Systematic as well as careful health planning by the Government should be made in the deprived health blocks in order to improve the health status. More and more health personnel including Medical Officers should be appointed in deficient health blocks to improve the health condition and also to reduce the population pressure on the same.
Acknowledgement:
The present article is a part of my M. Phil Dissertation and hence, I would like to express my deep gratitude to my Research Supervisor Prof. Nishamani Kar, Department of Geography, Rajiv Gandhi University, Arunachal Pradesh for his constant support and help, encouragement and proper guidance, without which the current article would have not been possible.
I am really thankful to Mr. Sanjib Kumar Rajkhowa, DDM cum DNM & e-Officer, NHM (National Health Mission), Sonitpur District for providing me necessary data pertaining to health care Personnel. I am also thankful to Health and Family Welfare Department (IDSP), Sonitpur District for providing me required data related to the distribution of Health personnel in the district.
Conflict of Interest: Nil
Source of Funding: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=4040http://ijcrr.com/article_html.php?did=4040
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareStudy of Association of Hba1c Levels with RDW and MCV in Patients of Type 2 Diabetes Mellitus in a Tertiary Care Center”
English175178Singh SEnglish Arora SEnglish Sharma AEnglish Bali IKEnglishIntroduction: Diabetes mellitus is one of the most common metabolic disorders and the degree and duration of hyperglycemia are related to the risk of macro-vascular and micro-vascular complications which are responsible for the morbidity and mortality associated with the disease. HbA1c (glycosylated haemoglobin) is measured as an index of glycemic control over the past 2-3 months. Red cell distribution width (RDW) and mean corpuscular volume (MCV) are components of routine complete blood counts (CBC). Increased HbA1c levels may cause structural and functional changes in the haemoglobin molecule and the red blood cell because of which RDW and MCV may be altered. This study aims to assess the association of HbA1c levels with RDW and MCV in patients with type 2 diabetes mellitus. Methods: A prospective, hospital-based, observational study of 6 months from March 2020 to August 2020 including 104 patients with type 2 diabetes mellitus (both new and previously diagnosed patients undergoing treatment) was done. Diabetes mellitus was diagnosed according to ADA (American Diabetic Association) guidelines- HbA1c≥6.5% (48 mmol/mol) or FBS≥126 mg/dl (7.0 mmol/L) or 2 hour postprandial glucose≥ 200 mg/dl (11.1 mmol/L) on oral glucose tolerance test or RBS≥ 200 mg/dl (11.1 mmol/L) with symptoms. Results: Out of the 104 patients, 63 were males (60.6%) and 41 were females (39.4%). Most of the patients (30.8%) were in the age group of 41-50 years followed by 51-60 years(29.7) by There was a significant positive correlation between RDW and HbA1c values (p=0.003) while the other parameters did not show any significant correlation. Interpretation & Conclusion: In the present study we found that as the HbA1c values increased there was a concordant increase in RDW values (p=0.003). More studies, with a larger sample size, will further help to explain the correlation between RDW and HbA1c.
English HbA1c, RDW, MCV, Type 2 diabetes mellitus, Metabolic disorder, HyperglycemiaINTRODUCTION
Diabetes mellitus is of one of the most common metabolic disorders whose incidence is on the rise globally due to increase in sedentary lifestyle, obesity, and elderly population. The associated macro-vascular and micro-vascular complications are majorly responsible for the morbidity and mortality associated with the disease 1. The degree and duration of hyperglycemia is related to the risk of these complications. HbA1c (glycosylated hemoglobin) is measured as an index of glycemic control over past 2-3 months 2. Hyperglycemia has several effects on RBCs like reduced deformability, increased adhesion and increased osmotic fragility leading to changes in erythrocyte structure apart from glycosylation of hemoglobin 3. Red cell distribution width (RDW) is a component of routine complete blood counts (CBC) and is a measure of variability in size and heterogeneity of erythrocytes. Mean corpuscular volume (MCV) is also a component of routine CBC. Increased HbA1c levels may cause structural and functional changes in the hemoglobin molecule and the red blood cell because of which RDW and MCV may be altered 4,5.
The aim of this study is to assess the association of HbA1c levels with RDW and MCV in patients of type 2 diabetes mellitus.
METHODS
A prospective, observational, hospital-based study was undertaken in the Pathology Laboratory of SGT Hospital for a period of 6 months from March 2020 to August 2020.104 patients with type 2 diabetes mellitus attending the medicine OPD of SGT Hospital were selected for the study. Both new and previously diagnosed patients undergoing treatment were included in the study. Diabetes mellitus was diagnosed according to ADA (American Diabetic Association) guidelines- HbA1c≥6.5% (48 mmol/mol) or FBS≥126 mg/dl (7.0 mmol/L) or 2 hour postprandial glucose≥ 200 mg/dl (11.1 mmol/L) on oral glucose tolerance test or RBS≥ 200 mg/dl (11.1 mmol/L) with symptoms 6.
The vitals of the patients were documented, and venous sample was withdrawn and sent for HbA1c and CBC investigations. RDW and MCV were noted from the CBC done using Automated 6-part Hematology Analyzer by flow cytometry method and HbA1c was measured using Automated Hemoglobin Analyzer using cation-exchange HPLC method. The data was tabulated with details of age, gender, RDW, MCV and HbA1c of each case.
The cases were classified into 3 categories based on HbA1c as good glycemic control (HbA1c ≤7%), poor control (HbA1c between 7.1-9%) and uncontrolled (HbA1c ≥9.1%); 2 categories for RDW (≤14.0 and >14.0) and 3 categories for MCV (100fl) as per the laboratory reference range.
Approval for waiver of patients consent and patient information sheet was obtained from Institutional Ethical Committee [National Ethical Guidelines by ICMR on biomedical research 2017, chapter 5, Informed consent process Box 5.2 (Conditions for granting waiver of consent)] since the study involved the data available in the record that were anonymized and coded to delink with any identity of patient7.
Inclusion criteria
1. Previously diagnosed cases of type 2 diabetes mellitus
2. Newly diagnosed cases of type 2 diabetes mellitus
Exclusion criteria
Patients with any history of anemia of any cause
Patients with any haemoglobinopathy
Patients with chronic liver disease
Patients with type 1 diabetes mellitus
Patients with any acute or chronic infections like malaria, tuberculosis or malignancy
Data was analyzed and statistically described in terms of mean and standard deviation. Correlation was done using Chi-square test where a p value≤ 0.05 was considered statistically significant.
RESULTS
Out of the 104 patients, 63 were males (60.6%) and 41 were females (39.4%). The mean age was 47.24±11.0, the youngest patient being 32 years and the oldest being 78 years. Most of the patients (30.8%) were in the age group of 41-50 years (Table 1).
The mean duration of diabetes mellitus was 4.73±3.75 (range 0-20) years. The HbA1c of the study population was found moderately uncontrolled and the mean HbA1c was 9.11±2.24, the lowest being 6.5 and the highest being 14.8. The mean RDW was 16.28±4.35, the lowest being 11.3 and the highest being 24.5. The mean MCV was 82.45±9.12, the lowest being 73.4 and the highest being 93.7 (Table 2).
Amongst the study population, 46% patients had HbA1c values between 7.1-9.0, followed by 34% and 20% patients with HbA1c values ≤7.0 and ≥9.1, respectively. RDW was ≤14.0 for 73% patients while >14.0 for 27% patients. Majority of the patients (58%) had MCV value between 80-100 fl (Table 3).
There was a significant positive correlation between RDW and HbA1c values (p=0.003); as the HbA1c values increased there was a rise in RDW values of the patients. The correlation of HbA1c with age (p=0.78) and MCV (p=0.51) did not show any significant correlation (Table4).
DISCUSSION
Diabetes mellitus has become a major contributor to global morbidity as persistent hyperglycemia leads to various life-threatening complications 8. HbA1c measurement is a routine part of standard diabetes diagnosis and management regimes 9. RDW and MCV are reported routinely with CBC.
In this study we found significant correlation of RDW with HbA1c (p=0.003). In a study done by Suryavanshi C et al., 2015 similar observations were documented with a mild inverse correlation (r=-0.235, p=0.001)10 and in a study done by Sherifet al., 2013 positive correlation between HbA1c and RDW was noted which was not statistically significant (p=0.92) 11. Chowta et al., 2013 found in a study that RDW of elderly diabetics (>60 years) was higher than that of the younger patients and was statistically significant (p=0.002) 12 and Yin et al., 2018 also showed in a study the there was an association between RDW and poor glycemic control in established patients of type 2 diabetes mellitus which is in concordance with the results obtained in this study 13.
There was no significant correlation of HbA1c with MCV in this study. Hardikeret al.., 2012 in a study of non-diabetic population showed an inverse correlation between HbA1c and MCV (r=-0.22, pEnglishhttp://ijcrr.com/abstract.php?article_id=4041http://ijcrr.com/article_html.php?did=40411. Malandrino N, Wu WC, Taveira TH, Whitlatch HB, Smith RJ. Association between red blood cell distribution width and macrovascular and microvascular complications in diabetes. Diabetologia.2012;55:226-35.
2. Rodriguez-Manas L, Arribas S, Giron C, Villamer J, Sanchez-Ferrer C, Marin J. Interference of glycosylated human hemoglobin with endothelium-dependent responses. Circulation.1993;88(5):2111-6
3. Cho YI, Mooney MP, Cho DJ. Hemorrheological disorders of diabetes mellitus. J Diabetes Sci Technol.2008;2:1130-8
4. Syemeonidis A, Athanassiou G, Psiroyannis A, Kyriazopoulou V, Kapatais-Zoumbos K, Missirlis Y, Zoumbos N. Impairment of erythrocyte viscoelasticity is correlated with levels of glycosylated hemoglobin in diabetic patients. Clin Lab Haematol.2001;23:103-9
5. Livshits L, Srulevich A, Raz I, Cahn A, Barshtein G, Yedgar S, Eldor R. Effect of short-term hyperglycemia on protein kinase C alpha activation in human erythrocytes. Rev Diabet Stud.2012;9:94-103
6. American Diabetes Association. 2. Classification and diagnosis of diabetes: standards of medical care in diabetes-2020. Diabetes Care 2020;43(1):14-31
7.National Ethical Guidelines by ICMR on biomedical research 2017, chapter 5, Informed consent process Box 5.2 (Conditions for granting waiver of consent)
8. Jabeen F, Rizvi HA, Subhan A. Effect of hyperglycemia on superoxide dismutase defense system and erythrocyte indices in diabetic patients. Pak J Biochem Mol Biol.2012;45(2):85-9
9. Nathan DM. International Expert Committee report on the role of A1c assay in the diagnosis of diabetes. Diabetes Care.2009;32:1327-34
10. Suryavanshi C, Manjula SD, Ragini B, Raghavendra RK. Association of increased levels of glycated hemoglobin with variations in red blood cell parameters in diabetes mellitus. Int J Adv Res.2015;3(6):31-7
11. Sherif H, Ramadan N, Radwan M, Hamdy E, Reda R. Red cell distribution width as a marker of inflammation in type 2 diabetes mellitus. Life Sci J.2013;10(3)1501-7
12. Chowta N, Shenoy A, Adhikari P, Chowta M. Analysis of hemogram profile of elderly diabetics in a tertiary care hospital. Pharmacology, Neurological Diseases. International Journal of Nutrition.2013;3(2):126-36
13. Yin Y, Ye S, Wang H, Li B, Wang A, Yan W, Mu Y. Red blood cell distribution width and the risk of being in poor glycemic control among patients with established type 2 diabetes. Theraputics and Clinical Risk Management.2018;14:265-73
14. Hardiker PS, Joshi SM, Bhat DS, Raut DA, Katre PA, Lubree HG et al.. Spuriously high prevalence of prediabetes diagnosed by HbA1c in young Indians partly explained by hematological factors and iron deficiency anemia. Diabetes CARE.2012;35(4):797-802
15. Koga M, Morita S, Saito H, Mukai M, Kasayama S. Association of erythrocyte indices with glycated hemoglobin in pre-menopausal women. Diabetic medicine: A journal of the British Diabetic Association.2007;24(8):843-7
16. Glesby MJ, Hoover DR, Shi Q, Danoff A, Howard A, Tien P, Merenstein D et al.. Glycylated hemoglobin in diabetic women with and without HIV infection: data from the Women’s Interagency HIV Study. Antivir Ther.2010;15(4):571-7
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareEvolving Trends in Physical Therapy Management in the Prevention of Knee Osteoarthritis from Mild to Moderate Grade: A Systematic Review
English179183Sowmya Madayi VeetilEnglish Kotteeswaran KandaswamiEnglish Vikram Adhitya Pathamadai SelvakumarEnglishIntroduction: Knee osteoarthritis (KOA) affects a large number of people, the world over especially the female population in their old age. As no proper remedy is available on the date, people prefer non-invasive treatments to overcome this malady. Physiotherapy approaches have been recognized as beneficial to the affected. Though the current intervention packages offer satisfactory results, a better treatment modality is proposed in this report. The main objective is to determine the effect of Physical Therapy management in preventing Knee Osteoarthritis from mild to moderate. Aim: This study aims to evaluate the evolving trends in physical therapy management in the prevention of knee osteoarthritis from mild to moderate grade. Methods: We included systematic reviews published between December 2000 and December 2019 that examined any physical therapy intervention for patients with osteoarthritis of the knee. We included reviews on patients with osteoarthritis in general if results from patients with knee osteoarthritis could be extracted separately. We excluded reviews with major limitations. Instruments and scales for assessment of the methodological quality of Randomized Control Trials (RCT) in the reviews (Eg: Jadad scale, PEDro scale) were extracted and entered into the table of characteristics. Results: A total of 23 review articles have examined the evolving trends in Physical therapy management in the prevention of osteoarthritis of the knee. These studies show high-quality evidence that exercise improves physical function and reduces pain. The reviews did not find any effect on psychological outcomes. The overview of this review on physical therapy interventions for patients with osteoarthritis of the knee is based on a thorough literature search, assessment of study quality, and synthesis of findings. Conclusion: Exercise, including a weight reduction program for patients who are obese, seems to be a valuable treatment option for patients with pain and functional problems due to osteoarthritis of the knee
English Exercise, Laser therapy, Pain, Osteoarthritis, Ultrasound, Weight reduction.INTRODUCTION
Knee osteoarthritis is the most common cause of functional limitation and pain in the knee joint which causes huge impact in human beings.1Exercise programs have been shown to be effective when patients are closely supervised by physiotherapists.27 The OA of knee joint mainly affects the active daily living activity of a person.2 Certain studies done previously suggest that there is a marked decrease in the aerobic capacity among the patients with OA knee when compared to people who are not affected by Osteoarthritis (OA) knee. The most common manifestations of OA knee are pain and muscle weakness which in turn causes decreased physical activity and results in negative health outcome. The OA knee which causes decreased physical activity may lead to many associated health problems like cardiovascular disease, chronic co-morbidity, musculoskeletal disorder, and reduced quality of life.3 Recent studies have suggested us that people with OA knee are making enough effort to execute the management with support from their health care provider. The early intervention is very important to prevent the further progression of the disease and improve the quality of life.4
Recent studies also suggest that there is a decrease in the muscle strength of hamstring and quadriceps among the patients with OA knee. The cause for the weakness is unknown but the main cause which appears is due to disuse dystrophy and activation deficits.5 This has been observed that there is more emphasize given on the quadriceps strengthening than the hamstrings. The hamstring muscle also provides the structural and functional stability to the knee joint and thus the hamstring strengthening is very important.6 There are very few studies done on the effect of the hamstring muscle strengthening among the OA knee patients and we would recommend an intensive research to be done in order to provide us a valid tool to prevent the progression of OA knee from mild grade of severity to moderate level.
There are various biomechanical factors which are involved in the progression of the disease. The major biomechanical factor which is responsible for the progression of the OA knee is the ankle rotation.7 Acute joint loading factor will cause damage to the joint tissue and lead to OA knee. External knee adduction movement during walking is one of the most correlated biomechanical factors which cause the medial compartment loading and lead to OA knee. To reduce the loading on the medial side and to overcome the pain the patient walk with externally rotated foot.8 There is another way to reduce the medial loading by increasing the lateral hamstring activation and decreasing the medial hamstring activation.9
Various treatment strategies for OA knee included pharmacological, non - pharmacological, surgical management. The physical therapy includes the treatment with the help of exercise, braces and orthosis, Transcutaneous Electrical Nerve stimulation, Thermotherapy, laser therapy, electrical stimulation, and ultrasound.10 The burden of knee OA alone is particularly high and is on the rise.11,12 There are various treatment strategies which are available for treating OA knee. This review mainly aims to find the modern and evidence based treatment strategies available for the treatment of OA knee. The main objective is to find the treatment to prevent the progression and severity of OA knee from mild to moderate.Therefore; it is of paramount importance to keep updating OA management guidelines so as to provide the best possible evidence-based management in the primary setting. This may help to delay progression into end-stage OA and thus decrease the need for arthroplasty and alleviate post-surgical complications.13,14
METHODS
ELIGIBLITY CRITERIA
We included systematic reviews published between December 2000 and December 2019 that examined any physical therapy intervention for patients with osteoarthritis of the knee. We included reviews on patients with osteoarthritis in general if results from patients with knee osteoarthritis could be extracted separately. Reviews on all types of physical therapy interventions (Eg: exercise, physical modalities, and patient education) were included. For the purpose of this overview, we have considered pain and physical function as primary outcomes, but we also have included psychological outcomes (Eg: scales of psychological disability or self-efficacy), as this information might be important to patients. The concept of “function” is based on the International Classification of Functioning, Disability and Health (ICF) where “function” is an umbrella term for body function, body structure, activities, and participation. We included only reviews published in English.
INFORMATION SOURCES
We searched the Cochrane Library (Cochrane Database of Systematic Reviews and DARE), MEDLINE, EMBASE, and PEDro for systematic reviews published from December 2000 to December 2019. In MEDLINE and EMBASE a filter based on the SIGN filters was used to identify reviews. In PEDro and the Cochrane Library, the searches were restricted to terms in the record title, abstract, or key words. In addition, we screened the reference lists of included studies. We did an updated search in the Cochrane Database of Systematic Reviews and MEDLINE in December 2019.
IDENTIFYING RELEVANT REVIEWS AND ASSESSMENT OF METHODOLOGICAL QUALITY
Two reviewers independently assessed the relevance of all references based on abstracts, read the full text of relevant reviews, and assessed the methodological quality of included reviews using a modified version of a previously validated checklist. Nine criteria related to search strategy, inclusion criteria, quality assessment, combining of studies, and conclusion were rated as “met,” “unclear/ partly met,” or “not met.” Disagreement was resolved by discussion between the 2 reviewers. Based on a summary of these 9 criteria, an overall scientific quality of each review was labelled as “minor limitations” (at least 7 of the criteria met), “moderate limitations” (at least 4 of the criteria met), or “major limitations” (fewer than 4 of the criteria met). We excluded reviews with major limitations. Data Extraction and Synthesis was done by one author. The author independently extracted data from each included review and discussed the data with the other author. Instruments and scales for assessment of methodological quality of RCTs in the reviews (Eg: Jadad scale, PEDro scale) were extracted and entered into the table of characteristics of included reviews.
PRISMA DIAGRAM
FIGURE NO:1
The literature search identified 1,027 relevant reviews (301 from MEDLINE, 552 from EMBASE, 114 from the Cochrane Library, and 60 from PEDro). After screening of abstracts, 49 reviews were retrieved in full text. Finally, 13 reviews fulfilled the inclusion criteria and were included in the overview. Characteristics and results of included reviews are presented in Table.1. The reviews covered the following topics: exercise, psychoeducational interventions, braces and orthoses, electromagnetic field, weight reduction, acupuncture, transcutaneous electrical nerve stimulation, low-level laser therapy, ultrasound, thermotherapy, electrical muscle stimulation, and balneotherapy. Sixteen of the reviews were of high quality (minor limitations), and 7 reviews were of moderate quality.
RESULTS:
Exercise
Exercise therapy can be performed actively, passively, or against resistance.15 Two reviews concluded that there was no difference in effect between aerobic exercise (including walking) and strengthening exercise. Another review included one study that compared high and low intensity exercise (stationary cycling) and found no difference in any outcome. From a descriptive summary of 7 RCTs on patients with osteoarthritis (2 studies on knee osteoarthritis), the authors concluded that interventions to enhance self-efficacy and social support are necessary to foster exercise adherence among people with osteoarthritis. All reviews concluded that exercise reduces pain and improves physical function.16 The effects are considered small to moderate in both high and moderate quality reviews. Thus, we conclude that there is high-quality evidence that exercise improves physical function and reduces pain. The reviews did not find any effect on psychological outcomes.
Weight Reduction
One recently published review evaluated the effect of weight reduction in patients with obesity who were diagnosed with osteoarthritis of the knee.The authors concluded that for obese patients with OA, a rapid reduction of atleast 10% of body weight must be prescribed. The challenge of how to maintain weight loss, and further research is required on how weight loss impacts a patient with osteoarthritis.26,17
Electromagnetic Field
The effects of pulsed electromagnetic energy and electromagnetic fields were presented in 2 reviews. These results suggest that Pulsed electromagnetic field therapy (PEMF) is effective for pain management in knee Osteoarthritis patients and also affects pain threshold and physical functioning. Current evidence suggests that electrical stimulation therapy may provide significant improvements for knee OA, but further studies are required to confirm whether the statistically significant results shown in these trials confer to important benefits.18
Transcutaneous Electrical Nerve Stimulation
One review compared transcutaneous electrical nerve stimulation with a conservative intervention. Those studies revealed a reduction in pain after transcutaneous electrical nerve stimulation compared with the conservative intervention.19 We conclude that there is moderate-quality evidence that transcutaneous electrical nerve stimulation reduces pain compared with a conservative intervention.
Balneotherapy
One review including 3 RCTs evaluated different types of balneotherapy. The authors concluded that baths seems to have a short-term benefit for pain relief compared with tap water. Based on few studies and heterogeneous results.20 We conclude that the effect of balneotherapy is unclear and has low-quality evidence.
Thermotherapy
One review included on the effects of heat packs, cold packs, or ice massage. All studies had small sample sizes and low quality. The results for pain or function are not consistent, and we conclude that Ice massage compared to control had a statistically beneficial effect on ROM, function and knee strength. Cold packs decreased swelling. Hot packs had no beneficial effect on oedema compared with placebo or cold application. Ice packs did not affect pain significantly, compared to control, in patients with OA.21
Low-Level Laser Therapy
We originally included 2 reviews on low-level laser therapy but in the updated search we found that the Cochrane Review on low-level laser therapy was withdrawn because it needed to be updated. Thus, only one review summarizing low-level laser therapy for knee osteoarthritis is included. The meta-analysis of 7 RCTs concluded that laser therapy reduced pain and improved function compared with a placebo intervention.22 We conclude that there is moderate-quality evidence that low level laser therapy reduces pain and improves function.
Psychoeducational Interventions
Three reviews summarized studies on self-management, psychoeducational interventions, and patient education. In the most updated review by R Marks and JP Allegrante. et al, The most effective psychoeducational interventions must be preceded by careful assessment of the patient, including their own goals and objectives.23 The most useful interventions are likely to be those that can influence emotional regulation and those that provide social support. We conclude that there is moderate-quality evidence that psychoeducational interventions improve psychological outcomes.
Braces and Orthoses
One review evaluated the effect of braces and orthoses. R W Brouwer 1, T S C Jakma, A P Verhagen, J A N Verhaar, S M A Bierma-Zeinstra in his review regarding the efficacy of braces and orthoses to reduce the pain. Two out of 3 studies selected were high end reviews where they concluded that NSAID intake is reduced with a laterally wedged insole compared with a neutral insole. [24]
DISCUSSION:
This overview on physical therapy interventions for patients with osteoarthritis of the knee is based on a thorough literature search, assessment of study quality, and synthesis of findings. One extensive overview of the effectiveness of exercise therapy was published earlier but to our knowledge no overview has used our explicit and systematic method. Only exercise for reducing pain and improving function and weight loss for disability were supported by high-quality evidence. Transcutaneous electrical nerve stimulation, and low level laser therapy for pain reduction were graded as moderate-quality evidence, although they were all close to high quality. For other interventions and outcomes, the quality of evidence was assessed as moderate, low, or no evidence from systematic reviews. New trials are needed within these areas. For a few interventions, no systematic review was identified.
Exercise therapy was covered in 2 reviews and it is well stated that most patients with osteoarthritis receive exercise as part of their treatment and physical therapists need updated evidence concerning type, frequency, and dose of optimal exercise. Many of the reviews concluded that both aerobic and strengthening exercise as well as individual and group exercises was effective in patients with knee osteoarthritis. One review concluded that weight reduction decreased pain and improved self-reported disability for patients who are obese. The intervention was carried out as a nutrition class and was combined with cognitive behavioural therapy. We included this review because physical therapists play an important role in supporting people to lose weight. Based on the high-quality evidence for weight loss and exercise, physical therapists should consider collaborating with dietitians in order to reduce pain and improve function in patients with osteoarthritis of knee.
It is also important for clinicians and policy makers not to interpret low-quality evidence as evidence of no effect. Low-quality evidence means unclear evidence, and findings should initiate more research and reviews. It was difficult to extract data on methodological quality and results from some reviews because of poor reporting. Authors of systematic reviews should use explicit and systematic methods for including, finding, assessing, and summarizing evidence although a meta-analysis cannot always be performed. We strongly encourage authors of systematic reviews to make a synthesis of the results instead of summarizing study by study only.
In this overview, 7 out of 15 included reviews come from 2 research teams. Whether this could introduce a source of bias is difficult to estimate, but it should be kept in mind. We included 15 reviews in this overview. Clinical guidelines often are based on evidence from systematic reviews; therefore, we need more reviews. From 1999 to 2006, the number of included reviews in the PEDro database increased from 200 to more than 1,400.
Physical therapy interventions might be useful for people with osteoarthritis of knee. This study also concluded that there was a mismatch between the amount of research and the degree of interest from consumers. A recent systematic review of the course of functional status and pain in people with osteoarthritis of the hip and knee showed increased muscle strength (force generating capacity) and better self-efficacy.
CONCLUSION
The findings and conclusions from the present overview confirm that physical therapy is beneficial for patients with osteoarthritis of the knee, but more research is needed as a means of evidence-based practice. Exercise which focus mainly on improving the muscle strength of both hamstrings, quadriceps and indirectly strengthening the ankle rotators to prevent the unwanted joint loading to the knee also proves beneficial in reducing the severity from mild grade to moderate grade of knee OA. A well-defined program such as weight reduction sessions for patients who are obese, seems to be a valuable treatment option for patients with pain and functional problems due to osteoarthritis of the knee.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Ethical Clearance: NA
Informed Consent: NA
Source of Funding: None
Conflict of interest: NIL
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OSTEOARTHRITIS OF KNEE JOINT International Journal of Current Research and Review. Vol 03 Issue 01, January, 18-27
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareDescriptive Study on Prevalence of Sensorineural Hearing Loss in Diabetes, Hypertensive Patients
English184189Bomma Vijay KumarEnglish Ambati Rathna KumariEnglish Sravani MaryadaEnglish Shoban BabuEnglishIntroduction: The chronic diseases caused by genetics, lifestyle, the environment and ageing itself are the key factors that affect health today; hence, we should concentrate our attention on our patients’ last years of life aimed at raising the number of elderly people in health, able to sustain their physical and mental functions. Aims: To study the incidence and degree of sensorineural hearing loss in diabetic, hypertensive patients. Materials and Methods: This is a prospective observational study done for 18 months. The study will be conducted on 50 subjects diagnosed with diabetes, 50 subjects diagnosed with hypertension and 50 subjects with both hypertension and diabetes and 50 normal subjects without hypertension and diabetes. All the subjects in the age group of 20-60 years with diagnosed diabetes, hypertension and normal subjects without hypertension and diabetes both males and females are included in the study. Results: Of 100 patients in the study age of the group with the associated disease is statistically higher in the group without the associated disease. It was found that out of 150 cases with hypertension or diabetes or both in the present study 138 were in the age group of 40- 60 and only 12 cases were between ages 20-40. Patients with hypertension (86%) were at a higher risk of developing SNHL when compared to controls (0%). Conclusion: The importance of preventive processes that may reduce the mechanisms that trigger hearing aid degeneration induced by circulatory problems especially high blood pressure and high blood sugar, and the need for much more information on the regulation of the effects of these comorbidities on hearing are highlighted.
English Sensorineural hearing loss (SNHL), Hypertension, Diabetes, Ischemic damage, Dyslipidemias, Hypoglycemic drugINTRODUCTION:
Hearing, also known as auditory perception, is the ability to sense vibrations and changes in the surrounding medium's pressure overtime via an organ such as the ear.1 Hearing is an essential part of how we communicate with others and become aware of sounds that happen in our immediate environment. Hearing loss, also known as hearing impairment, is a partial or total inability to hear. Hearing loss is any degree of impairment of the ability to comprehend sound. Acquired hearing loss is defined as a loss of hearing function due to nongenetic causes, for example triggered by environmental agents such as chemicals, drugs and noise. Sensorineural hearing loss in which the root cause lies in the inner ear or sensory organ (cochlea and associated structures) or cranial nerve VIII or neural part. SNHL may arise from number of different etiologies. Damage of the auditory hair cells, supporting cells, spiral ganglion cells, and other cell types may arise from a variety of factors. Gene mutations, trauma, inflammation, tumors, structural abnormalities, and altered ion homeostasis such as in endolymphatic hydrops, all may result in SNHL Systemic disorders, especially systemic hypertension, diabetes mellitus, and dyslipidemias, are directly or indirectly implicated in the assessment of patients with sensorineural hearing loss. Prevalence of Diabetes Mellitus (DM) and hypertension are increasing worldwide and it is more pronounced in India. This hypertension and diabetes causes SNHL by affecting the blood supply of cochlea as main path way.
The cochlea is provided with a terminal capillary bed and is not supplied by collateral vessels which could restore blood flow in ischemic regions. Moreover, since cochlear hair cells have a high metabolic activity, they are particularly vulnerable to hypoxic or ischemic damage. It has been demonstrated experimentally that cochlear tolerance to ischemia is very limited and that the action potential is impaired after 60 sec of anoxia, while after 1 hour of vessel obstruction, cochlear function does not recover . Hearing loss is a common public health problem that affects work productivity, functional status, social interactions, personal safety and well-being, and quality of life.2 The hearing loss (HL) is a factor that irrespective of the degree of commitment affects the quality of life and when acquired in adults, it appears gradually and may make the oral language receiving difficult. May cause psychosocial effects, like low self-esteem, isolation, depression and irritability, which can interfere with the quality of life of the individuals.
As there is increasing prevalence of diabetes and hypertension in the people, chance of sensorineural hearing loss may increase at an early age debilitating the persons day to day life. There are many studies on complications related to CAD, stroke, opthalmic complications due to hypertension and diabetes but less studies related to SNHL This study is done to evaluate the prevalence of sensorineural hearing loss in diabetes and hypertensive subjects.
MATERIALS AND METHODS
This is a prospective observational study done for a period of 18 months from January 2018 to june 2019. The study will be conducted on 50 subjects diagnosed with diabetes, 50 subjects diagnosed with hypertension and 50 subjects with both hypertension and diabetes and 50 normal subjects without hypertension and diabetes. Study conducted in the department of Ear, Nose and Throat (ENT) of the Gandhi Medical College in association with audiologist. Ethical clearance was obtained from institutional board(IEC-17113002076D) and Informed Consent will be taken and complete history about duration of diabetes, hypertension and their medication history and any symptoms of hearing loss history is taken. Spot blood pressure in hypertensive patients is measured and >= 140/90 mmhg is considered as uncontrolled and HBA1C in diabetic patients are performed and > 7 is considered as uncontrolled. Pure tone audiometry is performed on all the subjects.
Inclusion criteria: All the subjects in the age group of 20-60 years with diagnosed diabetes, hypertension and normal subjects without hypertension and diabetes both males and females are included.
Exclusion criteria: Subjects under 20 and above 60 and with any congenital malformations causing hearing loss, conductive hearing loss and mixed hearing loss in patients, other causes of sensorineural hearing loss like Exposure to loud noise, Head trauma, Viral infections, Autoimmune inner ear disease, Hearing loss that runs in the family, Malformation of the inner ear, Meniere’s Disease, Otosclerosis, Tumors.
Questions regarding the duration of hypertension and diabetes, treatment history, and the associated complications were asked. Any complaints of hearing loss, duration was enquired. The study excluded patients with occupational noise sensitivity, ototoxic and chemotherapy drug use, serious head injury, family history of deafness, ear infection, ear surgery, head or neck radiotherapy, or upper respiratory tract infection in the previous month.
Identification data: name, age, gender was noted. Subjects with a history of physician diagnosed diabetes or who were taking oral hypoglycemic drugs or insulin were defined as diabetic. For those without a diagnosis of diabetes and not taking any antidiabetic medications, the value of fasting blood glucose was used to assess the presence of diabetes according to the American Diabetes Association guidelines (5year (100%) diabetes than cases with 5year (100%) diabetes than cases with 7(85%) than with HBA1C Englishhttp://ijcrr.com/abstract.php?article_id=4043http://ijcrr.com/article_html.php?did=4043
Plack, C. J: The Sense of Hearing. Psychology Press Ltd. :2014: ISBN 978 1848725157.
Yavuz E, Morawski K, Telischi FF, Ozdamar O, Delgado RE, Manns F et al: Simultaneous measurement of electrocochleography and cochlear blood flow during cochlear hypoxia in rabbits: J Neurosci Methods 2005; 147: 55–64.
Axelsson, S.E. Fargerberg: Auditory function in diabetics Acta Otolaryngol., 66 (1968), pp. 49-64.
BrohemV.M.A. , CaovillaH.H. , Ganança M.M.: Dos sintomas e achados audiológicos e vestibulares em indivíduos com hipertensão arterial Acta AWHO., 15 (1) (1996), pp. 4-10.
MarchioriL.L.M. , FilhoE.A.R. , MatsuoT. Hipertensão como fator associado à perda auditive Braz J Otorhinolaryngol., 72 (4) (2006), pp. 533-540
Carrasco VN, Prazma J, Faber JE: Cochlear microcirculation effect of adrenergic agonists on arteriole diameter. Arch Otolaryngol Head Neck Surg. 1990;116:411–417.
Gates GA, Cobb JL, D′Agostinho RB, Wolf PA: The relation of hearing in the elderly to the presence of cardiovascular disease and cardiovascular risk factors: Arch Otolaryngol Head Neck Surg. 1993;119:156–161.
Dubno JR, Lee FS, Matthews LJ, Mills JH: Age-related and gender-related changes in monaural speech recognition. J Speech Lang Hear Res. 1997;40(2):444–452.
Pearson JD, Morrell CH, Gordon-Salant S, Brant LJ, Metter EJ, Klein LL et al: Gender differences in a longitudinal study of age-associated hearing loss. J Acoust Soc Am :1995, 97(2):1196–1205.
de Mores Marchiori LL, de Almeida Rego Filho E, Matsuo T: Hypertension as a factor associated with hearing loss. Braz Otorhinolaryngol ; 72(4): 533-40.
Agarwal S, Mishra A, Jagade M: Effects of hypertension on hearing Indian J Otolaryngol. 2013; 65 (suppl 3) 614- 618).
Friedman SA, Schulman RH, Weiss S: Hearing and diabetic neuropathy. Arch Intern Med. 1975 ;135(4):573-6.
Kakarlapudi V, Sawyer R, Staecker H: The effect of diabetes on sensor neural hearing loss. Otol Neurotol. 2003;24(3):382-6.
Celik O, Yalçin S, Celebi H, Oztürk A: Hearing loss in insulin dependent diabetes mellitus. Auris Nasus Larynx.1996;23:127-32.
Dalton DS, Cruickshanks KJ, Klein R, Klein BE, Wiley TL: Association of NIDDM and hearing loss. Diabetes Care 1998;21:1540-4.
Weng SF, Chen YS, Hsu CJ, Tseng FY: Clinical features of sudden sensorineural hearing loss in diabetic patients. Laryngoscope.2005;115(9):1676-80.
Nakashima, K., Tanaka, K: Pathological changes of the inner ear and central auditory pathways in diabetics. Ann Otol Rhinol Laryngol.1971;80:218-288.
Van den Ouweland JM, Lemkes HH Gerbitz KD, Maassen JA: Maternally inherited diabetes and deafness (MIDD): A distinct subtype of diabetes associated with a mitochondrial tRNALeu(UUR) gene point mutation. Muscle Nerve. 1995;3:S124-30
Lisowska G, Namyslowski G, Morawski K, Strojek K: Otoacoustic emissions and auditory brain stem responses in insulin-dependent diabetic patients. Otolaryngol Pol. 2002;56(2):217-25.
Fukushima H, Cureoglu S, Schachern PA, Paparella MM, Harada T, Oktay MF: Effects of type 2 diabetes mellitus on cochlear structure in humans. Arch Otolaryngol Head Neck Surg. 2006; Sep;132(9):934-8
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareEffectiveness of Child-Centred Distraction in the Management of a Child’s Dental Anxiety During Invasive Dental Procedures
English190197Sahithi VEnglish Elicherla SREnglish Saikiran KVEnglish Challa RREnglish Nuvvula SEnglishBackground and Aim: Distraction is the technique of diverting the patient’s attention from an unpleasant procedure. It is of two type’s active and passive distraction. The present study was performed to evaluate the efficacy of child-centred distraction (CCD) in alleviating dental anxiety of children using three techniques during invasive dental procedures. Materials and Methods: Sixty children (40 boys and 20 girls), aged 7 to 11 years, were randomly allocated into three groups: Group1- Mobile video games (VG), Group 2- Virtual reality (VR), and Group 3- Mobile cartoons (MC) respectively, during the treatment sessions. The anxiety of the children was assessed using physiologic measures (heart rate) at three different time points, i.e., before, during, and after the procedure, whereas RMS pictorial scale was employed as a subjective measure before and after the procedure. Kruskal Wallis- ANOVA and Wilcoxon Sign Rank Test was used to analyze the RMS Scores, and repeated measures of ANOVA was used to test the mean difference of pulse rates. Results: On intergroup comparison, there was no statistical difference among the three groups before commencing the treatment (P-value > 0.001). But, a statistical difference in all the groups (P-value ≤ 0.001) was evident after instituting the distraction techniques. Amongst all the three groups, a significant reduction in anxiety scores was elicited by the children in group 1. Conclusion: This study has attempted to enhance the salience of distraction techniques in tumbling a child’s dental anxiety. Involving the child in decision making while using distraction techniques has a foremost impetus in most children, instilling a new positive attitude towards the dental procedures.
EnglishBehaviour guidance, Dental anxiety, DistractionDental anxiety is a widespread emotional phenomenon anteceding a dental appointment. Anxiety can involve behavioral, emotional, cognitive, and physiological components, and their countenance might differ.1,2,3 [A1] Many terminologies have been used over a while to explain dental anxiety, dental fear, and dental phobia. Dental anxiety and fear are often used indistinctly in the scientific literature, but they both represent contrasting progressive degrees of the same psychological condition. Dental fear is generally associated with known stimuli such as injections or drills, whereas dental anxiety is due to an unknown threat that is not immediately present.4 Dental anxiety is the fifth-most common cause of anxiety and the prevalence of dental fear and anxiety among children ranges from 6% to 42% in different populations.5-10 Various factors and aspects are involved in the development and acquisition of dental anxiety in children. A child's first dental visit is a climacteric moment for the decline or addition of dental anxiety,11 whereas atypical dental anxiety can sometimes relate to a series of uncooperative or troublesome behaviors, given that it can limit children's access to quality oral health care.12 When clinicians treat children with dental anxiety, the former are subjected inevitably to increased stress with more time-consuming procedures, increased costs, and other difficulties encountered during their dental practice.13 Therefore, appropriate management of a child's anxiety during a dental appointment may enhance access to dental care and also subsidize a high quality of dental care, which in turn contributes to the psychological well-being of both the child patient and pediatric dentist.14
The American Academy of Pediatric Dentistry (AAPD) outlined a series of nonpharmacological techniques to deal with a child's behavior in the dental setting.15 Among those, the present trend advocates a simple, safe, cost-effective, and non-aversive approach i.e., distraction.16-19 These distraction techniques seem to can have a positive impact on young individuals' dental fear and anxiety. Robson reported the first documentation of the distraction technique in 1925. The distraction techniques aim to forestall the child's attention from what may be perceived as unpleasant stimuli and shift their focus to exciting and fascinating distractors.20-23 McCaul and Mallot's theory testified that a person's perception of pain decreases when he/ she is distracted from an unpleasant stimulus.24 Distraction techniques can be of two forms i.e., active and passive. Active methods comprise activities that entail the direct participation of the child. They often distract an additional source of sensation i.e., kinesthetic sensation e.g., playing mobile video games and toys.25-28 In contrast, passive techniques rely on practices employing music and video, deprived of involving the child directly, in which children were distracted only using their senses, i.e., vision and hearing, respectively.29,30,31 [A2] Two such widely employed forms of passive distraction in pediatric dentistry are Audio (various categories of music) and Audio-visual distraction (cartoons on TV and two-dimensional video glasses).
A systematic review and meta-analysis by Valverde et al., addressed that VR is a useful distraction technique to reduce anxiety and pain perception in children undergoing dental procedures, thus enlightening the child's behavior towards dental care.32 Ashokan S et al., reported that active distraction plays an important role compared to passive distraction in relieving pain more effectively in children.33 Likewise, Patel et al., observed that video games gained a higher acceptance than parental presence during treatment sessions.25 The accomplishment of the passive distraction technique has been affirmed in medical setups; however scanty literature is accessible to gauge the potency of these techniques in terms of the pediatric population.34 Investigations of visual and auditory distractions in the dental clinic have not reliably found reductions in pain, anxiety, or disruptive behavior.35,36 One possible explanation for these conflicting outcomes is that many of the most communal distracting stimuli (e.g., TV, music) may lack adequate salience to compete for attention as the active distractors alone did not adequately enhance the salience of distraction. One of the best ways to ameliorate the salience of distractors is the addition of a choice component to achieve a receptive child's behavior.37 Hence, the present study was contrived to evaluate the effectiveness of child-centered (choice-based) distraction using three techniques i.e., mobile video games (VG), virtual reality (VR), and mobile cartoons (MC) in the management of a child's dental anxiety during invasive dental procedures.
MATERIALS AND METHODS
Source of data and participants:
The present self-explanatory trial was conducted in the Department of Pediatric and Preventive Dentistry, Narayana Dental College and hospital, Nellore over three months (August to October of 2019). There were no gender, race, or ethnic restrictions used in the study. Signed informed consent was obtained from the parents or guardians who agreed to participate in the study after providing information regarding the procedures involved. A total of 345 children, who visited the department, were initially examined, of which 60 children who met the following selection criteria were enlisted.
• Healthy children aged 6-12 years
• Children requiring invasive dental procedures
• Children without any previous dental experience.
• Children whose behavior rated as positive (+) or negative (-) based on Wright's modification of the Frankl behavior rating scale.38
• Children who were willing to participate in the study.
Exclusion Criteria:
• Children with any disabilities and underlying systemic diseases.
• Children or parents who refused to participate in the study.
• Children whose behavior rated as definitely positive (++) or definitely negative (--) according to Wright's modification of the Frankl behavior rating scale.
• In addition, to evaluate the independent effects of the distraction, children who required nitrous oxide or general anesthesia were also excluded.
Allocations:
A total of 60 children (40 boys and 20 girls) aged 6-12 years requiring invasive dental procedures were included in the study. Children were allocated based on their choices into three groups: Group-1 mobile video games (VG), Group-2 virtual reality (VR), Group-3 mobile cartoons (MC). In all the groups, children were treated by a single trained dentist within a single appointment using either of the distraction techniques during the execution of invasive dental procedures.
Interventions:
In the VG group (group 1), we initially collected information regarding the most commonly played games by the children in our local region, and those games have installed on the mobile from the IOS store. The games used in this study were friendly, not showing any aggressive, pain, or distress-related content. Before starting the treatment, children were asked to choose their favorite video game, which aids in preventing boredom and keeping attentional by engaging them. Most girls preferred the BarbieTM Magical Fashion game by Budge Studios TM, and boys preferred Temple Run game by Imangi Studios, LLC. Later the children were asked to play the video game of their choice during the treatment sessions.
In the VR group (group 2), children were given a few minutes to get accustomed to the eyeglasses. These 3D VR eyeglasses (ALDIVO R Virtual Reality Glasses 3D VR Box headsets for 3.5- 6 "mobile phones, model no: a236, India) helps in blocking the visual field of the child entirely and had in-built headphones to deliver the sound effectively to avoid hearing any voices and helps in distraction. The children were asked to choose their favorite videos on the phone, where most of the children preferred Doraemon cartoon videos. Later, 3D VR glasses were mounted to the mobile phone (Apple iPhone 7 Plus, California) capable of playing MP4 audiovisual files. Once the VR device was secured on the child's eyes, cartoon videos are played.
In the MC group (group 3), children were provided with a mobile phone and headset for better audio as a means of distraction, where they opted to view their favorite cartoon videos in the regional language.
Materials for measuring a child's anxiety:
RMS Pictorial Scale (RMS-PS): The RMS-PS is anxiety measuring scale consists of original photographs of both boy and a girl child. RMS-PS consist of five faces from very happy to very unhappy. The children were asked to choose a face that closely resembles how they feel like at that moment. This was recorded by giving a value one to the very happy face and five to very unhappy face.39 Pre and Post-operative anxiety were measured using an RMS pictorial scale. Anxiety levels before, during, and after the treatment procedure was assessed by recording the heart rate (physiologic measurement) using a Portable Non-Invasive Fingertip pulse oximeter device (EZ- LIFE Professional PD- 10*7*5 cm. ASIN B084TQQTVN).40 A single dentist who was blinded to the allocation procedure recorded both the heart rate and the RMS scores for all the children.
Outcomes measures:
1. The primary outcome measure considered was the Pulse (heart) rate, which is a physiological parameter
2. The secondary outcome measured was pre and post-operative anxiety using the RMS pictorial scale.
Statistical methods:
All statistical analyses were performed using standard software (SPSS 20.0 for Windows, SPSS Inc., Chicago, USA). Kruskal Wallis- ANOVA and Wilcoxon Sign Rank Test was used to analyze the Intergroup and Intragroup comparison of pre-op and post-op RMS Scores.
Intergroup comparison of anxiety before, during, and after was analyzed using One-Way ANOVA. Whereas, for Pair-wise comparison of Anxiety in Group I, II, III LSD Bonferroni Test was used. Intragroup comparison of anxiety was assessed using Repeated Measures of ANOVA, and for Pair-wise comparison of Anxiety Tukey's Post Hoc Analysis was used.
P-value < 0.05 was considered statistically significant.
RESULTS:
The recruitment, randomization, allocation, and completion of children in different groups were represented in the flow diagram.
Intervention Effectiveness:
Intergroup Pre-operative anxiety measured for children in all the groups on a subjective scale, i.e., RMS pictorial scale, showed no significant differences among them. However, a significant difference was elicited for post-operative anxiety among all the three groups, children in the first group exhibited fewer anxiety scores than the counterpart. (Table 1)
Intragroup comparison of pre and post-operative anxiety scores showed a significant difference for the children in group I and group III. It was not significant for the children in group II (P-value ≤ 0.004). (Table 2)
The children's intergroup comparison of pre and post anxiety scores didn't illustrate any statistically significant difference among them. In contrast, a significant difference was exhibited for the anxiety scores during the procedure. (Table 3)
For the Intragroup comparison of anxiety scores, a significant difference was elicited for all the children in three groups. But upon keen evaluation of the Mean +- SD values, there was more decrease in the mean +-SD. Values compared to other groups. (Table 4)
Discussion
Anxiety and fear due to dental treatment, affect 15% - 20% of the population, being recognized by the World Health Organization (WHO).41, 42 It poses a significant problem for children who are affected by it, resulting in avoidance of even the most primary dental treatments, such as simple dental check-ups or cleanings.43 Thus, its management is essential to enhance the child's oral health quality of life.44 The dentists and the parents accepted variety of behavior guidance techniques adopted by American Academy of Pediatric Dentistry, among that distraction is one of the contemporary technique which is capable reducing anxiety by engaging the child most effectively during their first dental visit.45 Ideal distracters would require an optimal amount of attention involving multiple sensory modalities (kinesthetic, visual, and auditory), active emotional involvement, and participation of the child to compete with the signals from the noxious stimuli.46,47 The most common distracting stimuli (e.g., TV, music, mobile) may lack adequate salience to compete for attention. In other words, common distracters may not be loud enough, close enough, or interesting enough to hold a child's attention in distracting him/her from the dental environment. Thus, one way to improve the effectiveness of Distraction may be to increase the salience of the distractors.37 Mainly the value of the distracting stimulus is linked closely to its quality, which usually is determined by the preference of the participant.48 Thus, one means of enhancing the effectiveness of a distracter may be to stick on the preference of the children by providing choices pertaining to the available distracters.49 This necessitates the need for research that improve insights to existing distraction techniques. Hence, present study was aimed to evaluate the effectiveness of child centered distraction (choice based) techniques in the management of a child's dental anxiety and fear based on their preferences. None of the children in the present study had previous exposure to dental treatment, and high levels of anxiety was observed before commencing the procedure it was consistent with the study reported by Alvin et al., Mason et al.50,51 Primarily, anxiety and fear of unknown situations predispose children to consider dental circumstances to be challenging.
In the present study, irrespective of the distraction methods used, there was an overall reduction in the reported Raghavendra Madhuri Sujatha (RMS) scores, which indicates a decline in the anxiety levels of children after the dental procedures. Two forms of distraction i.e., active and passive which include playing video games on a mobile phone, and Audio-visual distraction with/without VR glasses respectively were used in this study. Although it has hypothesized that active strategies are more effective than passive, other studies suggest that passive distraction was useful or even better since the active forms are too demanding for children.52, 53
Likewise, in this study, playing a Mobile phone video game, which acts as an active distraction technique, reduces a child's anxiety better than passively watching the cartoon with or without VR glasses. This reduction in anxiety scores can be explained as stated by Koepp et al.,54 that endogenous dopamine is released and bound to receptors in the human striatum during a goal-directed motor task like VG playing. Dopaminergic neurotransmission might be involved in learning reinforcement of behavior, attention, and sensorimotor integration. Likewise, a randomized cross-over trial by Shah et al.,55 concluded that pre-procedural gaming resulted in a statistically significant difference in hemodynamic parameters of 60 children between 5 and 10 years old. Coinciding with this, we witnessed a substantial reduction in mean pulse rates in children who had their treatments while playing mobile video games.
As per the findings of the present study, anxiety scores in children have also been reduced using audiovisual distraction (AVD), which might be due to the partial visual obstruction of the operating environment.56 There were few adverse effects of AVD in literature stating their concerns towards pain experience during dental visits of children.57,58 The anxiety scores of mobile gaming has shown high significance when compared to AVD which was reflected not only in the Heart rate scores (physiological) but also in the RMS scores. These results were consistent with Attar et al.,59 who suggested that passive distraction, such as watching a film, is not as effective as an active distraction (e.g., playing a video game) in reducing patient anxiety. In this study, we found that there seems no significant difference in anxiety found between both boys and girls. This is because of the reason that we ensured the availability of games that girls would find interesting. These findings are similar to Nuvvula et al.,60 but Khotani et al.,61 reported that girls showed a more significant reduction in anxiety when compared with the boys. Virtual reality immersion was shown to be somewhat more effective than audiovisual distraction because it augments detachment from viewing and hearing what is happening in the environment.62,63 In this study, mobile phone video games were mostly preferred instead of virtual reality eyewear as most of the children in the study population had not exposed to a sophisticated device. VR glasses are not well known among kids of all age ranges and socioeconomic groups. Even though there was a reduction of postoperative anxiety in a child using VR, procedural anxiety was increased in the VR group as these had blocked the vision of the child, making him/ her anxiety about not knowing what was going around them during the dental procedures. Nausea, headache, and interference to communicate with the children were some of the other problems encountered.
Sullivan et al.,64 discovered that although VR had no significant effect on children's behavior or anxiety during dental treatment, VR did considerably lower their pulse rates. Since, the children in the present study had the opportunity of choosing their preferred cartoon and games, one can believe that this can compensate for the lack of salience in distractors. Nevertheless, asking the child to choose the distraction can provide him/her in having a sense of control during dental treatment, which in turn assists in reducing the chance of uncooperative behavior. This coincides with a study by Filcheck et al.,65 where the authors concluded that choice-based distraction is a relatively practical method to implement, a valuable alternative technique to the health care professionals and parents in reducing the distress of children who visit the dentist. Most children were satisfied and comfortable with the distractors provided and used in this study, which are safe, clinically feasible, and easy to operate without any prior training for the clinicians.
But certain limitations were noted in this study, primarily regarding with the usage of same sized VR glasses for children with small face/head size, because of their unavailability of different sizes and a small sample size.
CONCLUSION:
From the above observations, the following findings were drawn:
1. Primarily, distraction techniques of choice-based could be an effective method in reducing a child's dental anxiety. Allowing the child to choose the distraction technique by him/herself instills a positive attitude in a child's mind that he/she actively participates in the dental procedure, thus reducing dental anxiety.
2. Secondly, Mobile video gaming, which is an active, cost-effective and readily available technique, also well known among children in all socioeconomic groups, could be a better alternative to all other distraction techniques used in the dental operatory.
Conflict of interest: NIL
Source of funding: NIL
Author contribution:
Varada Sahithi (Conceptualization; Writing – original draft)
Sainath Reddy Elicherla (Data curation; Writing – original draft)
Kanamarlapudi Venkata Saikiran (Data curation; Writing – review & editing)
Ramasubba reddy Challa (Formal analysis; Supervision)
Sivakumar Nuvvula (Writing – review & editing)
Englishhttp://ijcrr.com/abstract.php?article_id=4044http://ijcrr.com/article_html.php?did=4044
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareIn Silico Screening of Phytochemicals of Styrax Benzoin Against the Inflammatory Mediators
English198206Swathy BEnglish Menaka MEnglish Kiran GEnglish Prabhakar Reddy VEnglishEnglishStyrax Benzoin, Inflammatory Mediators, SARS-CoV-2, Wound, 1RAK4, NLRP3 inflammasomeINTRODUCTION
Inflammatory mediators are upregulated during SARS-CoV2 infections and also during injury and surgery. Viruses can affect the wound healing process by causing physiological changes. As per WHS (Wound Healing Society), wound is categorized as break down or opening of the skin, which could lead to malfunctioning of skin.1 The physiology stages of wound healing are primary and secondary interventions, smaller wounds heal by primary interventions and larger wound are heal by secondary interventions.2, 3 Among the different stages in wound healing the first stage is the inflammatory stage and is very essential phase in wound healing process.2, 4. These clots release monocytes and forms macrophages and further produce the cytokines.5When the tissue is injury that going to release inflammatory cytokines from the damaged tissue cells.6, 7 Neutrophils, also contribute in wound healing by releasing the cytokines and growth factors and also has phagocytosis functions which protect the wound against bacterial infections.8, 9. Therefore, it could essential to find therapeutics for inhibiting the signaling pathways responsible for release of negative inflammatory mediators. Inflammatory mediators like cytokines, chemokines and growth factors play the key role in wound healing by releasing fibroblasts and keratinocytes from cells and replace or restore the skin integrity.10, 11 NLRP3 (Nod-like receptor protein) inflammasome cellular pathway is involved in wound healing and various inflammatory skin diseases.12, 13Yimin Chai group have studied role NLRP3 expression in diabetic wounds in humans and the results demonstrates the higher expression of caspase1, NLRP3, IL-1β inflammatory mediators.14 These mediators could be the potential targets for the diabetic wound healing process. IRAK4 (interleukin-1 receptor-associated kinase 4) is an important molecular target for the release of inflammatory substances.15, 16 IRAK inhibitors could be useful in the prophylaxis treatment of psoriasis, sclerosis, myocardial infarction, lupus erythematous, and arthritis.17, 18
Styrax Benzoin (Latin: Benzoinum) is a balsamic resin and other species are Sumatra Benzoin and Siam Benzoin and belongs to family Styraceae.19 It is grown highly in tropical rain forests of South-Eastern Asia Countries like Indonesia, Thailand, China and Vietnam. (20) The plants grow up to 14 cm long and flowers are white in color and bell-shaped. Sumatra benzoin resin contains chemical constituents are balsamic acid which esters of benzoic and cinnamic acids.21 They also contains Triterpenoid acids like summaresinolic and siaresinolic acids are present.22 Whereas, Siam Benzoin about 76% of coniferyl benzoate is present as chief active constituent.23 The sytrax benzoin resin is prepared as tincture and used as expectorant, carminative, disinfectant and diuretic.24-27 It also has the biological uses in throat infection and upper respiratory tract infections.28 The aim of this study is to investigate the In Silico computational study of 22 Phytoconstituents of Styrax Benzoin against the inflammatory mediators 1RAK4 and NLRP3 inflammasome.
EXPERIMENTAL
Protein Preparation:
The present study is aimed to perform the computational studies of phytochemical analogs of Styrax Benzoin against COVID-19 negative immune regulators such as IRAK4 (Interleukin-1 Receptor Associated Kinase 4) with PDB ID: 6F3I and innate immune signaling receptor NLRP3 (NOD-, LRR-, and pyrin domain-containing 3) inflammasome with PDB ID: 6NPY.29,30The X-ray crystal structures of IRAK4 in complex with pyrrolotriazine inhibitor and NLRP3 bound to NEK7 were retrieved from Protein Data Bank (https://www.rcsb.org/structure/6F3I; https://www.rcsb.org/structure/6NPY). The protein targets were downloaded in PDB format and protein structural preparation in Macromolecule protocol was carried out in Discovery Studio software with default settings. Protein structures were cleaned and missing residues, Hydrogen’s were added and 3D protonation were carried out to the target protein and minimized for the selected active residues.
Ligand Preparation:
The important phytochemicals of Styrax Benzoin were collected from the literature survey and also from TCIM database. The canonical smiles were saved in .csv format and structures were generated by using Data warrior software and all the 22 Phytoconstituents were saved in SD file. All the ligand structures were energy minimized using CHARMm force field in Small-molecule Protocol and different conformers were generated.
Molecular Docking Studies:
Molecular docking were carried out for the 18 Phytoconstituents of Styrax Benzoin (1-22) to identify the molecular interactions between inflammatory targets 1RAK4 (PDB ID: 6F3I) and NLRP3 inflammasome (PDB ID: 6NPY).29, 30All the ligands were docked with by using Accelrys Discovery Studio version 3.5 with Libdocker and CDocker software. The protein structures were retrieved form protein data bank and the protein preparation and minimization were carried out with the default settings in Discovery Studio. The active site sphere generated from by ligand binding sites with current selection of Define and Edit Binding site in Receptor-Ligand Interaction tools. The binding site sphere specified based on the binding interactions of co-crystal ligand against the target protein, Docking Tolerance as 0.25, Docking Preferences as High Quality. The results were analysed and 3D and 2D interactions were obtained with Discovery studio Visualizer.
Pharmacophore Modelling.
Pharmacophores features are generated between receptor-ligand using Interaction Pharmcophore generations in DS Protocol. Different molecular interactions like HBA (hydrogen bond acceptor), HBD (hydrogen bond donor), HY (hydrophobic center) and PI (Positive ionisable) were generated for receptor-ligand complex. The study was done for best docked pose of p-coumaryl cinnamate6 and coniferyl benzoate12 for 1RAK4 and NLRP3 complex proteins.
In Silico Absorption Distribution Metabolism Excretion (ADME) and Toxicity Prediction:
All the Phytoconstituents of Styrax Benzoin(1-22) were predicted In silico ADME properties and Toxicity analysis were carried out using Discovery Studio, pKCSM web server and Data Warrior Software.31,32
RESULTS AND DISCUSSION
Molecular Docking Studies
The molecular docking studies were carried out in Discovery Studio Docking software. The 3-dimensional proteins (PDB: 6F3I and 6NPY) were retrieved from the protein data bank. All the proteins were prepared and their energies were minimized by the protein preparation wizard. The receptor sphere around their co-crystal ligands were generated using current selection of co-crystal ligand interactions. All the selected 22 Phytoconstituents of Styrax Benzoinwere downloaded from Pubmed (Figure-1). The molecular docking using normal mode was carried out and results were analyzed.
The initial rationale molecular docking studies of all 22 Phytoconstituents of Styrax Benzoin (1-22) in the active site of 1RAK4 (PDB ID: 6F3I) and NLRP3 inflammasome (PDB ID: 6NPY)were carried out in order to predict the binding efficiencies. The molecular docking scores are summarized in (Table:1-3). Initially the docking studies were carried out for all ligands with Libdock which High Throughput Screen-based software and best ligand poses were further docked with CDocker.
Molecular Docking Studies with 1RAK4 (PDB ID: 6F3I):
The molecular docking study was carried out for 22 phytoconstituents of Styrax Benzoin (1-22) into the active site of 1RAK4 (PDB ID: 6F3I). IRAK family (IRAK1-4) plays a central role in positive and negative inflammatory responses by regulating the expression of genes in immune cells.33 These signals which stimulus the various inflammatory mediators and plays key role for elimination of pathogens like virus, bacteria and carcinogenic cells, as well as for wound healing.
Among the ligands docked against IRAK-4, coniferyl benzoate (12) has showed excellent free energy binding with Lib dock score 99.36 and with Cdock score -20.73 and with binding energy value of -78.73 kcal/mol. Coniferyl benzoate(12) exerted H-bond interactions and bond distance in Å with Glu194(2.43), Met265(1.91), Val263(2.84) Tyr264(2.63) amino acid residues and hydrophobic interactions with Val200, Met192, Tyr262, Ala211, Leu318 residues. Similarly, p-coumaryl cinnamate has exhibited H-bond interactions with Met265(2.01), Asn316(2.23), Tyr264(2.86) residues and hydrophobic interactions with Val200, Ala211, Leu318, Met192 amino acid residues with Libdock Score 105.19and Cdock score -20.90and binding energy value of -36.49 kcal/mol. (Table-1 & 2)
Whereas, Crystal ligand CKN (Pyrrolotriazine) has involved key interactions with residues forming H-bond with Arg273(1.87), Arg273(2.88), Asn316(2.38), Asp329(2.48), Asp272(2.81), Asp272(2.37), and hydrophobic interactions with Met192, Val200, Lys213, Ala211, Val246, Met265, Leu318, residues with Libdock Score 130.28 and Cdock score 30.24 and binding energy value of -82.79 kcal/mol. It signifies that Coniferyl benzoate(12) is occupying the same residues of active site of crystal ligand. (Figure: 2 & 3)
Molecular Docking Studies with NLRP3 inflammasome (PDB ID: 6NPY):
The molecular docking study was carried out for 22 phytoconstituents of Styrax Benzoin (1-22) into the active site of NLRP3 inflammasome (PDB ID: 6NPY). NLRP3 inflammatory signalling pathway plays a key role in release of inflammatory mediators, on activation of NLRP3 abrupt the cytochrome storms viz Interlukins (IL-1β, IL-6) and TNF-αand causes inflammatory in lower respiratory tract.34 On inhibition of NLRP3 will stops the release of negative inflammatory mediators.
Among the ligands docked against IRAK-4, coniferyl benzoate (12) has showed excellent free energy binding with Lib dock score 119.99and with Cdock score -27.54 and with binding energy value of -63.66 kcal/mol. Coniferyl benzoate(12) exerted H-bond interactions and bond distance in Å with Thr167(2.22), Thr167(3.03), Arg165(2.40), Gly229(2.45), Gly227(2.95), amino acid residues and hydrophobic interactions with Phe371, Pro410, Ile232, Leu411, and Leu162 residues. Similarly, p-coumaryl cinnamate(6) has exhibited H-bond interactions with Thr167(1.98), His520(2.17), Thr167(2.02), Gly229(2.41) residues and hydrophobic interactions with Pro410, Ile232, Arg235 amino acid residues. (Table 1 & 3)
Whereas, Crystal ligand CKN has involved key interactions with residues forming H-bond with His163 and Glu166 with a bond distance 2.06 Ao and 2.18 Ao, respectively and hydrophobic interactions with His41, Met49 and Met165 residues. It signifies that p-coumaryl cinnamate(6) and Coniferyl benzoate(12) is occupying the same residues of active site of crystal ligand. (Figure: 4-6)
Structure-Based Pharmacophore: The best protein-ligand pose of docking were further analysed for Pharmacophore features using Interaction Pharmacophore Generation Protocol. Table-4 give the details about Common Pharmacophore Feature for ligand p-coumaryl cinnamate 6 has HHDA pharmacophore feature and fit value 3.99 and rank 9.13 and whereas, coniferyl benzoate 12 has HHHDA pharmacophore features with fit value 4.99 and rank 11.50 which shows better features. The interaction pharmacophore features for receptor-ligand complex among the result coniferyl benzoate-6F3I complex has 10 pharmacophore models with H-bond interactions Glu194, Val263, Tyr264, Met265 and with hydrophobic interactions Met192, Val200, Ala211, Tyr262, Leu318. Similarly, with coniferyl benzoate-6NPY complex has 10 pharmacophore models with H-bond interactions Arg165, Thr167, Gly227 and hydrophobic interactions Leu162, Ile232, Phe371, Pro410, Leu411. The interaction pharmacophore features are shown in Figure-7.
In Silico ADMET Prediction:
In Silico Prediction of ADME and Toxicity parameters were analysed for the Phytoconstituents of Stryax Benzoin by using Discovery Studio, pKCSM webserver and Data Warrior Software. All the phytochemicals has obeyed Lipinski’s rule of 5 in which the Mol. Wt is below 500, logP -2.5 consider to be low skin permeability. Among analysed compounds, cinnamyl alcohol13 was consider to have low skin permeability with logKp = -1.70.
None of the phytochemicals are substrate for p-glycoprotein which is an efflux transporter which excretes chemicals or drugs from the cells. All phytochemicals have apparent volume of distribution the limits are VDss is low if log VDss 0.45. For Blood-Brain Barrier permeability, compound with logBB > 0.3 consider to cross the BBB and logBB < -1 are impermeable to brain. Phytoconstituents 12-16 & 20 will cross the BBB as predicted values are logBB>0.3. Regarding CNS permeability, phytochemicals 6, 7, 9, 11, 13, 14, 15, 16 & 20 have high CNS permeability (logPS > -2).
Cytochrome P450 is important enzyme for biotransformation of drugs in liver and inhibitors of CYP450 will affect the pharmacokinetic properties of drug. All phytochemicals are not substrate for CYP2D6, Compound 12, 13,
16 & 20 are substrate for CYP3A4. Compound 6, 12 & 13 are inhibitors for CYP1A2 inhibitor.
Regarding toxicity compound 6 has Ames toxicity, and compounds 3, 9, 11 have hepatoxicity, 4, 13, & 20 has skin sensitisation problems. All phytochemicals have hERG toxicity and are free form cardiotoxicity. From these observations it could revealed that all phytochemicals of Styrax Benzoin have shown good drug-like properties viz., no toxicity, good oral absorption, metabolism and excretion and no interaction with cytochrome P450 enzymes and free from cardiotoxicity.
Conclusion:
InSilico computational studies like molecular docking, pharmacophore mode, ADMET prediction could provide helpful information for rapid design of drugs. Wound infection causes cytokine storm and release negative inflammatory mediators such as 1RAK4 and NRLP3. Therefore, it could essential to find therapeutics for inhibiting the signaling pathways responsible for release of negative inflammatory mediators. To find potent inhibitors for inflammatory targets 1RAK4 and NRLP3 inflammasome we performed molecular docking studies for 22 Phytoconstituents of Styrax Benzoin using Libdocker and Cdocker. The results shown p-coumaryl benzoate 6 and coniferyl benzoate 12 have high binding affinity against the protein targets. A detail pharmacophore features were also generated against these docked complexes. ADMET prediction studies indicate that all the Phytoconstituents are having good oral absorption and less toxicity. The results suggest that the Phytoconstituents of Styrax Benzoin have the potential to be developed as novel inhibitors of inflammatory mediators. These inflammatory mediators are upregulated during SARS-CoV-2 infections. However, their clinical usage against inflammatory mediators is a subject of further investigations and clinical trials.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareArnold Chiari malformation - A Case Study
English212214Aiswarya Lekshmi RVEnglish G RajuEnglish K ChandrakumariEnglishIntroduction: Arnold Chiari malformations are composite brain irregularities within the posterior cranial fossa where Cerebellum and Spinal cord associate. So herniation of the Cerebellum, Spinal cord and Cerebellar tonsils downwards through the foramen magnum will prevent the continuous flow of cerebrospinal fluid from the brain to the spinal canal which produces a collection of cerebrospinal fluid in subarachnoid space resulting in asymptomatic or fatal signs. Aim: To find out the associated findings in the detected case of Arnold-Chiari malformation. Case Report / Result: Out of Fifty specimens, one case of Arnold-Chiari malformation was reported having some features of Chiari Malformation Type 2. Discussion: Chiari malformation Type 2 is severe than Type 1. Symptoms appear only in childhood. Cerebellar herniation protrudes into the spinal canal producing Hydrocephalus. Chiari malformation type 2 is connected with a form of split spine and Myelomeningocele. Conclusion: One female child was reported with features of Type 2 Arnold Chiari malformation. Congenital anomalies are more observed in mothers of low socioeconomic groups, increasing maternal age and a history of consanguineous marriage.
English Cerebellum, Cerebellar tonsil, Cerebrospinal fluid, Foramen magnum, Spinal cord, Subarachnoid spaceINTRODUCTION
Chiari Malformations were entitled after an Austrian pathologist, Hans Chiari initial point out Type 1-3 (1891). Chiari Malformation Type 2 definition was further expanded by Julius Arnold.1 It is also called as Inborn Tonsillar Herniation, Tonsillar Ectopia or Tonsillar descent. Chiari Malformations are a classed together of composite brain deformities that make a difference to the area in the lower posterior skull. Small posterior fossa may cause herniation of the Brainstem and Cerebellum or Cerebellar Tonsils causing pressure on the Brain causing Hydrocephalus. Patients can be asymptomatic or with potentially debilitating or life-threatening symptoms.2 The classification and diagnosis are done based on the length of the Cerebellar tonsils projecting along with the Foramen magnum in addition to the symptoms produced.
Photo Courtesy:https://commons.wikimedia.org/wiki/
Signs & Symptoms2
Some are Symptomatic while others are Asymptomatic and may have serious manifestations such as the abnormal function of a body area. Particular indications are permitted to take place in distinct distributions that predominantly give back abnormality of the Cerebellum, Brainstem, Spinal cord and lower Cranial nerves. Influenced individuals may not have all of the symptoms discussed below. Associated Symptoms are :
Occipital headache.
Pain in Neck and Shoulders
Coughing, Straining / Sneezing.
Diplopia, Photophobia
Blurred vision, Nystagmus and Sinusitis
Vertigo, Dizziness, Tinnitus and Bilateral hearing impairment.
Coordination disorders
Muscle weakness
Dysphagia, Dysarthria
Palpitation, Syncopal episodes
Tingling / Paresthesias
Sleep apnea and Chronic fatigue syndrome.
Syringomyelia, Hydromyelia
Muscle atrophy
Tingling or prickling / Peripheral neuropathy
Scoliosis
Incontinence
Persistent pain
Tightening or shortening of muscle
Impaired coordination, spasticity
MATERIALS AND METHODS
Duration session of January 2014 to July 2016 a study ( SGMC: IEC No.10/95/01/2014/) was managed at Sree Gokulam Medical College & Research Foundation, Thiruvananthapuram about the Foetal anomalies, Ultrasound and Autopsy comparative study. Detailed recording of the history of the patients was obtained in the form of a Proforma and Informed Consent for Autopsy from the Parents were collected. Collected Foetuses and Placenta were obtained ranging from sixteen to twenty weeks of gestation were preserved in 10% formalin which is the fixative used.
OBSERVATION AND RESULTS
Arnold Chiari Malformation
Among the Fifty specimens we studied, One case of Arnold Chiari malformation was found out.
Features of Foetus :
A Female baby
1. Small Cerebellum.
2. Medulla herniated into the Vertebral canal.
3. Lumbosacral canal has Spinal widening (Spina bifida)
4. Meningocele
5. Dilated Lateral ventricles
6. Talipes Equino Varus (TEV) of both limbs.
DISCUSSION
TYPES OF CHIARI MALFORMATION2,3
TYPE 0
Minimal or Absence of herniation of Cerebellar tonsils through Foramen magnum occur in some individuals whereas Syringomyelia, Absence of herniation of Cerebellar tonsil, Occipital headache occur among other individuals.
TYPE 1
May not source some indication, frequently not acknowledged as valuable before mature. Not connected to some other neurological deformities, be able to source neurological indications because of being compressed of the Brain stem and Spinal cord.
TYPE 2
Severe than type 1. Symptoms appear only in childhood. Disorganization can happen in the future cause serious, potentially fatal difficulties during early childhood/period of being a child. Cerebellar herniation protrudes into the Spinal canal producing Hydrocephalus. Vomiting, Irritability, Seizures, delay developmental milestones are usually seen.
Chiari malformation type 2 connected with a form of Split spine/Spina bifida presenting with Myelomeningocele. Producing insufficiency of Urinary and Bowel incontinence.
TYPE 3
Rare, more severe connected with Encephalocele. Affected individuals have some symptoms connected with Chiari malformation Type 2.
TYPE 4
Not connected with herniation of brain continuously Foramen magnum. Brain underdeveloped (Hypoplastic) or fails to develop (Aplastic). The most severe form usually causing death during early childhood; because the absence of herniation of the Cerebellar tonsil is not considered a typical Chiari malformation.
Incidence :
Females are affected more than Males.
Related Disorders :
Vague comprise of Multiple sclerosis, Myalgic encephalomyelitis, Fibrositis and Spinal cord tumours.
CONCLUSION
Out of Fifty specimens of Medical Termination of Pregnancy 6 to 20 weeks – Male and Female foetuses, both Ultrasound Imaging andconfirmed by Autopsy was done and One case of Arnold Chiari malformation was reported having some features of Chiari Malformation Type 2. Congenital anomalies are observed more in Low Socioeconomic group mother’s, Increase in Maternal age with a History of Consanguineous marriage.
Conflicts of interest
All authors have none to declare.
Financial support and sponsorship
No funding to declare.
Acknowledgements
We acknowledge the contribution of Dr. Alex. K. Ittyavirah, Radiologist and Ultrasonologist, Ittyavirah Scan and Research Centre, Thiruvananthapuram and the faculties of the department of Anatomy.
Englishhttp://ijcrr.com/abstract.php?article_id=4046http://ijcrr.com/article_html.php?did=4046[1] Pakzaban P. Chiari malformation. E Med J. Updated: Feb 4, 2014. Available at: http://emedicine.medscape.com/article/1483583-overview. [last accessed on 2020, December 17]
[2] National Institute of Neurological Disorders and Stroke. Chiari Malformation Fact Sheet. Last updated December 30, 2013.Available at: http://www.ninds.nih.gov/disorders/chiari/detail_chiari.htm [last accessed on 2020, December 17]
[3] Mayo Clinic for Medical Education and Research. Chiari malformation. Aug.21, 2013. Available at: http://www.mayoclinic.com/health/chiari-malformation/DS00839 [last accessed on 2020, December 17]
[4] Mutchnick IS, Janjua RM, Moeller K, Moriarty TM. Decompression of Chiari malformation with and without duraplasty: morbidity versus recurrence. J Neurosurg Pediatr. 2010;5:474-478. http://www.ncbi.nlm.nih.gov/pubmed/20433261
[5] Galarza M, Lopez-Guerrero AL, Martinez-Lage JF. Posterior fossa arachnoid cysts and cerebellar tonsillar descent: a short review. Neurosurg Rev.2010;33:305-314. http://www.ncbi.nlm.nih.gov/pubmed/20480382
[6] Aghakhani N, Parker F, David P. Long-term follow-up of Chiari-related syringomyelia in adults: analysis of 157 surgically treated cases. Neurosurgery.2009;64:308-315. http://www.ncbi.nlm.nih.gov/pubmed/19190458
[7] Attenello FJ, McGirt MJ, Gathinji M. Outcome of Chiari-associated syringomyelia after hindbrain decompression in children: analysis of 49 consecutive cases.Neurosurgery.2008;62:1307-1313. http://www.ncbi.nlm.nih.gov/pubmed/18824997
[8] Dauvilliers Y, Stal V, Abril B. Chiari malformations and sleep-related breathing disorders. J Neurol Neurosurg Psychiatry.2007;78:1344-1348. http://www.ncbi.nlm.nih.gov/pubmed/17400590
[9] Szewka AJ, Walsh LE, Boaz JC, Carvalho KS, Golomb MR. Chiari in the family: Inheritance of the Chiari I malformation. Pediatr Neurol. 2006;34:481-485. http://www.ncbi.nlm.nih.gov/pubmed/16765829
[10]StevensonKL.ChiariTypeIImalformation:past,presentandfuture.NeurosurgFocus.2004;16:1-7. http://thejns.org/doi/pdf/10.3171/foc.2004.16.2.6
[11] Greenlee JDW, Donovan KA, Hasan DM, Menezes AH. Chiari I Malformation in the very young child: the spectrum of presentations and experience in 31 children under age 6 years. Pediatrics.2002;110:1212-1219. http://pediatrics.aappublications.org/content/110/6/1212.full.pdf
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareA Clinical Study of Paediatric Tracheostomy: Our Experience in a Tertiary Care Hospital in North India
English207211Gupta REnglish Verma REnglish Anoop MEnglish Nishad RKEnglishIntroduction: Tracheostomy is a surgical procedure to establish direct communication between the trachea and external environment by creating an opening into the anterior wall of the trachea and introducing a cannula into it. While performing pediatric tracheostomy, chances of complication are more especially in newborns and infants. In modern times, the long term outcome of tracheostomy is considered satisfactory due to more specific indications. Aims: Paediatric tracheostomy is a lifesaving procedure to secure airway, practised since ancient days. Paediatric tracheostomy is quite a less studied topic among literature. We took up this clinical study to assess its recent trends in terms of indications, complications, and management of its complications. Material and Methods: This is a prospective, observational study of 3 years duration, which was carried out in a tertiary care hospital of north India with the participation of Otorhinolaryngology, Paediatric and General surgery departments. Results: A total of 39 paediatric tracheostomies were included in this study. The major indications in this study were infective causes like Diphtheria (46%) and Tetanus (16%). The male to female ratio was 1.5: 1 and the rural to urban ratio was 4.5: 1. The most common complications were intraoperative haemorrhage, sudden apnea, secondary haemorrhage and difficult decannulations. The mortality rate in this study is found to be 46%. Conclusions: Upper airway obstruction due to infections like Diphtheria and Tetanus are the most common indications for paediatric tracheostomy in rural areas. Sound knowledge of the anatomy of the pediatric trachea combined with good surgical skills can reduce almost all the major complications associated with tracheostomy in children. Mostly, the higher mortality attributed to paediatric tracheostomy is due to the primary disease condition itself rather than related to complications arising out of tracheostomy procedure.
EnglishPaediatric tracheostomy, Airway obstruction, Diphtheria, Tetanus, ComplicationsIntroduction
Tracheostomy is a surgical procedure to establish direct communication between the trachea and the external environment by creating an opening into the anterior wall of the trachea and introducing a cannula into it. Many ancient texts described tracheostomies performed in ancient Egypt. Tracheostomy is considered one of the oldest surgical procedures.1While performing pediatric tracheostomy, chances of complication are more especially in newborns and infants.2 The indication of pediatric tracheostomy has changed over the years. In modern times, the long-term outcome of tracheostomy is considered satisfactory due to more specific indications.3 The main objective of the present study was to analyze the complications of pediatric tracheostomies in our institute and the methods used to tackle the complications.
Before the beginning of the twentieth century, tracheostomy was considered a very dangerous procedure with both patients and surgeons extremely worried about the outcome of the procedure. This scenario is changed only after the introduction of antisepsis and improved anaesthesia techniques in the early twentieth century. Nowadays, the technology of endotracheal intubation is very much improved and assisted by video laryngoscope and fiberoptic bronchoscope etc. due to which many upper airway emergencies can be managed by nasotracheal or orotracheal intubation or percutaneous tracheostomy. Intensivists are frequently performing bedside percutaneous tracheostomies now a day, due to these advances’ health care professionals of other branches are also facing problems of tracheostomy care and decannulation.4
Before the introduction of antisepsis and improved anaesthesia at the end of the nineteenth-century tracheostomy was an extremely hazardous procedure and was undertaken with a good deal of trepidation on the part of both surgeon and patient. In recent years, with improvements in the technology of endotracheal intubation, an increased number of upper airways emergencies can be managed with nasotracheal or orotracheal intubation or percutaneous tracheostomy. The growth of such techniques particularly that of percutaneous tracheostomy in the past ten years has meant that surgical management of upper airway obstructions is no longer the exclusive province of an otolaryngologist. The result is that more and more health care professionals are being confronted with the problems associated with tracheostomy care and decannulation procedures.4
Material and methods
This prospective observational study of 3 years duration (from December 2017 to November 2020) was conducted on pediatric patients, who underwent tracheostomies at a tertiary care health institute in northern India. Institutional Ethics Committee approval was taken and informed consent was obtained from the patient’s parents or legally acceptable relatives. The demographic details of each patient were recorded. The diagnosis, surgical procedures, complications and management of complications concerning pediatric tracheostomies were recorded and systematically analyzed.
The main objective of the present study was to analyze the various types of complications related to pediatric tracheostomies and their management. The age pattern, sex pattern and populations distributions of these patients were also analyzed. The study group includes patients who were under 18 years of age and underwent tracheostomies. Patients above 18 years of age, previous history of tracheostomy, bleeding disorders and congenital heart disease were excluded from the study.
All paediatric tracheostomies were accomplished by senior otolaryngologists under monitored anaesthesia care either bedside or in the operation theatre. All tracheostomies were performed according to departmental S.O.P. (Standard Operative Procedure) for tracheostomy. The indication and timing of tracheostomy were decided by the treating physician. Decannulation was planned when the child is off inotropes, hemodynamically stable and maintaining oxygen saturation on room air. The decannulation protocol involves downsizing of the tracheostomy tube and then gradual occlusion of it. After discharge patients were followed up fortnightly for one month and monthly thereafter for at least 6 months.
Results
Among 43 pediatric tracheostomies conducted at our institute during the study period, 39 were included in this study. Three cases were excluded due to the previous history of tracheostomy and one due to the non-willingness of guardians to give consent for this study.
Most of the patients who underwent tracheostomy were under 5 years of age, the median age at tracheostomy was 5 years (Table:1). There was no statistically significant difference between the median age at the time of tracheotomy between children who developed Intraoperative (5 years), early (4.5 years), late (5 years) or no complications (5.5 years) using the Wilcoxon rank-sum test (P>0.05). The male to female ratio in this study was 1.5:1 and the rural versus urban ratio was 4.5:1(Table 2 &3).
The most common causative factor for pediatric tracheostomy was diphtheria (18 patients) followed by ventilatory dependent respiratory failure (11 patients), tetanus (6 patients) and congenital anomaly (4 cases) (Figure:1).
Among 39 patients 24 patients (61.53%) developed complications. The complications were classified according to time of occurrence as intraoperative, early postoperative and late postoperative complications. In this study 31 complications were developed in a total of 24 patients. Some patients developed more than one complication as shown by data (Table:4).
In this study, two types of Intraoperative complications were noticed i.e. primary haemorrhage and sudden apnea. Four patients developed bleeding during dissection which was controlled successfully by ligating the bleeding vessels and in three cases patients developed sudden apnea immediately after opening the trachea.
Tube blockage was the most common complication in the early postoperative period, seen in seven patients. Three patients developed subcutaneous emphysema in the neck and upper part of the chest which was subsided within two days. One patient developed a secondary haemorrhage, the wound was immediately explored at the bedside and bleeding vessels were ligated. Infection of the stomal site was seen in one patient.
Difficulty in decannulation was the most common late complication with seven patients having multiple failed decannulation attempts. All patients who had failed decannulation attempts were undergone bronchoscopic examination under general anaesthesia, among them two patients were found to have subglottic stenosis. Both of these subglottic stenosis patients were managed with the bronchoscopic placement of silicon airway stent. Both of these airway stents were successfully removed after 1year follow-up. So, to date, all surviving patients of this study were successfully decannulated. The Decannulation rate of this study was 54%. Granulation at the stomal site was seen in three patients.
Mortality was high in this study after one month follow up 18 patients (46%) died and 21patients (54%) survived. In this study, mortality was associated with primary disease conditions and none died due to complications of tracheostomy.
Discussion
Tracheostomy is a surgical procedure that involves creating a temporary or permanent opening in the anterior wall of the trachea to place a tube to communicate to the external environment. The credit for the first tracheostomy goes to the Asclepiades of Rome in 2ndcentury BC. Antonio M. Brasovala an Italian physician successfully performed a tracheostomy on a patient with an abscess of the trachea in the 16th century AD.5In 1766, Caron had done a tracheostomy on a seven-year-old child for removing a foreign body. This is supposed to be considered the first paediatric tracheostomy in the history of ENT practice.6 In 1833, Trousseau saved nearly 50 children with diphtheria by doing paediatric tracheostomies. It also described postoperative care after paediatric tracheostomy.6 In 1921, Chevalier Jackson demonstrated a reduction in mortality due to paediatric tracheostomy by following standard protocols of performing it.7 Chevalier Jackson contributed tremendously to standardized paediatric tracheostomies, thereby, reducing complications and increasing its tolerance. The next major development to its increasing usage came when Galloway reported using paediatric tracheostomy with children with poliomyelitis.8
Embryologically larynx develops from the cranial most part of the laryngotracheal tube. The trachea develops from the intermediate part of the laryngotracheal tube that lies between the points of its bifurcation into branchial or lung bud and the larynx. With the caudocranial extension of the tracheoesophageal septum, the trachea elongates. At birth the bifurcation of trachea lies at the level of lower border of 4th thoracic vertebra.9 A study was conducted by Anne Dsouza et al on 28 spontaneously aborted / still born human fetuses to found that during second and third trimester of gestation tracheal length increase significantly but not the diameter.10
Tracheostomy is a speedy, safe, effective lifesaving procedure practised since ancient times. Pediatric tracheostomy differs significantly from the adult one. Sound knowledge of pediatric airway, greater care and skill are required for performing a pediatric tracheostomy.
In our study, 39 pediatric tracheostomies were done in a study period of 3 years from December 2017 to November 2020. The mean age group in this study was 5 years. In other studies, by Carron et al11 Ang et al12 and Ozmen et al13 the mean age was 3.2 years, 3.24 years and 2.25 years respectively. In our study mean age group was comparatively on the upper side. Maximum patients were in the age group 0 to 5 years. The male to female ratio was [1.5:1] which is comparable to a study conducted by Carron et al in which the male to female ratio was 1.2:1. This slight male preponderance could be due to the increased susceptibility of male children to congenital and acquired diseases.
In this study, the most, common indication for performing pediatric tracheostomy was infection leading to upper respiratory obstruction. It was diphtheria (46%) followed by tetanus (16%). These were compared with the study done by Ozmen13 and the one by Kremer et al.14 Children with prolonged ventilatory support (28%) and congenital anomaly (10%) added to the rest of the figures. In this study, a smaller number of patients with congenital anomalies could be due to lack of early recognition, lack of awareness by the parents, lack of prenatal and perinatal screening procedures. The mortality rate was slightly higher in our study. 18 patients (46%) who underwent pediatric tracheostomy died and 21 patients (54%) survived. The mortality in this study was fully attributable to primary disease condition and none died due to surgical procedure or complication of pediatric tracheostomy. The higher mortality could be due to the late presentation of children at an advanced stage of disease and ignorance among the rural population. Mortality due to diphtheria was higher than due to tetanus, even though both are the vaccine-preventable disease.
There is enough description in pediatric literature for diphtheria being a disease-causing higher mortality. The diphtheria toxins are very potent, poor socio-economic background of children, poor host response to diphtheria antiserum are a few to mention.15,16,17
In this study 24 patients (61.53%) developed complications. The complications were studied as three subsets i.e. intraoperative, early postoperative and late postoperative complications. Total 31 complications developed in a total of 24 patients. Some patients developed more than one complication. The percentage of complications of this study (61.53%) was a little higher compared to other studies by Carron et al. (44%) and Ozman et al (18%). The possible explanation for the higher rate of complication in this study could be the lack of ideal operating facilities in the pediatric intensive care unit, where most of the bedside tracheostomies are done. The complications were noticed more in male patients.
Haemorrhage while performing tracheostomy was the most common intraoperative complication noticed in this study. Four patients developed intraoperative haemorrhage. It is controlled by ligating the bleeding vessels the commonest vessel causing bleeding while performing tracheostomy could be the anterior jugular vein, thyroid vein, thyroid ima artery.18
Sudden apnea was the other intraoperative complication three patients developed. Sudden apnea was recovered spontaneously. One patient needed carbogen inhalation
Tube blockage (18%) was the most common early postoperative complication noticed. seven patients developed tube blockage which was comparable to the study done by Wetmore et al19 where the tube blockage contributed (16%).
In this study, all surviving patients (54%) were successfully decannulated. The Decannulation rate was 82% in a study conducted by Sharma and Vinayak.20
Conclusions: The indications of pediatric tracheostomies are showing a change in its trend in recent years due to the better availability of neonatal ICUs and neonatologists skilled in endotracheal intubation. Still, in rural setups, upper airway obstruction due to infections like Diphtheria and Tetanus are the most common indications for paediatric tracheostomy. Sound knowledge of the anatomy of the pediatric trachea combined with good surgical skills can reduce almost all the major complications associated with tracheostomy in children. Mostly, the higher mortality attributed to paediatric tracheostomy is due to the primary disease condition itself rather than related to complications arising out of tracheostomy procedure.
Acknowledgement: We express our sincere gratitude to Dr. Gaurav Khandelwal Professor & HOD Department of ENT, Dr. Avinash Saxena Professor & HOD Department of Surgery and Dr. Sonia Bhat Professor & HOD Department of Pediatrics for their constant support for this study.
Conflict of Interest: Ritu Gupta, Reetu Verma, Anoop M and Rajeev Kumar Nishad declare that they have no conflict of interest.
Ethical Approval: Approval was taken from F.H. Medical College Institutional Ethics Committee (IEC No.138 dated 16th Nov.2017) before starting the project.
Informed Consent: Informed consent was obtained from all individual participants included in this study
Source of Funding: None
Author Contributions
Ritu Gupta, Conception and design, literature research, acquisition of data, analysis and interpretation of data
Reetu Verma, acquisition of data, analysis and interpretation of data, supervision, draft writing;
Anoop M, acquisition of data, analysis and interpretation of data, critical revision of the manuscript, administrative and technical support;
Rajeev Kumar Nishad, literature research, acquisition of data, analysis and interpretation of data, critical revision of the manuscript, final approval of the manuscript, Corresponding author.
Englishhttp://ijcrr.com/abstract.php?article_id=4047http://ijcrr.com/article_html.php?did=4047
Frost EA. Tracing the tracheostomy. Ann Otol Rhinol Laryngol. 1976 Sep-Oct;85(5 Pt.1):618-24. doi: 10.1177/000348947608500509. PMID: 791052.
Wilson DP. Paediatric Tracheostomy. Grand Rounds. Philadelphia, PA: Philadelphia University,1997. pp. 454–63.
Ghosh T, Yewale V, Parthsarthi A, Shah NK. Paediatrics Infectious Diseases. Indian Academy of Pediatrics series (Under IAP Action Plan 2006)
Pracy Paul, Tracheostomy; in Michael Gleeson, George G, Browning, Martin J Burton et al: Scott-Brown’s Otolaryngology-Head and Neck Surgery Volume 2, Seventh edition, 2008, Hodder Arnold London. 2292-95
Wetmore RF. Tracheotomy. In: Bluestone CD, Stool SE, Alpes CM, Arjmand EM, et al., editors. Pediatricotolaryngology. 4th ed. Philadelphia: Saunders; 2003.p. 1583-98.
Gooddal EW. The story of tracheotomy. Br J Child Dis. 1934;31:167-76.
Jackson C. High tracheotomy and other errors: the chief causes of chronic laryngeal stenosis. Surg Gynecol Obstet. 1921;32:392-8.
Galloway TC. Tracheotomy in bulbar poliomyelitis. J Ame Med Ass. 1943;123:1096-7.
Subhadra Devi V, Respiratory system, body cavity and diaphragm, In Inderbir Singh’s Human Embryology Eleventh Edition Jaypee, 2018, New Delhi: 215-19
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Ang AH, Chua DY, Pang KP, Tan HK. Pediatric tracheotomies in an Asian population: the Singapore experience. Otolaryngol Head Neck Surg. 2005;133(2):246–50.
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Sachdev HPS, Choudhury P, Bagga A, Chugh K, Ramji S, Puri RK (Eds.). Principles of Pediatric and Neonatal Emergencies, 2nd edn. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd, 2004. pp. 689–94.
Ghai OP, Paul VK, Bagga A (Eds.). Pediatric critical care. In: Essential Pediatrics, 7th edn. New Delhi: CBS Publishers, 2013:686–712.
Gaudet PT, Peerless A, Sasaki CT, Kirchner JA. Pediatric tracheostomy and associated complications. Laryngoscope. 1978; 88(10):1633–41.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30HealthcareNutritional Composition and Sensory Properties of Value-Added Health Mix for Undernutrition and Better Cognition
English215219Anitha REnglish PA RaajeswariEnglishEnglishUndernutrition, Health mix, Nutritional quality, Sensory evaluationhttp://ijcrr.com/abstract.php?article_id=4048http://ijcrr.com/article_html.php?did=4048Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30Healthcare
Assessment of Labor Pain Among Primigravid Mothers
English220224Nitanjali PatilEnglish Afsana MulaniEnglish Jyoti A. SalunkheEnglish Sheetal A. KadamEnglish Mahadeo ShindeEnglish
Introduction: Pregnancy is a lovely and natural situation for any woman. There are nine pivotal months of suspense. The childbirth pain is great, but the memories of pain decreases over time. Labor is an emotional experience that encompasses psychological as well as physiological elements. Labor, which is characterised by regular, painful uterine muscular contractions that grow in frequency and intensity, is the best way for delivering a healthy foetus. The study’s goal was to assess labour discomfort in primigravid moms. Objectives: Determine the amount of pain and the relationship between the level of pain and chosen sociodemographic characteristics. Material and Method: The descriptive method was utilised. Study environment, Krishna Hospital and Medical Research Centre, Karad. 40 primigravida. Selected using a practical sampling technique. Socio-demographic characteristics and the Visual Analog Scale were employed as research tools. Data was obtained with the approval of the relevant authority. Content that was well-informed was collected. Using descriptive and inferential statistics, the collected data was examined in terms of the study’s objectives. Results: Maximum 77.5% of mothers were from 21-25 years, 35% were graduate and above. Sixty percent were employed. Monthly income ranged from Rs.13,161/ to Rs.26,354/ for 57.5%. 35% belonged to the upper-bottom socioeconomic class. Maximum 92.5% reported severe pain, 7.5% reported moderate discomfort, and none reported severe pain. The mean was 8.22, the median was 8, and the standard deviation was 1.25. Except for monthly income, there was no statistically significant connection. The chi-square value is 26.212, and the p-value is 0.0001. Conclusion: Primigravida experience increased labour discomfort during the first stage of labour. According to the findings of the current study, 92.5% of mothers were in severe discomfort. They also have insufficient knowledge of pain management procedures during labour.
EnglishUndernutrition, Health mix, Nutritional quality, Sensory evaluationhttp://ijcrr.com/abstract.php?article_id=4642http://ijcrr.com/article_html.php?did=4642Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411316EnglishN2021August30Healthcare
Effects of Foot Reflexology on Lactation in Postnatal Mothers at a Tertiary Care Hospital in Karad
English225229Anagha V. KattiEnglish Mahadeo shindeEnglish Afsana MulaniEnglish
Introduction: Patients’ mothers who are admitted to the maternity ward, as well as the nurses who work in the maternity department, may have learning needs or nursing care priority needs. On the other hand, the majority of studies have concentrated their attention on the mother’s knowledge in a variety of domains, and the majority of the research has been carried out in hospitals. Aims: The purpose of this study was to evaluate the efficacy of foot reflexology in promoting lactation in postnatal women. The goals of this study are to determine whether or not foot reflexology stimulates lactation in the experimental group. Methods: At a particular hospital in Karad city, postnatal mothers participated in a descriptive research study that was carried out. The evaluation of sixty postnatal caesarean mothers was carried out with the use of the purposeful sampling technique. The LATCH scale was used to collect data from postnatal moms using a semi-structured questionnaire. The questionnaire was designed to gather background information. Result: The results of the study showed that postnatal women had their lactation levels tested and evaluated to determine how far along they had progressed. With a standard deviation of 0.75 and 0.50 respectively, the mean LATCH score of postnatal caesarean moms in the experimental group using the LATCH breastfeeding assessment scale was 3.53, and it climbed to 9.08 following Reflex zone Stimulation. Foot massage is helpful for post-natal mothers in improving their ability to breastfeed their children. According to the results of the study, the administration of reflex zone therapy is an effective method for initiating the release of breast milk and promoting breastfeeding. Conclusion: The findings demonstrated that stimulating the reflex zones was a very useful method for increasing the amount of breast milk produced by postnatal mothers. The findings demonstrated that reflex zone stimulation is an extremely efficient method for increasing the amount of milk produced by postnatal moms.
EnglishEffectiveness, Foot reflexology, Lactation, Postnatal mothers, Reflex zone therapy, Breastfeedinghttp://ijcrr.com/abstract.php?article_id=4643http://ijcrr.com/article_html.php?did=4643
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