Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Industry-Ready Active Packaging Technologies in Food Sector
English0106Arumugam Siddhu AdhiamanEnglish Kulathooran RamalakshmiEnglish Dhanraj MadhushaliniEnglish
Food packaging aims to deliver food to the consumer in a sound state. A good food package aims to preserve food commodities from external spoilage factors. With the evolution of Industry 4.0, active packaging food technologies take a leap towards next-generation technology with artificial intelligence and big data in the food sector. The main functions of a common food packaging element comprise containment, convenience, communication and cost. In recent days, the purpose goes beyond this. Active packaging is a fast-growing food packaging technology in which the additives are incorporated into the packaging layer of primary food so that the desired preservation effect is achieved with high efficiency. Active packaging is a modern technology that aims to benefit food manufacturers by helping them to deliver high-quality natural food without any artificial additives added to the primary food item to their consumers. The incorporated additives may be in the form of moisture absorbers, antimicrobial agents, oxygen scavengers, ethylene absorbers etc. In this review article the basic active packaging technology, its uses, procedure, advantages, limitations are discussed from an industry perspective.
EnglishArtificial Intelligence, Efficiency, Incorporation, Industry 4.0, Procedure, Manufacturing, Natural food
INTRODUCTION
Packaging technology gives food manufacturers a strategic advantage in the market. Packaging normally protects the food from external factors like moisture, microorganisms, heat, light, foreign matter, unwanted gases etc. Packaging is the technology that protects the food from external factors and delivers the food to the consumers in a sound state. The main role of food packaging is to protect the food from the outside environment, to prevent cross-contamination; to make consumers informed choices about the nutrition of the food that has been packed. Many packaging technologies have been developed to meet the quality requirements of foods like modified atmospheric packaging, controlled atmospheric packaging, vacuum packaging and so on. Packaging is also a marketing factor. It also influences logistics and distribution in the supply chain. Nowadays the design of the packaging material is given importance among all the factors as this plays a vital role in cost-cutting measures.
Traditional packaging technology provides only a barrier against the external environment conditions, but not in the preservation of the food in contact. On the other hand, active packaging besides protecting the food from the external environment also gives the packed food a preservation effect owing to the active principle components used in the technology. As the growth of convenience food is increasing with pace and subsequent increase in e-commerce, the food industry is demanding novel packing technologies that provide a one-stop solution for food packaging.
FOOD PACKAGING MATERIALS
According to the nature of the food to be preserved, there are many types of packaging material available in the market. Primary packaging material is one in which the food will be in direct contact with the packaging material, whereas secondary package refers to the packaging material that covers the primary packed food. Mostly secondary packages are used for wholesale and institutional supplies. Many packaging materials like steel cans, aluminium cans, polypropylene, polyethene, polyolefin, polyethene terephthalate, glass, polycarbonate, polyvinyl acetate (PVA), Fluoropolymers, Cellulose-based materials, High nitrile polymers, polyvinylidene chloride, polystyrene, acrylonitrile butadiene styrene, polyamide, ethylene vinyl alcohol, ethylene-vinyl acetate (EVA), styrene-butadiene are being used in the food industry.
Due to low cost and good barrier properties against various physical, chemical and biological factors, polyethene films are widely employed in the food industry. The main disadvantage of polyethene material is that it is chemically inert which makes its use in active packaging technology on a limited scale. This forces the technologists to make some changes to this material in the form of pre-treatments to create an active environment and in turn, produces better results. Some of the methods for modification are plasma, UV and wet chemical treatments.1
ACTIVE PACKAGING TECHNOLOGY
Active packaging is sometimes called interactive packaging. Active components can be incorporated into the packages in the form of sachets, pouches, patches and so on. Research on intelligent labelling systems is given importance to bring in more innovations in food packaging. Active packaging materials interact with the headspace gases and also make a compatible environment with the food inside the package either in form of antioxidants or antimicrobial agents. The direct addition of any preservative either a chemical preservative like nitrates, sorbates or a bacteriocin such as a nisin to the food may alter the nature of the food to a certain extent.2 Also the efficacy rate of the added chemicals may vary and in some cases even produce undesirable effects. To overcome this, a new promising method of food packaging is employed in the food industry. Active packaging is adding or incorporating the additives on the food packaging layer or in the headspace of the primary food so that direct contact between the food and preservative are avoided.3 It aims to reduce or remove the use of chemical preservatives, to add more hurdles to increase the package efficiency. Active packaging can be synergistically combined with other packing techniques such as MAP (Modified Atmospheric Packaging) and CAP (Controlled Atmospheric Packaging) to improve the preservation effect and package efficiency.
Oxygen Scavengers
One of the commonly used subcategories of active packaging technology is the oxygen scavengers in food products, especially in meat-based foods. Ferrous oxide is one of the most used elements for scavenging oxygen in the food industry. Oxygen absorbers possess various inhibitory mechanisms to stop the oxidation chain reaction.4They also prevent discolouration of fresh meat and keep out the pests. Oxygen scavengers are most widely used in meat packages where the chance of quality deterioration is high due to oxygen. In addition to metallic oxygen scavengers, some of the non-metallic based scavengers like ascorbic acid and their derivatives are also used in the industry for scavenging the oxygen in food items. In some systems, oxygen scavengers are based on an enzymatic base (usually with glucose oxidase or ethanol oxidase) which are added in the form of sachets and also directly fortified into the layer of the package.
Carbon dioxide scavengers / emitters
Certain food products like roasted coffee, beef jerky are prone to damage by produced carbon dioxide. CO2absorberscanbebasedonsodiumhydroxideandcalciumbased organic components.5 Package bursts can be prevented by using Carbon dioxide emitters. Roasted coffee in a fresh state can release considerable amounts of carbon dioxide due to the reaction called Strecker degradation between sugars and amines. The generated carbon dioxide can make the packaging burst due to an increase in internal pressure. The carbon dioxide has to be removed from the package to extend its shelf life and to ensure the aroma of the roasted coffee is not vaporized. A formula comprising and activated charcoal and calcium oxide is used in Polyethylene coffee pouches to inhibit the CO2 but nowadays combined oxygen and carbon dioxide scavenger sachets are commercially used for canned and foil pouched coffees in Japan and the USA.6These dual-purpose sachets contain iron powder for scavenging oxygen and calcium hydroxide for scavenging carbon dioxide where it is converted to calcium carbonate under high humidity conditions.3 Usually carbon dioxide absorbers are of two types – containing physical absorbents like zeolite and a chemical absorbent like Calcium hydroxide. Carbon dioxide, if present in excess inside the package also bursts at one point causing the burst of the food package. CO2 scavengers are used in the form of sachets in food products.
Ethylene Scavengers
Ethylene is a plant growth regulator responsible for the process of ripening horticultural commodities like flowers, fruits and vegetables. The effect of ethylene is very much important in each and every stage of development of fruits and vegetables. The various stages of development includes flowering, development of colours in certain fruits and vegetables, root production stimulation, bitter flavour development etc.,7 During the supply chain, the effect of ethylene should be suppressed or controlled so that the ripening process is delayed during transit. To suppress the effect of ethylene, food industries are using ethylene scavengers in the package lot (individual/bulk). As a result, the ripening takes place once the commodity is near to the consumer in the supply chain and not before that. This technology greatly reduces the losses of horticultural commodities during transportation and fetches good returns to the industry.8 Most of the ethylene absorbers used in the food industry are based on potassium permanganate (KMnO4). The oxidation of the ethylene into ethanol and acetate by Potassium permanganate will induce a colour change to brown from purple indicating the available scavenging capacity of ethylene. Potassium permanganate-based ethylene scavengers can be used both for the retail package as well as can be used in warehouse or packhouses that has facilities for storing fruits for long term storage. The forms in which the scavengers can be employed are sachets, embedded paper bags or any other such provisions suitable.
Ethanol Emitters
In contrast to the ethylene absorbers to absorb excess ethylene produced to influence the ripening of the horticultural commodities, ethanol emitters are substances that have antimicrobial properties and are particularly effective against moulds. They can also inhibit bacterial and yeast growth. Research has been made on the preservation effects of ethanol on most commonly used food articles to extend their shelf life.9 It has been proven that sachets containing ethanol or ethanol incorporated packaging films have a good preservation effect against the spoilage moulds specifically at a concentration of above 90%. Ethanol is encapsulated in silicon dioxide to achieve a slow-release of ethanol vapour. Ethanol-based sachets and films are to be customized according to the nature of the food item to be packed. When food is packed with an ethanol-emitting sachet, the food absorbs moisture and releases ethanol vapour and spreads into the headspace package.
Flavour absorbers
Certain chemical and biochemical reactions inside the food matrix results in the production of off and undesirable odours due to the breakdown products consisting of fatty acids, amines, aldehydes and ketones. Oxidation usually produces off odours indicating the deteriorative quality of the food to the consumer. Some unpleasant odours can be sensed by consumers when the package is opened, although the food appears to be safe.10 Plastic processing like moulding, extrusion also can lead to off flavours. Antioxidants can also be used to decrease unpleasant odours. Undesirable flavour scalping of desirable food components can be done using the flavour absorbers. Also bitter and undesirable astringent components can be removed by using these types of absorbers. Dupont’s Odour and Taste Control (OTC) technology claims the removal of aldehydes such as hexanal and heptanal from package headspaces. In certain foods where flavour and aroma are desirable as in the case of horticultural crops like aromatic flowers, distinctive aromas are slowly released upon opening the packet by using suitable technology.11 Flavour and aroma emitters give a pleasant sensation to the consumers indicating the freshness of the particular food, although the food has been packed a long ago. Some commercially available products are ABSCENTS, AROMA-CAN, SINCERA etc.
Antimicrobial films
Antimicrobials are substances that are based either on natural sources like herbs, plant extracts or artificial sources like food additives.12 Antimicrobial food additives can be incorporated directly onto the food packages to reduce the growth of spoilage microorganisms in the food items. Antimicrobial packaging helps to extend the lag phase and reduced the growth rate of microbes resulting in prolonged shelf life and better food safety. Antimicrobial active packaging film releases the antimicrobial agent on the food and maintains its concentration on the food surface above the minimum inhibitory concentration for the target microorganism. They are applied mostly on bakery, cheese, meat and fish products and also some horticultural commodities. The antimicrobial agent incorporation into the food polymer is done using a solvent casting method. It has been shown that antimicrobial incorporated food packages stop the growth of pathogenic microorganisms in the food. Antimicrobial agents may include essential oils, herbal extracts, and natural plant substances and so on.13 Proper coating methods and controlled release of the incorporated agents are crucial factors in attaining effective results. Antimicrobial films are usually made by incorporating one of the active components having antimicrobial properties either from plant animals or any other source. In the food industry, antimicrobial additive components are directly incorporated into the polymer matrix to improve the efficiency of preservation. Normal antimicrobial components incorporated are organic acids, herbal extracts, spice extracts, chelating agents, antifungal agents etc., To design a green and sustainable food package, antimicrobial agents can be used along with biodegradable substances.
Antioxidant films
Fat and oil-containing food items are highly prone to oxidation reaction via a free radical process. This undesirable reaction in fat and fat-containing food items produce off odours and rancid flavours due to the formation of aldehydes and their breakdown products. In dried foodstuff and fat-containing food kinds of stuff, antioxidant releasers or antioxidant packaging films are employed to control the release of oxidized products or the chain reaction of oxygen.14 One of the reasons for use of antioxidants in the film layer is to avoid the direct addition of synthetic antioxidants like Butylated Hydroxy Toluene, Butylated Hydroxy Toluene, and TertiaryButyl Hydro Quinone into the food items. The food industry is also looking in such a way as to avoid synthetic additives and to use natural antioxidants in the packages. Antioxidant incorporated food packages are designed to release the antioxidants in a slow and controlled manner so that long-lasting storage can be attained during the storage of foods containing fats and oils. Natural antioxidants like vitamin E are used for direct incorporation into the food polymer matrix for food active packaging.15 One of the advantages of active antioxidant packaging is the absence of the residual effect in the final product. The method of adding antioxidants may be in form of sachets, pads or incorporating in the package labels.
Moisture Absorbers
Moisture is one of the important spoilage factors in food items. Moisture absorbers are used to arrest the moisture movement and thereby inhibiting the growth of microorganisms in the food item. Moisture is collected in the package due to changes in temperature, drip loss etc. Water is also produced during the breakdown of macromolecules present in the food.16 The excessive water can be removed by use of a food package that is highly impermeable to water vapours. Common absorbing systems include a super absorbent polymer present between two layers of microporous or non-woven polymer. Some of the moisture absorbents are polyacrylate salts, carboxymethylcellulose (CMC) and graft copolymers of starch. Another approach for the control of excess moisture in high water activity foods is to intercept the moisture in the vapour phase. This approach allows food packers or even householders to decrease the water activity on the surface of foods by reducing in-pack RH. This can be done by placing one or more humectants between two layers of water-permeable plastic film.
ADVANTAGES
Active packaging evolved as a potential preservation tool for consumer food items due to its flexibility. They also render sufficient support to the food processors to shape and utilize the technology to the maximum effect, thus supporting the economic health of especially agricultural and horticultural businesses further down the value chain; active packaging can also bring other obvious process benefits to the farmer and industry. Recent developments also show that these methodologies can be combined as Hurdles to increase the preservation effect in packed food items.
DRAWBACKS
Although active packaging systems eliminate the direct incorporation of additives into food, there are certain limitations with the system. The risk of accidental breakage which can lead to consumption of the content (sachets/pads) along with the food is the one major disadvantage in sachet?based active packaging technologies.17Undesirable vapour formations occur in certain Active Packaging systems involving hormone emitters. After the end-user, the recyclability of the active packages is a question mark. Proper recycling methodologies should be employed to address this issue. Although the efficiency and no contact preservation is established, the cost of active packages is a little higher than the conventional package system due to the additional incorporation.18 The polymer and film should be standardized and suitable compatibility to both must be established to obtain the desired result.
FUTURE PROSPECTS IN THE FOOD INDUSTRY
As the manufacturing sector is gearing up for industry 4.0, these types of packaging technologies must be implemented in all food products for a synergistic transformation of the food industry. One of the important goals of active packaging is to enhance the preservation of the contained food and beverage products through non-contact mode.19 Standardized active packages should be designed to boost the packing operation. Proper research should be done on changes during the handling of perishable horticultural commodities like fruits and flowers in the supply chain. More market-oriented subject studies should be given importance so that an effective packaging solution can be achieved. More precise studies on preservation effect, incorporated materials, polymer components need to be studied thereby making the active packaging technology a widely accepted one in the evergreen food industry.
DISCUSSION
In present day modern food industry, with the development of new preservation techniques to enhance the shelf life of products, the discussed techniques so far have most desirous effect of providing advanced storage techniques to almost all kinds of food products available in the market. The consumer acceptability for these types of packages also growing nowadays, which shows a positive sign for transformation in packaging techniques of foods. Factors like cost of synthesizing active packages, method of preservation/mode of inhibition of spoilage factors are also to be considered from the manufacturer point of view. Thus, if suitably compiled and applied, active packaging will be the most sought method of packaging in the Evergreen food industry.
CONCLUSION
As discussed, a variety of Active packaging techniques are in use for effective food preservation. The spoilage inhibitory mechanism of various preservatives should be carefully analysed to be used in different food commodities. The concept of Hurdle Technology also can be incorporated to increase the efficiency of food preservation. Importance should be given to no contact preservatives to increase consumer acceptability. To boost the processes food sector, thus a thriving combination of the latest preservation techniques like active and other packing techniques should be given importance.
ACKNOWLEDGEMENTS
The authors wish to thank Rajalakshmi Engineering College, Chennai for providing an ambient environment and the infrastructure facilities provided at the institute.
Compliance with ethical standards
Conflict of Interest: The authors declare that there is no conflict of interest.
Source of Funding: The source of funding is from the authors themselves
Englishhttp://ijcrr.com/abstract.php?article_id=4219http://ijcrr.com/article_html.php?did=4219
Lee DS. Antioxidant packaging system. In Innovations in food packaging, 2nd ed.; J. H., Han, Academic Press: San Diego, USA, 2014:111-131.
Labuza TP, Breene W.M., Applications of active packaging for improvement of shelf-life and nutritional quality of fresh and extended shelf-life foods.J. Food Process. Preserv, 1989; 13(1):1-69.
Rooney ML. Overview of Active Packaging. Inactive Food Packaging, 1st ed.; M.L.Rooney., Eds. Blackie Academic and Professional: Glasgow, UK, 1995;1-37.
Appending P, Hotchkiss JH. Review of Antimicrobial Food Packaging. Innov. Food Sci. Emerg2002; 3(2) :113-126.
Manso S, Becerril R, Nerin C, Gomez-Lus R. Influence of pH and temperature variations on vapour phase action of an antifungal food packaging against five mould strains. Food Control 2015;47: 20–26.
Rivero S., Giannuzzi M.A. and Pinotti A., Controlled delivery of propionic acid from chitosan ?lms for pastry dough conservation. J. of Food Eng. 2013. 116(2): 524–531.
Anon., Pursuit of freshness creates packaging opportunities. Jpn. Pack. News 1995; 12: 14-15.
Otoni C.G., Trends in antimicrobial food packaging systems: Emitting sachets and absorbent pads. Food Res Int. 2016; 83: 60-73.
Fitzgerald M.Non-destructive monitoring of oxygen profiles in packaged foods using phase-fluorimetric oxygen sensor. J. Food Sc.2001; 66(1): 105–110.
Day BP, Active packaging. In Food Packaging Technology, 1st ed., R.Cole; D. McDowell; M.J.Kirwan., Eds. CRC Press: Boca Raton, FL, USA, 2003: 282–302
Lavoine N., Design, processing and characterization of innovative functional bio-nano-materials for packaging 2013. PhD. Dissertation, Grenoble University, Grenoble, France.
Vermeiren L, Devlieghere F, Van Beest M, De Kruijf N. and Debevere J., Developments in the active packaging of foods. Trends Food Sci Technol. 1999; 10(3): 77-86.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Solid Phase Synthesis of Imines via Mechanochemistry and Screening for their Antifungal Activity
English0711Bendale Atul R.English Sethiya JigarEnglish Narkhede Sushil P.English Jadhav Anil G.English
Aim: To develop facile synthetic techniques for the preparation of imines, a series of imines were synthesized via mechanochemistry. Introduction: Imines are important in biological and medicinal chemistry because along with anti-bacterial action they also exhibit anti-parasitic and anti-cancer properties. Methodology: Present synthetic technique complies with principles of Green chemistry. During the screening of synthesized imines for their antifungal activity, some compounds showed better action against fungi when compared with standard. Result: Herein imines were synthesized by implying mechanical force and were monitored and screened by spectroscopic techniques. Green chemistry pertains across the life span of chemical products which provides simple methods and highly efficient products with excellent yields in a shorter period. Conclusion: Adopted mechanochemical technique found to be safer for a chemist, yields maximum yield without the use of catalysts. Such type of techniques provides certain advantages like Short reaction time, increased safety, economic.
EnglishSchiff bases, Imines, Mechanochemistry, Organic solid phase synthesis, Green chemistry, Antifungal activity
Introduction
An amine is a nitrogen derivative of either ketone or aldehyde in which the acyl (c=o) group is reformed as the imine (C=N-R) group.2 It is generally formed by condensation of ketone or an aldehyde with a primary amine. Imines that possess aryl substituents are significantly stable and more readily synthesized as compared to alkyl substituents, which is relatively unstable. Aromatic Schiff bases are effective conjugation and are more stable.1
Schiff bases formation is a very important reaction in biological chemistry as they play an imperative role in living organisms such as decarboxylation, transamination and C-C bond cleavage. Hence, they are used in the biosynthesis of hormones, neurotransmitters and pigments. Schiff bases containing contributor atoms can take part in the chilation of the transition of metal ions. Schiff bases are widely studied and research of this compound imparts the following properties: anti-parasitic, bactericidal and anticancer agents.
Green chemistry is the design of compound products and processes that trim down or eliminate the use or generation of harmful substances. Green chemistry is also recognized as sustainable chemistry. Green chemistry applies across the life span of chemical products, including its blueprint, manufacturing, use and ultimate disposal3. It provides certain advantages like Short reaction time, increased safety, economic and prevention of pollution.
This is the primary cause for the rediscovery of mechanochemistry. Mechanochemistry is a division of chemical and physiochemical changes of substances of all states of agglomeration due to the influences of mechanical energy such as milling, grinding, shearing and scratching. 4,6
The novel, high performance, low-cost materials and faster decomposition of synthesis are reasons for the burgeoning of mechanochemistry subject7. It is used for the manufacturing of intermetallic products and alloys in metallurgy, amalgamated and complex oxides for materials, nanocrystalline substances, for production of fertilizers, building materials, pigments, etc. and hence it is the topic of choice of researchers for the synthesis of organic molecules.5,
Materials and Methods-
All the required chemicals and reagents were acquired from commercial sources (SD Fine Chemicals, India; Aldrich, United States; Merck; Germany) and used without purification. Solvents incorporated in the work were freshly distilled and used. The purification of products was performed by recrystallization with a suitable solvent system. For induction of mechanical force- mortal pestle and Coslab made mechanical mill was used. Melting points was determined on Equip-Tronics EQ 730 Digital Melting Point apparatus. Spectra of IR have been recorded on Perkin Elmer (Spectrum Two) FTIR spectrophotometer. The purity of the product was checked using the TLC technique; spots were developed by exposure to iodine vapours and UV cabinets. Ultraviolet spectra were taken on Agilent Technologies Cary 60UV-Vis Spectrophotometer. Mass spectra were recorded in the QP-2010 PLUS GC-MS system. Nuclear Magnetic Resonance spectra were recorded with AVANCE 300MHz, using CDCl3.
Experimental:
All the synthetic procedures were performed by grinding together 10 mmol of the pure primary amine with 10 mmol of the pure substituted aldehyde in a mortar and mechanical ball mill room temperature (Scheme 1-5).12-14 Some mixtures liquefied intermediately on mixing, but most of these could be run without melting at lower temperatures.9 The completion of the reactions was checked by a permanent change in colour of the product and confirmed by TLC, generally, it changes from white to yellow/ orange. (Product of schemes 2 and 3 were kept further at room temperature in dark for 24hr. to ensure the proper uniform colour appearance of the product.) The water produced in the reaction was removed at 80 0C under a vacuum and recrystallized with a suitable solvent. The TLC was carried out by using combinations of mobile phases, reported in table 3(Reaction Parameters). The percentage yield was reported in table 1(Physiochemical and analytical characterization of synthesized compounds). Chemical analysis was carried out by IR and NMR spectroscopy which gave the expected peaks and signals. Thin-layer chromatography and comparison of melting points with literature data confirmed the purity of the products.
Biological activity studies- antifungal activity.10,11
The antifungal activity was performed by using the cup plate method. By pouring 10-15 ml of the base layer medium into each sterilized petri-dish, the bottom layer was obtained and was kept at room temperature. The subculture which is over nightly grown was mixed with seed layer medium, about 10-15 ml, was transferred over the base layer and again allowed to attain room temperature.
The cups for the study were made by cork borer. After the addition of test compounds solutions (Scheme 1-5) to the cups, plates were incubated at 370C for 48 hours. Inhibitory action was measured in mm, repeated three times to confirm the findings and the average of the readings was taken into consideration and reported as the mean of readings in table 4. (Biological screening for antifungal activity of synthesized Imine compounds)
The two fungi, C. Albicans and A.niger were collected and used in the fungicidal bioassays, using 100 μg/ml and 150 μg/ml concentrations of each imines (Scheme 1-5) using Fluconazole as reference standard and dimethylformamide (DMF) as a control for the activity. All the compounds show moderate inhibitory activity, the data of antifungal screening is given in Table 4(Biological screening for antifungal activity of synthesized Imine compounds.).
RESULT AND DISCUSSION
A Novel series of imines were synthesized using a nonconventional method i.e. Mechanochemistry. Selected aromatic primary amines were ground or milled with corresponding aromatic aldehydes and ketones with constant rpm at room temperature, finally at a definite time; the colour of reactant changes from original to else.
Spectroscopic data reveals that the imines show stretching bands of Ar-H, C-N at the region of 3500-3200 and 2985-2833.24 cm-1 respectively. The 1H NMR spectra showed in each case the signal at δ= 7.94-7.17 ppm attributes to aromatic protons and at δ= 4.62-4.57 ppm due to ch3 proton. Besides this C13 NMR spectra are shown in each case of carbon of C=O and C=N at δ=201.11-180.85, and 155.28-174.94 ppm. The aromatic and CH2 carbon resonated at δ=163.93-112.86 and 56.69-44.35 ppm respectively. Spectral characteristics of synthesized compounds were summarized in table 2 (Spectral characteristics of the synthesized compound). The elemental (C, H, N, O) analyses were found within the limit of theoretical values, reported in table 1. The synthesized compound complies with the spectroscopic studies. Among the different reactants used in synthesis, scheme 2 shows maximum yield with a short duration of the reaction. Other compound yields more than the traditional route of synthesis in slighter time.
Among synthesized compounds 4-({(1Z)-[4(dimethylamino)phenyl]methylene}amino)benzoic acid shows better fungicidal action compared with a standard against C. Albicans species, while 4-{[ (1E)-(4-hydroxy-3methyoxyphenyl)methylene]amino}benzoic acid shows improved action against both i.e. C. Albicans and A. Niger. Other all synthesized compounds (scheme 3-5) shows comparative antifungal action
CONCLUSION
The result obtained directed that herein reported methods are more convenient and reactions can be carried out in superior yield, shorter reaction period and gentle conditions and safer to the analyst, Compared with conventional techniques. Herein developed green procedure can be adopted for other organic or medicinal synthesis. The synthesized compound exhibit superior fungicidal action against C. Albicans and A. Niger
Acknowledgement
The authors are grateful to Dr. Anil G. Jadhav, Principal of Sandip Foundation's, Sandip Institute of Pharmaceutical Sciences, Nashik for providing research facilities.
Conflict of interest: NIL
source of funding: NIL
Individual author’s contribution:
Bendale Atul R.: Planning and conceived of the presented idea
Sethiya Jigar: Developed the theory and performed the reactions
Narkhede Sushil P.: Contributed to the interpretation of the results
Jadhav Anil G.: Directed the project
All authors discussed the results and contributed to the final manuscript
Englishhttp://ijcrr.com/abstract.php?article_id=4220http://ijcrr.com/article_html.php?did=4220
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Bendale, A. R., Narkhede, S. P.; Narkhede. S. B.; Jadhav. A.G.; and Vidyasagar. G.; Mechanochemistry - A New Era in Synthesis for Pharmaceutical Researchers, Asian J. Res. Chem. 4(6): June 2011: 851-856
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Bendale, A. R.; Kotak. D.; Narkhede, S. P.; Damahe. D. P.; Jadhav. A.G.; and Vidyasagar. G.; Novel green approaches for the synthesis of quinoxaline derivatives, Der ChemicaSinica, 2011, 2 (2): 20-24
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Xu H, Chen K, Liu H-W, Wang G-W. Solvent-free N-iodosuccinimide-promoted synthesis of spiroimidazolines from alkenes and amidines under ball-milling conditions. Organic Chemistry Frontiers. 2018;5:2864-2869.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Expression of Estrogen and Progesterone Receptors in Ovarian Neoplasms
English1216FaizahEnglish Aziz Mir RizwanEnglish Sharma UmaEnglish
Introduction: Ovarian cancer is one of the most aggressive malignancies of the female reproductive system and is the seventh most common cause of cancer-related deaths in females constituting about 4.0% of all female malignancies. Among cancers of the female genital tract, the incidence of ovarian cancer rank below only carcinoma of the cervix and the endometrium. Aim of the Study: The study aims to analyze the expression of estrogen receptor (ER) and progesterone receptor (PR) immunohistochemical markers in ovarian neoplasms and correlate these with age, histological type and grade of the tumour. Material and Methods: A retro-prospective study was conducted in the Pathology department of our institution for a period of 1 year, from April 2019 to March 2020. 57 cases of ovarian tumours were studied. Haematoxylin & Eosin staining was done followed by immunohistochemical staining for ER and PR. Results: Most of the tumours were benign and serous tumours were the most common histopathological entity. Expression of ER was more in malignant tumours (76.92%) than borderline (66.66%) and benign tumours (53.65%). The expression of PR was more in benign (60.97%) than borderline (33.33%) and malignant (38.41 %) tumours. Conclusion: ER expression was more in malignant tumours and PR expression was a more prevalent feature of benign tumors. This may support the role of estrogen in oncogenesis and indicate a protective role of progesterone in the development of ovarian carcinomas.
EnglishEstrogen, Neoplasm, Ovarian, Progesterone, Reproductive system, IHC
INTRODUCTION
Ovarian tumours can arise from surface epithelium, germ cells, sex cord and ovarian stroma and have a diverse spectrum of histological features according to the particular tumour entity.1,2 The World Health Organization (WHO) Classification for ovarian tumours is based on the tissue of origin: surface epithelial (65%), germ cell (15%), sex cord-stromal (10%), metastatic (5%) and miscellaneous.3 Surface epithelial tumours are further sub-classified by cell type (serous, mucinous, endometrioid, clear cell carcinoma and Brenner’s) and atypia (benign, borderline or malignant). Most malignant ovarian tumours are surface epithelial (90%).1,2 About 80% of ovarian tumours are benign, and these occur mostly in young women between 20 and 35 years whereas borderline tumours occur at a slightly older age.3,4 Risk factors in ovarian carcinogenesis are not well defined. Pregnancy and oral contraceptives reduce, whereas family history increases the risk.
Steroid hormones, primarily estrogen and progesterone have been implicated in ovarian carcinogenesis.5 Estrogen favours neoplastic transformation of ovarian surface epithelial cells, whereas progesterone offers protection against ovarian cancer development.
As a higher expression of estrogen receptor (ER) and progesterone receptor (PR) has been reported in ovarian neoplasm, it is hypothesized that expression patterns of ER and PR may be related to tumour behaviour, prognosis, or both. 6, 7
Ovarian neoplasms are characterized by changes in the receptor status; they may be primarily receptor-negative or may have lost receptors during disease progression.
Previous studies show estrogen receptors increased positivity in high-grade / malignant tumours and progesterone receptors more in low-grade tumours. In patients with carcinoma of the breast and endometrium, the relationship between tumour estrogen and progesterone receptor (PR) levels and the prognosis is well documented.8 The clinical significance of ER and PR expression in ovarian carcinomas has not been well established in the literature. There are more studies on surface epithelial tumours, as being commonest, than compared to other ovarian neoplasms.9 Clinical significance of ER and PR expression in ovarian carcinoma has not been well established.8
MATERIAL AND METHODS
The study is based on 57 cases of ovarian neoplasm, including benign, borderline and malignant tumours, received in the Department of Pathology of our institution. This is a prospective and retrospective study after clearance from the ethical committee.
Relevant clinical details were obtained from patients' records including age, marital status, parity and presenting complaints. All specimens were thoroughly examined for size, laterality, the surface extension of tumour, unilocular/multilocular, cystic/solid or both, microscopic subtypes and grade of the tumour.
Haematoxylin & Eosin staining was done on paraffin sections of ovarian specimens received in the department. Immunohistochemical staining for ER and PR was done as per the standard procedure.
STATISTICAL ANALYSIS
Statistical analysis was done with Microsoft Excel 2007 software and further analyzed in SPSS version 24. All the categorical variables were expressed in terms of number/ frequency and percentages. Bar and pie charts were used to describe the categorical variables. A p-value less than 0.05 was considered statistically significant.
RESULTS:
The overall mean age of the patients was 40.5 ± 15.4 years with the mean age in the malignant group being higher (51.27 ± 16.05 years) than in the rest. About two-thirds of the patients in this study were of the premenopausal category. Overall, the most common complaint was pain abdomen and abdominal distension. A family history of ovarian or other malignancies was seen more in the malignant group (Table 1).
On gross examination, most of the tumours were cystic comprising about 74% of the total. An overwhelming majority of these tumours were found to be benign. Only 4(7%) of the tumours were predominantly solid and all of these turned out to be malignant on histopathology. The rest of the tumours had a variegated appearance with both solid and cystic components (Chart 1).
Serous tumours were the most common histopathological entity comprising approx. 50% of the benign group as well as the overall tumours. The next common tumour was benign cystic teratoma or dermoid (24.6 %). All of these tumours were found to be benign on histopathology. Mucinous cystadenocarcinomas (15%) and immature teratomas (3.5%), two cases each, were noted in the malignant category.
In the current study, the expression of ER was more in malignant tumours (76.92%) than borderline (66.66%) and benign tumours (53.65%) (Table 3, Chart 2). This may support the role of estrogen in oncogenesis.
The expression of PR was more in benign (60.97%) than borderline (33.33%) and malignant (38.41 %) tumours (Table 3, Chart 2). This probably indicates the protective role of progesterone in the development of ovarian carcinomas.
DISCUSSION
Ovarian cancer is the seventh most common cancer worldwide (The age-standardized mortality rate being 4.0/100,000). In India too, female cancer cases, especially ovarian cancer figures are escalating. India shows dangerous data of having the 3rd highest number of cancer cases among women after China and USA. India has the 2nd highest incidence of ovarian cancer globally. 10 The present study was carried out on 57 cases of various ovarian neoplasms. Tumours were classified according to WHO classification. Age has a strong correlation to ovarian cancer risk and 80% of cases are diagnosed after 50 years of age. The age range in our study was 15 to 75 years (mean 40.5 ± 15.4 years) similar to some of the previous studies.11 It is observed that benign tumours occur in the younger age group while malignant ones mostly occur in the 5th and 6th decade. The peak incidence of benign ovarian tumours was in the age group of 20- 40 years. The youngest case in the present study was 15 years old girl, who had a dermoid cyst of the right ovary. In the Ganga Pilli et al. study, peak age was 3rd to 4th decade accounting for 55.7% of cases. The youngest case was 8-month old.12 Basu et al. reported mean age as 48.8±11.2 years.13 Another study in India by Mondal et al. reported median age of 48 years at diagnosis and a maximum incidence of 44.3% in the age group of 41-50 years.14
Pain abdomen was the most common presenting symptom. Nausea, vomiting and ascites were seen in malignant tumours. In a study conducted by Sarkar et al. too, pain abdomen was the most common chief complaint overall.15
Studies reported that most of the cases of epithelial ovarian cancer occur after menopause in Caucasians. A multicentre case-control study also showed that 73% of epithelial ovarian cancer occurred after menopause in the United States. 16 In our study we found that the prevalence of epithelial ovarian cancer was slightly higher in postmenopausal women (54%) than in premenopausal women (46%). This incidence is quite similar to one found in another study conducted in Chinese women.17
Family history of malignancy was elucidated from all the patients in our study and a positive family history of ovarian or other malignancies was seen more in the malignant group. Many studies have established higher ovarian cancer risk in women with a family history of ovarian cancer, breast cancer and cancers of other sites.18
On gross examination, the majority of the tumours were cystic in appearance comprising 40 cases (70.17 %). The next common category of tumours had a mixed appearance with both cystic and solid components contributing to 12 cases (21.05%). The rest of the cases were purely solid in appearance. A similar proportion of cases was seen in a study conducted by Sarkar et al.15
Out of 57 cases, 41 cases were benign (71.92%), 13 cases were malignant (22.80%) and 3 cases of borderline tumours (5.26%). Similar incidences of histopathological subtypes have been noted in many previous studies (Mondal et al., Sarkar et al. 14, 15)
In the present series surface, epithelial tumours were the commonest, comprising 40 cases of 57 ovarian neoplasms. Serous type of tumours contributed to the majority i.e. 29 (50.9%) of total tumours as well as the benign i.e. 21 (51.2%) and malignant i.e. 6 (46.1%) ones (Table 2).
High estrogen (E2) levels, one of the risk factors for ovarian cancer development are often observed in ovarian cancer patients which increases the mobility of ovarian cancer cells by the inhibition of cell to cell adhesion resulting in metastasis. ER and PR show the effects of estrogen and progesterone on proliferation and apoptosis of ovarian cancer cells and a review of the literature shows that ER or PR positivity may be linked with metastasis of ovarian cancer. Ovarian cancers commonly show early peritoneal metastases; the peritoneal cavity is also the most common site of ovarian cancer recurrence.19
Similar to other studies, the present study also showed higher expression of ER in malignant cases than the expression of PR. Among the histological subtypes, ER expression was seen mostly in the serous tumours. The solitary cases of endometroid, Brenners’s and granulosa cell tumours, respectively, also showed positive ER expression.
The PR expression was mostly a feature of benign tumours in our study with the dermoid cyst showing maximum PR positivity (78.57%) followed by the serous subgroup.
These results of steroid hormone immunohistochemical expression were consistent with the previous studies like Naik et al.20 and Verma N et al.21
CONCLUSION
In our current study with limited sample size, we found that the ER expression was more in malignant tumours and PR expression was a more prevalent feature of benign tumours. This may support the role of estrogen in oncogenesis and indicate a protective role of progesterone in the development of ovarian carcinomas. However, this needs more extensive research with a much greater number of cases for better inference and a greater appeal.Acknowledgement:
The authors wish to acknowledge the lab technicians of the Department of Pathology of the institution for their support.
Source of Funding: Nil
Conflict of Interest: The authors declare there is no conflict of interest among them.
Author’s Contribution:
Faizah - Concept, study design, data analysis and manuscript preparation.
Aziz M R - Manuscript preparation and statistical analysis.
Sweta and Sharma U - Collection of data, data analysis and manuscript drafting
Englishhttp://ijcrr.com/abstract.php?article_id=4221http://ijcrr.com/article_html.php?did=4221
1. Su D, Pasalich M, Lee AH, Binns CW. Ovarian cancer risk is reduced by prolonged lactation: a case-control study in southern China. Am J Clin Nutr 2013; 97:354-9.
2. Mittal K, Soslow R, McCluggage WG. Application of immunohistochemistry to gynecologic pathology. Arch Pathol Lab Med 2008; 132:402?23.
3. Duska LR, Kohn EC. The new classifications of the ovarian, fallopian tube, and primary peritoneal cancer and their clinical implications. Ann Oncol. 2017; 28(suppl 8): viii8- viii12.
4. Sylvia MT, Kumar S, Dasari P. The expression of immunohistochemical markers estrogen receptor, progesterone receptor, Her-2-neu, p53 and Ki-67 in epithelial ovarian tumours and its correlation with clinicopathologic variables. Indian J Pathol Microbiol 2012; 55:33-7.
5. Ho SM. Estrogen, progesterone and epithelial ovarian cancer. Reprod Biol Endocrinol 2003; 1:73.
6. Lukanova A, Kaaks R. Endogenous Hormones and Ovarian Cancer: Epidemiology and Current Hypotheses. Cancer Epidemiol Biomarkers Prev 2005; 14:98–107.
7. Yager JD. Chapter 3: Endogenous Estrogens as Carcinogens Through Metabolic Activation. J Natl Cancer Inst Monographs 2000; 2000:67–73
8. Liehr JG. Is estradiol a genotoxic mutagenic carcinogen? Endocrine reviews. 2000 Feb 1;21(1):40-54.
9. Atla B, Sarkar RN, Rasaputra M. Clinicopathological and IHC study (estrogen receptors, progesterone receptor, HER2/NEU) in malignant ovarian tumours. Int J Res Med Sci. 2016 Apr;4(4):1068-73.
10. Hussein MJ, Salai JS. Clinical and histopathological features of ovarian cancer in Rizgary Hospital/Erbil City from 2014 to 2017. Medical Journal of Babylon. 2019;16(2):112-8.
11. Maheshwari V, Tyagi SP, Saxena K, Tyagi N, Sharma R, Aziz M, et al. Surface epithelial tumours of the ovary. Indian J Pathol Microbiol 1994; 37:75-85.
12. Pilli GS, Suneeta KP, Dhaded AV, Yenni VV. Ovarian tumours: a study of 282 cases. J Indian Med Assoc. 2002;100(7):420-447.
13. Basu P, De P, Mandal S, Ray K, Biswas J. Study of ‘patterns of care of ovarian cancer patients in a specialized cancer institute in Kolkata, Eastern India. Indian J Cancer. 2009; 46:28-33.
14. Mondal SK, Bandyopadhyay R, Nag DR, Roychowdhury S, Mondal PK et al. Histologic pattern, bilaterality and clinical evaluation of 957ovarian neoplasms: A 10-year study in a tertiary hospital of eastern India. J Can Res Ther. 2011; 7:4337.
15. Sarkar M, Jha T, Das TK, Sau V, Mitra S, Roy K. Spectrum of epithelial ovarian tumours with HER2/neu expression by the carcinomas among patients admitted in a tertiary care hospital in Eastern India. Int J Med Sci Public Health 2015; 4:1388-1392
16. Moorman PG, Alberg AJ, Bandera EV, Barnholtz-Sloan J, Bondy M, Cote ML et al. Reproductive factors and ovarian cancer risk in African-American women. Ann Epidemiol. 2016; 26:654–62.
17. Shen F, Chen S, Gao Y, Dai X, Chen Q. The prevalence of malignant and borderline ovarian cancer in pre-and post-menopausal Chinese women. Oncotarget. 2017 Oct 6;8(46):80589.
18. Negri E, Pelucchi C, Franceschi S, Montella M, Conti E, Dal Maso L et al. Family history of cancer and risk of ovarian cancer. Eur J Cancer 2003; 39: 505– 10.
19. Chen S, Dai X, Gao Y, Shen F, Ding J, Chen Q. The positivity of estrogen receptor and progesterone receptor may not be associated with metastasis and recurrence in epithelial ovarian cancer. Scientific Reports. 2017 Dec 5;7(1):1-7.
20. Naik PS, Deshmukh S, Khandeparkar SG, Joshi A, Babanagare S, Potdar J, et al. Epithelial ovarian tumours: clinicopathological correlation and immunohistochemical study. J Midlife Health. 2015;6(4):178–83
21. Verma N, Kumar M, Sagar M, Babu S, Singhai A, Singh N, et al. Expression of estrogen receptor, progesterone receptor, and human epidermal growth factor receptor type 2/neu in surface epithelial ovarian tumours and its clinicohistopathological correlation. Indian J Health Sci Biomed Res 2018; 11:19-24.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Knowledge, Attitude and Practices of Informed Consent Documentation Among Researchers in Medical Colleges in Tamil Nadu - a Questionnaire-Based Study
English1722Mohesh GladEnglish Ramalingam LathaEnglish Prakash RevinselvanEnglish
Introduction: Considering the rise in the number of health research activities amid the ongoing coronavirus disease-2019 pandemic, there is an immense need to understand the knowledge, attitude and practices of the medical researchers on the informed consent documentation process in their research studies. Academic research in medical colleges is booming for two exclusive reasons, namely, the need for research papers for academic promotions, and the student projects guided by the faculty. Objective: To determine the knowledge, attitude and practices about the Informed consent documentation (ICD) process among researchers in medical colleges. Methods: This was a cross-sectional survey done using an online questionnaire among 241 researchers in various medical colleges for their knowledge, attitude and practice on the process of ICD in their research. Results: About 91.5% of them were aware of the importance of informed consent, 85.9% believe that the ICD process safeguards the rights of the research participants and nearly 92.5% practised obtaining informed consent from the participants in their projects. Statistically significant results (pEnglishInformed consent, Ethics, Medical research, Human participants, Research documentation
Introduction:
Medical research involving human participants has increased greatly in most of developing countries to improve the quality of healthcare in them, like in India.1 Researcher bear the responsibility for revealing the complete information about the research to their prospective study participants to keep them informed about the proposed research, procedures involved, goals and even the potential risk along with the benefits. International ethical guidelines consistently impose researchers to follow some kind of informed, voluntary and competent informed consent documentation to minimize the chance of exploitation of the study subjects.2
As human participants were involved in medical research, to maintain the participant's autonomy and rights, and also for the research to be guided by fundamental ethical principles to ensure the protection of their welfare, it is mandated by various national and international regulatory bodies to insist upon the collection and maintenance of informed consent documentation.3,4
Informed consent documentation, among all the other ethical practices in research, has gained the most attention among researchers. It may be because the practice of informed consent before any research had become the fundamental element that serves to protect both research participants and the researcher from any prosecution.5 Informed consent documentation is consistently required to ensure that research is informed, and voluntary and there is no exploitation of the study subjects.2
The Indian council of medical research, the primary authority in India that regulates medical research published revised new guidelines on ethics in the year 2018. This revision has happened after a decade and hence it becomes a necessity for every researcher to get introduced to the new guidelines. Changes in the informed consent documentation (ICD) process was evident in the recent guidelines and to understand if the researchers are aware of these changes, we conducted the present study to ascertain the knowledge, attitude and practices about the ICD among researchers in medical colleges.
Materials and methods
This research was conducted after obtaining approval from the Institutional Ethics Committee (SSSMCRI/IEC/2019/500) and written informed consent was obtained from each of the study participants. The choice of the decision on participation in the online survey was inducted within the online survey form and only those who have consented got the opportunity to access the remaining part of the questionnaire of survey.
This cross-sectional descriptive study was conducted with an online questionnaire which was emailed to researchers (300) in different medical colleges across the state of Tamilnadu and the responses were collected online (google forms). The total number of samples was estimated as 241, based on an earlier publication,5 with the desired confidence interval of 95% and an expected drop-out of 10%. Both male & female faculties working in the medical colleges (Professors, Associate professors, Assistant Professors and Tutors, who have completed at least 1 year of service as Assistant professors and with at least one completed research work and one publication were included in the study. Tutors, Assistants with less than 1 year of experience and those without any publication were excluded from the study.
A standardized questionnaire with 30 questions on knowledge, attitude and practice (KAP) was designed in Google forms - a free survey tool provided by google was used to collect the data. All the questions were excerpts from the regulations for informed consent documentation (ICD) in Indian Council of Medical Research (ICMR) guidelines 2018. Both the face and content validation of the questionnaire was done before the initiation of the study. The questionnaire had a brief introductory note and a statement on the confidentiality of the data collected to the respondents.
The study questionnaire was emailed to most of the researchers in the state through email and their responses were populated in the Google response sheet. Multiple response options were blocked and hence one participant submitted one response only. These responses were collected between May 2019 to December 2019. Responses were then transferred to an MS office-Excel sheet and were coded to perform the required statistical analysis. Percentage distribution of the medical researchers in the various sections of the study objectives was analysed for statistical significance and is described in the results of the study. Descriptive statistics were used to explain the demographic data. A Chi-square test was done using SPSS v 19.0 to find if there is any association between the designation of the subjects and their KAP about the informed consent documentation process. Statistical significance was set for a value of p Englishhttp://ijcrr.com/abstract.php?article_id=4222http://ijcrr.com/article_html.php?did=4222
1. Normile D. The promise and pitfalls of clinical trials overseas. Science 2008; 322 (5899): 214-6.
2. Sayed, Nancy E. Kass. Attitudes of Sudanese researchers on obtaining informed consent from study subjects involved in health research. Sudan. J. Public Health 2007; 2(2): 95-102.
3. World Medical Association. Declaration of Helsinki. Ethical principles for medical research involving human subjects. Jahrbuch Für Wissenschaft Und Ethik. 2009;14(1):233-8.
4. Macrae DJ. The Council for International Organizations and Medical Sciences (CIOMS) guidelines on ethics of clinical trials. Proceedings of the American thoracic society 2007;4(2):176-9.
5. Sinha RK, Hiba I. Knowledge, attitude and practice of informed consent. Management in Health 2016; 20(1):14-21.
6. Del Carmen MG, Joffe S. Informed consent for medical treatment and research: a review. The oncologist 2005;10(8):636-41.
7. Levy MD, Larcher V, Kurz R. Informed consent/assent in children. Statement of the Ethics Working Group of the Confederation of European Specialists in Paediatrics (CESP). Eur J Pediatr 2003;162(9):629-33.
8. Chandrashekar J, Seby JG. Knowledge, attitudes and practices related to healthcare ethics among medical and dental postgraduate students in south India. Indian J. Med. Ethics 2014;11(2):99-104.
9. Nijhawan LP, Janodia MD, Muddukrishna BS, Bhat KM, Bairy KL, Udupa N, Musmade PB. Informed consent: Issues and challenges. Adv Pharm Technol Res2013;4(3):134.
10. Grady C. Enduring and emerging challenges of informed consent. N Engl J Med 2015; 372(9):855-62.
11. Kegley JA. Challenges to informed consent: new developments in biomedical research and healthcare may mark the end of the traditional concept of informed consent. EMBO reports 2004; 9: 832-6.
12. Anderson OA, Wearne IM. Informed consent for elective surgery—what is best practice?. J R Soc Med 2007;100(2):97-100.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
An Unusual Occurrence of Pyogenic Granuloma
English2325Preethi MuraliEnglish Uma RavichandranEnglish
Introduction: Pyogenic granuloma (Granuloma pyogenicum) is one of the inflammatory hyperplasias seen in the oral cavity. This term is considered a cryptonym because the lesion is unrelated to infection and it can arise in response to various stimuli which can either be a low-grade local irritation or traumatic injury due to local factors. It is non-neoplastic in nature. Pregnancy tumour, pregnancy epulis and gingival epulis are the various other terms used when arising in pregnant women. Case Report: Here we present a case report of a 24-year-old female who developed a pregnancy tumour in the tongue which is an uncommon site and did not regress after parturition. Conclusion: The growth continued to remain due to traumatic factors and was surgically excised.
EnglishPregnancy tumour, Pyogenic granuloma, Coroplast, traumatic, Epulis, Tongue growth
Introduction
Pyogenic granuloma (Granuloma Pyogenicum) is one of the inflammatory hyperplasia seen in the oral cavity. This term is a misnomer because the lesion is unrelated to infection and, arises in response to various stimuli such as low-grade local irritation, traumatic injury or local factors.1It is non-neoplastic. It is the most common gingival tumour in the Lips. The buccal mucosa is the next common site and occasionally it occurs in the tongue. It is slightly more common on the maxillary gingiva. Anterior areas are more frequently affected. It is much more common on the facial aspect of the gingiva than the lingual aspect.2 Pregnancy tumour, pregnancy epulis and gingival epulis are the various other terms.
Case Report
A 24-year-old female presented with a history of a small growth in the tongue for the past 9 months. She first developed the growth when she was in her second trimester. The growth did not resolve after her parturition. The patient also complained of pain and discomfort during mastication and speech. The growth was ulcerated and was bleeding often. The patient was afebrile, without any underlying systemic disease. She didn’t have any relevant medical or family history. On intraoral examination, the growth was exophytic, pedunculated measuring 1x1 cms, and bled on slight probing (Fig 1). She had a fractured maxillary lateral incisor corresponding to the lesion which seems to have aggravated the growth and resulted in ulceration. The growth was provisionally diagnosed as Pregnancy Tumor/ Pyogenic Granuloma. The patient was asked to rinse the mouth with chlorhexidine gluconate mouthwash and the local application of topical anaesthetic gel along with antibiotics and analgesics were prescribed. After a week, the margins were narrowed, and the ulceration was healed. However, the growth persisted. (Fig 2)
Considering the smaller size and patient ease, an excisional biopsy was done under local anesthesia. Coronoplasty was done in the associated tooth. The histopathologic diagnosis confirmed the clinical diagnosis of Pyogenic Granuloma. The patient was asked to continue the prescribed medications for 7 days during the first post-operative week. The growth resolved and did not recur in 2 months of follow up. ( Fig 3)
Discussion
Pregnancy tumour of the oral cavity develops in up to 5% of pregnancies, hence the terms” pregnancy tumour” and “granuloma gravidarum” are often used(2) Though they are quite common in almost all sites of the oral cavity, unusual sites like nasopharynx have also been reported.3 The tumour usually grows rapidly and a direct relationship has been established between the growth rate of the tumour and the decreased level of estrogen and progesterone, occurring during pregnancy.1,2,3,4The reason for pregnancy tumour can be due to the production of vascular endothelial growth factors in macrophages as a result of Estrogen.5,6In this case, the lesion was initially small and wasn’t ulcerated. Due to the presence of a traumatic factor, there was ulceration causing high discomfort to the patient and making inconvenience in activities like mastication and phonetics. Coronoplasty was done on the fractured tooth as an attempt to eliminate the causative agent for ulceration. Bacterial origin is also an etiologic factor for pyogenic granuloma. The presence of gram-positive and gram-negative bacilli in ulcerated forms pyogenic granuloma was demonstrated by Bhaskar and Jacoway.7Oral pyogenic granuloma has capillary growth inside a mass of granulation tissue, this justifies that pyogenic granuloma is a misnomer.
Conclusion
Although pyogenic granuloma is non-neoplastic, it arises in response to various stimuli. In this case, in addition to the hormonal factor, the traumatic factor of the fractured maxillary lateral incisor aggravated the growth. Removal of irritants that cases a tumour is the major line of treatment. Excisional surgery is the most common treatment of choice for pyogenic granuloma.
Acknowledgment: 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.
Source of Funding: Self
Conflict of Interest: Nil
Authors’ Contribution:
Dr.PreethiMurali – Case preparation and manuscript formation
Dr.UmaRavichandran– Photography and technical assistance
Englishhttp://ijcrr.com/abstract.php?article_id=4223http://ijcrr.com/article_html.php?did=4223
AzinMirzadeh,Nader Navabi, MoloukTorabi, Parizi. The unusual occurrence of Pregnancy Tumor on the tongue. Iran J Public Health. 2014;.43(6):845-846.
Hamid JafarZadeh,MajidSanatkhani and NashinMohatsham.Oral Pyogenic granuloma: a review. J Oral Sci.2006;48(4):167-175.
Fernandes VL, Pinto NM, Sanzgiri VB, Khandholkar P, Sukhthankar, I.R et al . A rare case report of Pyogenic granuloma of the tongue(International Journal of Otolaryngology and Head &Neck Surgery. 2018;7:75-79.
Hartzell MB. Granuloma Pyogenicum. J Cutan Dis Syph. 1904; 22,520-525
Eversole LR (2002) Clinical Outline of oral pathology; diagnosis and treatment.3rded, BC Decker, Hamilton,113-114.
Oral pregnancy Tumor, Shailesh et al. Contemporary Clin Denti. 2010 Jul-Sep; 1(3): 190–192.
Bhaskar SN, Jacoway JR. Pyogenic granuloma – Clinical features, incidence, histology, and the result of treatment: Report of 242 cases. J Oral Surg. 1966;24:391–8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Effectiveness of Directional Lingual Exercise on Subjects with Post Stroke Dysphagia
English2629Priyanga SeemathanEnglish T DivyaEnglish Kumaresan AEnglish Prathap SuganthirababuEnglishEnglishStroke, Oropharyngeal dysphagia, FOIS, Tongue strength, Tongue endurance
INTRODUCTION
Stroke is a focal neurological disturbance of presumed vascular origin that lasts for more than 24 hours which in turn produces disturbance in the brain causing motor, cognitive and sensory problems.1 Dysphagia is the common swallowing problem that occurs after the stroke which has an increased risk of death, dependency, decrease in quality of life, pneumonia occurrence, and causes prolonged stay in hospital. Swallowing difficulties often occur in post-stroke survivors in about 25%-62%.2
Swallowing is a voluntary physiological process that transports the ingested material and saliva from the mouth to the stomach. Stroke negatively impacts the part of the brain that controls the swallowing muscles.3 The role of the tongue is mandatory in the swallowing process as it helps to chew by pushing the food towards the teeth during grinding.4 And it also presses the crushed food against the palate and moves the bolus that initiates the swallowing process.5 The other diseases that affect the function of the tongue are tongue cancer, Beckwith-Wiedemann syndrome, an overactive thyroid, acromegaly, amyloidosis, sarcoidosis, hypothyroidism, Kawasaki disease and also in down syndrome.6
Swallowing consists of four phases that include oral preparatory, oral propulsive, pharyngeal, and oesophagal phases, in which stroke usually affects the first three phases which interrupt the voluntary control of chewing and the process of moving the food around the mouth or delaying the pharyngeal reflex.7 The tongue strength is necessary for enabling the swallowing process because the tongue is involved in the pharyngeal phase of swallowing, it produces an elevation movement and sweeps posteriorly to pass the bolus past the anterior tonsillar pillar and it stimulates the swallowing reflex. Tongue strength in a normal person is 56kPa.8 And the tongue strength for post-stroke dysphagia patients reduces.9
The tongue strength is improved using various techniques like oral motor exercise, myofunctional therapy, abilex exerciser, shaker technique, pacing and feeding strategies, postural and positional techniques, effortful swallow, Mendelsohn manoeuvre, supraglottic swallow, super-supraglottic swallow, Masako manoeuvre, head-lifting exercise, lingual isometric exercise.10
Directional lingual exercise is used to increase the tongue pressure which in turn increases the tongue strength and endurance that helps the patient to recover from swallowing difficulties.11 Thus tongue strength and endurance play an important role in swallowing function.12 Directional lingual exercise consists of forwarding, lateral and vertical task that improves the tongue strength.13 Directional lingual exercise is a particular technique that is easily understandable for the patients and it is comfortable. This does not require supervision or the help of the therapist. It can be done in the house of the patient, the hospital setting is not necessary.14
MATERIAL AND METHODS:
The study was designed as a Quasi-experimental study design; the study setting was done at the Physiotherapy outpatient and inpatients department, Saveetha medical college and hospital; 30 subjects who were willing to participate were selected using convenience sampling technique based on inclusion and exclusion criteria. The inclusion criteria included both the gender under the age group of 30-50 years, the person who was positive in water swallow test, subjects with post-stroke dysphagia. The exclusion criteria included unconscious patients; people who are not willing to participate; patients with brain injury; a mouth ulcer that leads to swallowing difficulty; persons with other neurological conditions and a person with an oropharyngeal tumour. The gender and age differences are shown in Figures 1 and 2 respectively. The materials required for the study were a Device used to measure tongue strength and endurance; ice stick. The safety and simplicity of the procedure were explained to the patients and written consent was obtained from the subjects in their known language.
All the subjects underwent the pretest measurement that included FOIS, lingual strength and endurance measurements were taken. Water Swallow Test was used for selecting the patients for the study in inclusion criteria. In this test, the patient was placed in a resting position and the patient's mouth was wet with the cold water and the patient was instructed to swallow repeatedly and the number of the swallow is monitored. This test was done to involve the patients in the exercise program. The functional oral intake scale was the assessment tool used to measure the current status of the oral intake of the patient. The scale consisted of 7 levels that were mentioned based on the status of the patient. Based on the diet level and swallowing function of the patients the FOIS was measured. The strength and endurance of the tongue is measured using the device that is used to measure the tongue strength and endurance. The patient was placed in the supine lying position. The device consisted of an air-filled bulb that was placed against the roof of the mouth and instructed the patients to press the bulb with maximum pressure the patient could to measure the strength of the tongue, which was displayed in the LCD of the device and the values were noted in kilopascal. The endurance was measured by quantifying the length of the time that the patient can maintain 50% of the maximum pressure in the device. These were the pretest measured before providing the intervention. The intervention included directional lingual exercise. The training protocol included the exercise period of 10 sessions/day,5 days/week for 2weeks. The patients exercised the anterior portion of the tongue using the ice stick and then with the posterior portion. The patients were asked to do the free lingual exercise in all the directions from anterior through protrusion and then to anterolateral to both the sides and then to upward and downward. After that, they were advised to do the same exercise using the ice tick for resistance. These exercises were given for 10 sessions as per the protocol. After the intervention, the Post-test evaluation was taken as the same as in the pre-test. The values were tabulated in Tables 1, 2 and 3 and statistically analyzed.
STATISTICAL ANALYSIS
Paired t-test was used to analyze significant changes between pre and post-test measurements of tongue muscle strength and endurance. Wilcoxon signed-rank test was used to analyze significant changes between pre and post-test measurements of functional oral intake scale. P-value Englishhttp://ijcrr.com/abstract.php?article_id=4224http://ijcrr.com/article_html.php?did=4224
Dodds WJ, Stewart ET, Logemann JA. Physiology and radiology of the normal oral and pharyngeal phases of swallowing. AJR Am J Roentgenol. 1990 May;154(5):953-963.
Tibbling L, Gustafsson B. Dysphagia and its consequences in the elderly. Dysphagia. 1991;6(4):200-202.
Youmans SR, Stierwalt JA. Measures of tongue function related to normal swallowing. Dysphagia. 2006 Apr; 21(2):102-111.
Stierwalt JA, Youmans SR. Tongue measures in individuals with normal and impaired swallowing. Am J Speech Lang Pathol. 2007 May; 16(2):148-156.
Kim HD, Choi JB, Yoo SJ, Chang MY, Lee SW. Tongue-to-palate resistance training improves tongue strength and oropharyngeal swallowing function in subacute stroke survivors with dysphagia. J Oral Rehabil. 2017 Jan;44(1):59-64.
Burkhead LM, Sapienza CM, Rosenbek JC. Strength-training exercise in dysphagia rehabilitation: principles, procedures, and directions for future research. Dysphagia. 2007 Jul;22(3):251-265.
Robbins J, Levine R, Wood J, Roecker EB, Luschei E. Age effects on lingual pressure generation as a risk factor for dysphagia. J Gerontol A Biol Sci Med Sci. 1995 Sep; 50(5):M257-262.
Clark HM, O'Brien K, Calleja A, Corrie SN. Effects of directional exercise on lingual strength. J Speech Lang Hear Res. 2009 Aug;52(4):1034-1047.
Lazarus C, Logemann JA, Huang CF, Rademaker AW. Effects of two types of tongue strengthening exercises in young normals. Folia Phoniatr Logop. 2003 Jul-Aug;55(4):199-205.
Robbins J, Kays SA, Gangnon RE, Hind JA, Hewitt AL, et al. The effects of lingual exercise in stroke patients with dysphagia. Arch Phys Med Rehabil. 2007 Feb;88(2):150-158.
Robbins J, Gangnon RE, Theis SM, Kays SA, Hewitt AL, et al. The effects of lingual exercise on swallowing in older adults. J Am Geriatr Soc. 2005 Sep;53(9):1483-1489.
Utanohara Y, Hayashi R, Yoshikawa M, Yoshida M, Tsuga K, et al. Standard values of maximum tongue pressure taken using newly developed disposable tongue pressure measurement device. Dysphagia. 2008 Sep;23(3):286-290.
Nicosia MA, Hind JA, Roecker EB, Carnes M, Doyle J, et al. Age effects on the temporal evolution of isometric and swallowing pressure. J Gerontol A Biol Sci Med Sci. 2000 Nov;55(11):M634-640.
McKenna VS, Zhang B, Haines MB, Kelchner LN. A Systematic Review of Isometric Lingual Strength-Training Programs in Adults With and Without Dysphagia. Am J Speech Lang Pathol. 2017 May 17;26(2):524-539.
Rogus-Pulia N, Robbins J. Approaches to the rehabilitation of dysphagia in acute poststroke patients. Semin Speech Lang. 2013 Aug;34(3):154-69.
Ono, T., Hori, K. & Nokubi, T. Pattern of tongue pressure on the hard palate during swallowing. Dysphagia 2004; 19:259–264.
Terré R, Mearin F. A randomized controlled study of neuromuscular electrical stimulation in oropharyngeal dysphagia secondary to acquired brain injury. Eur J Neurol. 2015 Apr;22(4):687-644.
Hara K, Tohara H, Kobayashi K, Yamaguchi K, Yoshimi K, et al. Age-related declines in the swallowing muscle strength of men and women aged 20-89 years: A cross-sectional study on tongue pressure and jaw-opening force in 980 subjects. Arch Gerontol Geriatr. 2018 Sep-Oct; 78:64-70.
Feng X, Todd T, Lintzenich CR, Ding J, Carr JJ, et al ,. Ageing-related geniohyoid muscle atrophy is related to aspiration status in healthy older adults. J Gerontol A Biol Sci Med Sci. 2013 Jul; 68(7):853-860.
Jacob P, Kahrilas PJ, Logemann JA, Shah V, Ha T. Upper oesophagal sphincter opening and modulation during swallowing. Gastroenterology. 1989 Dec;97(6):1469-1478.
Butler SG, Stuart A, Leng X, et al. The relationship of aspiration status with tongue and handgrip strength in healthy older adults. J Gerontol A Biol Sci Med Sci. 2011 Apr ;66(4):452-458.
Dworkin JP, Aronson AE, Mulder DW. Tongue force in normals and dysarthric patients with amyotrophic lateral sclerosis. J Speech Hear Res. 1980 Dec;23(4):828-37.
Cho YS, Oh DH, Paik YR, Lee JH, Park JS. Effects of bedside self-exercise on oropharyngeal swallowing function in stroke patients with dysphagia: a pilot study. J Phys Ther Sci. 2017;29(10):1815-1816.
Kim HD, Choi JB, Yoo SJ, Chang MY, Lee SW. Tongue-to-palate resistance training improves tongue strength and oropharyngeal swallowing function in subacute stroke survivors with dysphagia. J Oral Rehabil. 2017 Jan;44(1):59-64.
Youmans SR, Youmans GL, Stierwalt JA. Differences in tongue strength across age and gender: is there a diminished strength reserve? Dysphagia. 2009 Mar;24(1):57-65.
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Clinical Profile, Ocular Morbidity and Visual Loss in Psoriasis
English3034Deb DEnglish Annamalai REnglish S. AnandanEnglish S. MuruganEnglish M. MuthayyaEnglish
Aim: To study the clinical profile of ocular psoriasis and to identify features that help in the recognition and prevention of ocular morbidity and visual loss in these patients. Methods: A prospective observational study was conducted on 100 patients with psoriasis in a tertiary care, multispecialty hospital. All patients underwent systemic evaluation by the dermatologist, followed by ophthalmic evaluation comprising of visual assessment, slit lamp examination, ophthalmoscopy, Schirmer’s test, tear breakup time, Rose Bengal staining and ancillary investigations such as fundus fluorescein angiography (FFA) and optical coherence tomography (OCT). Results: Among 100 patients with psoriasis, the prevalence of ophthalmic manifestation was 60%, of whom 42% were symptomatic. Ocular features were most common in scalp psoriasis and pustular psoriasis. The type and severity of ocular manifestation had a positive correlation with the duration of psoriasis. The most common ophthalmic feature was keratoconjunctivitis sicca (55%), followed by meibomitis (50%), cataract (35%), blepharitis (20%) and uveitis (5%). Uveitis had associated with psoriatic arthritis. The correlation was established using the kappa coefficient. Statistical significance was found in the conjunctival staining pattern with a p-value = 0.02. Steroid-induced glaucoma occurred in 24%. Keratoconjunctivitis sicca and corticosteroids used in the management of systemic psoriasis were found to be the most frequent causes of visual morbidity. Conclusion: Ophthalmic clinical features, signs and symptoms in psoriasis may be subtle and a complete ophthalmic evaluation is required both for early detection of ocular abnormalities and complications. A multidisciplinary approach is required to reduce ocular morbidity in the active phase of psoriasis during and after treatment in these patients.
EnglishCataract, Corticosteroids, Keratoconjunctivitis sicca, Psoriasis, Uveitis, Visual morbidity
INTRODUCTION
Psoriasis is an autoimmune, chronic, painful, and disabling disease that affects the quality of life of the patient.1 It is an immune-mediated condition where TH1 produces pro-inflammatory cytokines such as TNF-α, IFN-γ, IL-6, and IL-12, which underlies the disease process. The prevalence of psoriasis worldwide varies between 0.09%- 11.4%.2,3 The prevalence of psoriasis in India is estimated at around 0.7%.4 The lesions seen typically in psoriasis have a well-demarcated plaque, erythematous base, and silvery scales on the surface of the lesion. These lesions are mostly seen on extensor surfaces and as scalp lesions. The most common type is psoriasis Vulgaris. The other types of psoriasis include guttate, erythrodermic, pustular, and inverse psoriasis.5
Psoriasis is known to be associated with multiple systemic conditions such as inflammatory bowel disease, arthritis, diabetes, cardiovascular disease, and stroke.
Ocular manifestations are seen in about 10% of cases with psoriasis,6,7 more so with the pustular psoriatic type. Ocular manifestations of psoriasis may be either direct involvement or immune-mediated. The various known ocular manifestations associated with psoriasis are blepharitis, ectropion, trichiasis, conjunctivitis, keratoconjunctivitis sicca, corneal melting, episcleritis, cataract, ocular hypertension, uveitis, and macular oedema.
Uveitis is seen more commonly in patients with psoriatic arthritis than psoriasis alone and the articular features precede the ocular manifestations. The severity of ocular inflammation correlates more with skin disease than the extent of joint involvement in psoriasis.8 The severity of psoriasis has a positive correlation with anterior uveitis. It has been postulated that patients with HLA B27 and psoriasis, present with a severe form of uveitis. Uveitis in turn may lead to retinal vascular occlusions, secondary glaucoma, inflammatory optic neuropathy, and retinal detachment, which results in temporary or permanent loss of vision.
This study aimed to identify the prevalence and analyze the various ocular morbidities and their association with the type of psoriasis. Since most of the patients with psoriasis present late to an ophthalmologist either due to lack of awareness or fewer symptoms, it is of utmost importance that the dermatologist and ophthalmologist evaluate a patient with psoriasis completely and in collaboration before they develop sight-threatening morbidities.
MATERIAL AND METHODS
This is a prospective, observational, descriptive study on 100 patients with psoriasis visiting a tertiary care centre in Chennai, South India. The hospital has a well-equipped psoriasis clinic and an Ophthalmology department. The study was conducted over 1 year from January 2020 to December 2020, after obtaining Institutional ethics approval (CSP-MED/18/OCT/47/171). The patients were followed up every 3 weeks and more frequently whenever required.
All psoriasis patients were referred to the Ophthalmology department for a complete ophthalmic evaluation. Psoriasis patients were diagnosed clinically and severity was rated using Psoriasis Area and Severity Index and the Dermatological Life Quality Index.9 We excluded severely ill patients, patients who had known ocular morbidities associated with other systemic conditions. Informed consent was obtained from each patient before enrolling them in this study. We noted down the demographic details of patients visiting us with psoriasis, along with the type of psoriasis, duration of the condition, treatment for the disease, and any family history of similar condition. The ophthalmic evaluation consisted of the assessment of extraocular movements, best-corrected visual acuity for distance and near vision, refraction, colour vision testing, slit lamp examination, ophthalmoscopy, and intraocular pressure assessment by Goldmann’s applanation tonometer. They were evaluated for dry eye by measuring the tear meniscus height, Schirmer’s test, tear break-up time, and Rose Bengal conjunctival staining. Van Bijsterveld scoring system was used to assess dry eye where the cornea is divided into three zones and graded in each zone and subsequently counted to give the total score.
The data collected were analyzed to calculate the prevalence of various ocular manifestations in psoriatic patients. During the follow-up visit, the patients were also reviewed by the dermatologist to assess improvement in the systemic illness.
Statistical analysis: All the data was collected and analyzed using IBM SPSS statistics software, Version 23.0. In descriptive statistics, frequency analysis for data distribution and percentage analysis was done for categorical variables. Mean and standard deviation was analyzed using continuous variables. Kappa coefficient was used for the correlation of test values. Statistical significance in categorical data was done using the Chi-Square test. A probability value of p < 0.05 was considered statistically significant.
RESULTS
A prospective, observational, cohort study was performed on 100 patients with an established diagnosis of psoriasis. In our study, among 100 patients, ophthalmic manifestations were noted in 60 patients (60%). Males were affected in 27% and females in 71%. The age group affected was most frequently between 40-65 years (median age 47 years). Bilateral involvement occurred in 88% of patients and was statistically significant with p=0.01. The most common symptom was irritation or burning and foreign body sensation in both eyes.
The most common type of systemic psoriasis in our patients was psoriasis Vulgaris(54%). Ocular features were seen more commonly in patients with psoriasis Vulgaris (41.6%) (Table 1). Keratoconjunctivitis sicca and ocular surface disease were more common in patients with scalp psoriasis (41%) and pustular psoriasis (6.7%).
36% of patients with ocular manifestation had psoriasis for less than 3years.
Among our study patients, 22% of the patients were symptomatic, with irritation of eyes being the commonest symptom, followed by water. The various ophthalmic features among psoriasis patients were ocular surface disorder in 33 patients (55%), cataract in 21 patients (35%), meibomitis in 30 patients (50%), blepharitis in 12 patients (20%), and anterior uveitis in 12 patients (20%) (Table 2). Keratoconjunctivitis sicca (dry eye) was most commonly noted.
Objective tests for evaluation of the tear film done showed that 43 eyes had abnormal Schirmers test I (Figure 2) indicating reduced aqueous secretion (Table 3). A positive score of greater than 6 on the Van Bijsterveld grading system was seen in 80% of patients (Table 4).58.5% had reduced tear break up time (Figure 1) indicating tear film instability (Table 5). Correlation between tests was calculated using kappa coefficient and statistical significance with a p-value of 0.01 was found in the pattern of conjunctival staining.
The prevalence of blepharitis was 20 %, associated meibomitis was seen in 50%, associated conjunctival keratinization in 2%, anterior uveitis in 12%, and superficial punctate erosion in 9%. None of the patients had peripheral corneal melting.
18 patients (30%) had borderline to high intraocular pressures ranging from 24-36 mmHg. Fundus examination in these patients showed a cup disc ratio of 0.4-0.5 with a normal neuroretinal rim in 47% of patients. Gonioscopy showed an open angle with visualization up to the scleral spur in 73% of patients. The use of topical corticosteroids was noted in the majority of these patients. In those with high IOP, the relationship between the IOP, cup to disc ratios, central corneal thickness, and neuroretinal rim thinning was studied. Steroid-induced glaucoma in 79% and ocular hypertension in 21% were identified. Perimetry in these patients showed nasal step and isolated scotoma in Bjerrum’s area in 3% of patients.
Uveitis was seen in 12%, among whom, 2% had acute uveitis and 10 % had chronic uveitis with old keratic precipitates and posterior synechiae (Table 6). All these patients had unilateral features. All of them were of the anterior type and non-granulomatous. 8% of patients with uveitis had an association with psoriatic arthritis.
Cataract was observed in 21% of psoriasis patients receiving oral steroids (Figure 3). Among them, 9% were less than 40 years. Most cataracts seen were immature senile types, which improved with refraction. The majority of the patients were on treatment with topical steroids (52%) and combined treatment with methotrexate(7%). A dry eye developed in 63% of patients who were being treated with immunosuppressives/ ciclosporin.
DISCUSSION
Psoriasis is a chronic, inflammatory disease that involves multiple organs, predominantly the skin. Among 100 patients, ocular manifestations occurred in 60 patients and were most frequent in psoriasis Vulgaris (54%). In those being referred for ocular complaints, inflammation of the ocular surface and complications of steroid use such as cataract and glaucoma was frequent finding.
Association between psoriatic arthritis and ophthalmic features has been studied previously by Lambert and Wright10 who have reported the incidence as 31.2%, The prevalence of ocular inflammation and uveitis in patients with psoriasis was reported to be 7-20% in a study conducted by Lambert et al., and Knox et al.11, whereas Chandran et al.12, 20078 and Kilic et al.,13 found a prevalence of 2%. Psoriatic arthritis was reported to be 1.5-2.5% in a study conducted by Paiva et al., 200014 and Niccoli et al.,15 Lambert et al., 1979, found that most of their study patients with psoriasis had anterior uveitis (7.1%). In the study conducted by Chandran et al, 2% of patients had uveitis. They also concluded that the presence of absence of uveitis correlated with the Lattice System Physician’s Global Assessment (LS-PGA), prompting an urgent ophthalmic evaluation if the score is greater than 5. Paiva et al concluded that the most common features of uveitis seen in patients with psoriatic arthritis were insidious onset, active bilaterally and posterior uveitis. In our study, arthritis with ocular involvement occurred in 8 patients (8%). Uveitis in psoriasis has been suggested to occur due to a breakdown of the blood-aqueous barrier due to subclinical inflammation. The intensity of which is likely to be proportionate to the duration, severity and age of the patient with systemic psoriasis.
We found an abnormal Schirmers test I of less than 5mm in 9.5% and between 5-15 mm in 12 %, indicating decreased aqueous secretion. 48% had reduced tear break up time less than 5 seconds and 10.5% had tear break up time between 5- 10 seconds. Van Bijsterveld score showed scores greater than 6 in 80% of patients with predominance of conjunctival involvement.
Conjunctival staining with Rose Bengal was significant and was more common in the central and inferior zones than superior due to evaporative dry eye.
On analysis, we inferred that in many of our patients, the tear film secretion was normal and the dry eye was because of tear film instability and chronic inflammation of the ocular surface. Goblet cell deficiency, an altered ocular surface and tear film debris was the cause of discomfort in these patients. Superficial punctate erosions and dry spots on the cornea were due to de-epithelialisation which is typical in keratoconjunctivitis sicca.
Squamous blepharitis was found in 20 % and was associated with meibomitis and tylosis. Worsening of symptoms occurred in patients with blepharitis due to secondary changes in the lipid layer of the tear film which resulted in increased evaporation. Meibomitis and blepharitis in psoriasis are due to increased turnover of epithelial cells which is a part of the systemic autoimmune disease process16. Blepharitis was treated with measures for lid hygiene such as warm compression, lid scrubs, topical ocular lubricants and antibiotic ointment. Response to treatment was good in all patients with inflammation clearing within 1 week with no recurrence. Conjunctival keratinisation, tear film debris and superficial punctate erosion was seen in those patients with severe dry eye. This probably occurred due to micro-trauma in the cornea. We did not see blinding or irreversible complications such as corneal ulcers or peripheral corneal melting in any of our study patients.
A common cause of visual loss in patients with psoriasis has been reported as cataracts. In our study, we found both corticosteroid-induced cataract and age-related lenticular changes.
We noted steroid-induced glaucoma in 18%, which responded well with treatment with brimonidine tartrate 0.2% or timolol maleate 0.5% eye drops. Among our study patients, the mean intraocular pressure was within the normal range in 82 patients (82%). 18% of patients had borderline high intraocular pressure (21- 30 mm Hg) due to prior ongoing treatment with topical and/or corticosteroids. These patients with steroid-induced glaucoma had both fundus and visual field changes. Whereas, in the study done on Singaporean patients with psoriasis, the prevalence of glaucoma was 2%.
Ophthalmic involvement and early ocular signs in psoriasis may be subtle and easily overlooked especially in the absence of symptoms. A comprehensive ophthalmic examination needs to be done to detect ocular abnormalities, ocular complications and sequelae of treatment in these patients. In most situations, inflammation can be fully treated with complete resolution with early treatment. Literature states that patients with psoriatic arthritis develop ocular involvement. We observed from our patients that they occur in patients without an arthritic component as well. Hence we recommend that all patients should be evaluated for ophthalmic involvement irrespective of the presence and extent of joint involvement.
Dry eye can be due to the evaporation of tears or aqueous tear deficiency. The combination of dry eye, an unstable tear film and chronicity in these patients with keratoconjunctivitis sicca can predispose to the development of allergic conjunctivitis and meibomitis, which can worsen the ocular surface disease. This cascade of ocular symptoms and discomfort must be detected and treated in the early stages to prevent ocular morbidity.
CONCLUSION-
We found a definite association between duration and severity of psoriasis with ophthalmic features. Visual morbidity due to ophthalmic manifestations can occur both during the active phase of the disease, due to complications after disease resolution or as a consequence of drugs used for the treatment of psoriasis. It is ideal to have a multispecialty approach in the treatment of psoriasis. A combined protocol of screening and timely treatment would benefit the patient in terms of both ophthalmic and holistic care.
ACKNOWLEDGEMENT- 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 the 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- NIL
NIL FUNDING/FINANCIAL INTEREST IN THIS STUDY
Englishhttp://ijcrr.com/abstract.php?article_id=4225http://ijcrr.com/article_html.php?did=4225
1. Cruz NFS da, Brandão LS, Cruz SFS da, Cruz SAS da, Pires CAA, Carneiro FRO. Ocular manifestations of psoriasis. Arq Bras Oftalmol [Internet]. 2018;81(3). Available from: http://dx.doi.org/10.5935/0004-2749.20180044
2. Gibbs S. Skin disease and socioeconomic conditions in rural Africa: Tanzania. Int J Dermatol. 1996;35(9):633–9.
3. Danielsen K, Olsen AO, Wilsgaard T, Furberg AS. Is the prevalence of psoriasis increasing? A 30-year follow up of a population-based cohort. Br J Dermatol. 2013;168:1303–10.
4. Enno C. Psoriasis: Epidemiology and clinical spectrum. Clinical and Experimental Dermatology. 2001;26:314–20.
5. Lebwohl M, Menter A, Koo J, Feldman S. Combination therapy to treat moderate to severe psoriasis. Journal of the American Academy of Dermatology. 2004;50(3):416-430.
6. Fraga N, Oliveira M, Follador I, Rocha B, Rêgo V. Psoriasis and uveitis: a literature review. Anais Brasileiros de Dermatologia. 2012;87(6):877-883.
7. Ajitsaria R, Dale R, Ferguson V, Mayou S, Cavanagh N. Psoriasis, psoriatic arthropathy and relapsing orbital myositis. Clinical and Experimental Dermatology. 2001;26(3):274-275.
8. Zohreh H, Leila S, Soheila S. Management of psoriasis in children: A narrative review. J Pediatr Rev. 2015;3:e131.
9. Agnieszka B, Adam R. The reliability of three psoriasis assessment tools: Psoriasis area and severity index, body surface area and physician global assessment. Adv Clin Exp Med. 2017;26(5):851–856.
10. Lambert JR, Wright V. Eye inflammation in psoriatic arthritis. Ann Rheum Dis. 1976;35(4):354–6.
11. Knox DL. Psoriasis and intraocular inflammation. Trans Am Ophthalmol Soc. 1979;77:210-24.
12. Chandran NS, Greaves M, Gao F, Lim L, Cheng BCL. Psoriasis and the eye: prevalence of eye disease in Singaporean Asian patients with psoriasis: Psoriasis and the eye. J Dermatol. 2007;34(12):805–10.
13. Kilic B, Dogan U, Parlak AH, Goksugur N, Polat M, Serin D, et al. Ocular findings in patients with psoriasis: Ocular findings in psoriasis. Int J Dermatol. 2013;52(5):554–9.
14. Paiva ES, Macaluso DC, Edwards A. Characterization of uveitis in patients with psoriatic arthritis. Ann Rheum Dis. 2000;59:67–70.
15. Niccoli R, Nannini C, Cassara E. Frequency of iridocyclitis in patients with early psoriatic arthritis. A prospective follow-up study. Int J Rheum Dis. 2012;15:771–784.
16. Zengin N, Tol H, Balevi ?, Gündüz K, Okuda S, Endo?ru H. Tear film and meibomian gland functions in psoriasis. Acta Ophthalmologica Scandinavica. 2009;74(4):358-360.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Bioprospecting and Therapeutic Applications of Cocos nucifera L. Sprouts
English3542S. Abiraami ValliEnglish S. Uma GowrieEnglish
Introduction: Cocos nucifera L. is known for all its multiple utilities especially for its nutritional value. The Coconut’s basal part of the embryo enlarges to form sprout/haustorium. Aim: The objective is to compare the phytoconstituents and its bioefficacy of the coconut meat (cellular endosperm) and its sprouts (haustorium) using bioassays leading to novel drug development recommending for the development of nutraceuticals. Methodology: Studies on toxicity, shelf-life of the dried powdered samples were carried out. Quantification of total lipids, flavonoids, vitamin- C, determination of amylase activity was performed using methanol and aqueous extracts. Bioassays such as antibacterial, in vitro antioxidant and anti-inflammatory assays, were conducted. Phytoconstituents were characterized by GC-MS. The cytotoxic effect of the samples was analyzed in human gastric adenocarcinoma epithelial (AGS) cell line infected with gastric ulcer. Results: Toxicity and shelf-life studies had indicated that the samples were non-toxic with the shelf-life extending up to 180 days. Quantitative analysis showed maximum flavonoids followed by vitamin-C with reduced levels of lipids in the coconut sprouts when compared to coconut meat. Promising amylase activity was revealed by coconut sprouts as these had the potency to decrease the concentration of starch substrate. Prominent zone of inhibitions in the antibacterial assay was recorded in the samples assayed. In vitro, antioxidant assays and anti-lipoxygenase activity signified the enriched bioactive potential of the coconut sprouts. GC-MS analysis had revealed variations in the presence of primary and secondary metabolites. Coconut sprouts extracts were found to be cytotoxic to the infected cells. Conclusion: Coconut sprouts can be recommended as an economically potent natural product for the commercial production of nutraceuticals in the food industry further to be used as a nutrient supplement in the prevention and management of peptic ulcers with a cost-effective approach.
EnglishCoconut sprouts, Coconut meat, Phytoconstituents, Phytochemical characterization, Cell line, Nutraceuticals
INTRODUCTION
Coconut (Cocos nucifera L.) belonging to Arecaceae is well known for all its utilities. India is the 3rd largest coconut producer where, Tamil Nadu, Kerala, Andhra Pradesh and Karnataka is said to produce 90 per cent of the coconut production. Coconut products are used in daily life by different classes of people. These are some of the prominent sources for the development of medicines and industrial products. Coconut and its products are used as folk medicine and therefore, the coconut palm in Indian classics is known as ‘Kalpavriksha’.1
After the germination of the coconut, the embryo (basal part) usually enlarges and produce sprout/haustorium and its cardioprotective effect was evaluated.2 Coconut sprouts wine was produced using Saccharomyces cerevisiae which was found to be enriched with antioxidant activity.3Primary and secondary phytoconstituents derived from natural products have gained attention for the prevention and management of several diseases. The presence of squalene, a potent triterpenoid with anti-ulcer activity in the sprouts of Cocos nucifera L. was confirmed through in silico molecular docking.4
Peptic ulcer occurs in the entire gastrointestinal tract. Gastric ulcers are produced when there is an imbalance between toxic and cytoprotective factors. Toxic endogenous factors include leukotrienes, pepsin, refluxed bile, hydrochloric acid and reactive oxygen species. Toxic exogenous factors include Helicobacter pylori, ulcer-causing gram-negative bacterial strains, steroidal as well as non-steroidal anti-inflammatory drugs (NSAIDs), alcohol which initiates the secretion of gastric acid and pepsin.5 Cytoprotective factors include prostaglandins, surface-active phospholipids, cell renewal followed by its migration, mucosal blood flow, enzymatic and non-enzymatic antioxidants and mucus-bicarbonate barrier. In recent years, the peptic ulcer has become a major challenge affecting many people. Recent advancements in gastric ulcer therapy aim to suppress the production of gastric acid through the use of antacids, H2-receptor inhibitors/blockers which include famotidine, ranitidine and several anticholinergics especially telezipine and pirenzepine or sometimes proton-pump inhibitors/blockers such as lansoprazole and omeprazole. However, the major drawback in these advances in modern medicine is the major side effects with limited bioefficacy caused by these drugs.6 Thus, in the present scenario, there is a need for prevention and management of peptic ulcers especially gastric ulcers using plant-derived natural products.
Coconut sprouts is a great boon to the food and pharmaceutical industries for the development of nutrient supplements and novel drugs for managing peptic ulcer. Since not much work has been carried out in Cocos nucifera L. sprouts, the objective and purpose of the present study are to compare the phytoconstituents and the bioefficacy of the coconut meat and its sprouts using various bioassays leading to novel drug development recommending for the development of nutraceuticals.
MATERIALS AND METHODS
Sample collection
Mature coconut (Cocos nucifera L.) and its sprouts (haustorium) were procured from Thirunelveli District, Tamil Nadu, India and were processed by shade dry method.7 (Figure 1).
Toxicity analysis
Dried powdered samples were analyzed for the presence of toxic heavy metals such as arsenic, cadmium, cobalt, chromium, mercury, nickel and lead using Inductively Coupled Plasma Optical Emission Spectrometry.8
Shelf-life study
Dried powder of the samples collected during the initial period of the study, after 3rd month and 6th month were screened for microbial content using serial dilution technique. Dilutions of 10-6, 10-7, 10-8 and 10-9 for total bacterial count and dilutions of 10-2, 10-3, 10-4 and 10-5 for total fungal count were used to test the microbial quality.9
Extraction and Quantificationstudies
Dried powdered samples were extracted with butanol, acetone, chloroform, methanol, aqueous w/v (1:10) using the cold percolation method.7Based on qualitative phytochemical studies4, methanol and aqueous extracts were taken for the present study. For the documentation of results, sample extracts were abbreviated as, coconut meat extracted with methanol (CCM), aqueous (CCAq); coconut sprouts extracted with methanol (CSM), aqueous (CSAq). Lipids10, flavonoids11 and vitamin- C12 were quantified and amylase activity was assayed.13
Antibacterial assay
Sample extracts of 20, 40, 60and 80 µg mL-1 were assayed against Bacillus subtilis, Staphylococcus epidermidis, Escherichia coli and Pseudomonas aeruginosa using agar well diffusion method.4
In vitro bioassays
In vitro antioxidant assays [assessment of metal chelating activity,14 2,2’-Azino-bis(3-ethylbenzthiazoline-6-sulphonic acid) ABTS+ assay]15 and assessment of anti-lipoxygenase activity16 (anti-inflammatory assay) was conducted.
Gas Chromatography-Mass Spectrometry (GC-MS) analysis
GC-MS analysis17 of methanol extracts of the samples were conducted at Sophisticated Analytical Instrument Facility (SAIF), IIT Madras, Chennai, Tamil Nadu, India.
3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT) assay
Human gastric adenocarcinoma (AGS) epithelial cell line with mucus-secreting epithelial cells was obtained from National Centre for Cell Science (NCCS), Pune, India. Indomethacin, an NSAID was used as a gastric ulcer-causing agent. Cimetidine, an anti-ulcer drug was used as standard. MTT assay using sample extracts were performed.7
Statistical analysis
For each experiment, the data presented are the means of three replicates. Values are expressed as mean ± SE.
RESULTS
Toxicity analysis
Heavy metals (As, Cd, Co, Cr, Hg, Ni, Pb) were found to be below the detectable limit (BDL) in the samples.
Shelf-life study
The study revealed nil growth of pathogenic bacteria and fungi at different dilutions used thereby indicating that the dried powdered samples (initial period of the study, after 3rd and 6th month) were found to be sterile and free from the microbial load with good shelf-life extending up to 180 days (Figure 2).
Quantificationstudies and determination of amylase activity
Total flavonoid content was reported as Quercetin equivalent, standard curve (0.0097x + 0.1349; R2 = 0.9981). Methanol and aqueous coconut sprouts extracts had maximum flavonoids (83.89 ± 0.07 and 82.37 ± 0.19 mg of QE g-1) whereas coconut meat extracts had 62.25 ± 0.20 and 61.38 ± 0.23 mg of QE g-1 of flavonoids. Vitamin- C was calculated from ascorbic acid standard curve (0.0096x + 0.0427; R2 = 0.9986). Methanol and aqueous coconut sprouts extracts had maximum vitamin- C (0.74 ± 0.02and 0.73 ± 0.02 mg g-1) whereas, coconut meat extracts had 0.38 ± 0.03 and 0.37 ± 0.02 mg g-1 of vitamin- C. Total lipids were calculated from cholesterol standard curve (0.0098x + 0.041; R2 = 0.9966). Methanol and aqueous coconut sprouts extracts had reduced levels of lipids (0.21 ± 0.02 and 0.25 ± 0.02 mg g-1) whereas, coconut meat extracts had 0.71 ± 0.04 and 0.78 ± 0.03 mg g-1 of total lipids (Figure 3).
Amylase activity monitored over 60 minutes period at 15 minutes interval, indicated that the concentration of substrate decreased with the time reducing from 18.2 ± 0.21 to 2.4 ± 0.12 µg mL-1 and 19.1 ± 0.22 to 2.8 ± 0.11 µg mL-1 in methanol and aqueous coconut sprout extracts when compared to the coconut meat extracts (20.3 ± 0.22 to 3.1 ± 0.13 µg mL-1 and 21.7 ± 0.23 to 4.3 ± 0.15 µg mL-1 in 60 minutes). It was observed that there were no marked variations between the extracts whereas remarkable variations were found between the coconut meat and its sprouts indicating that the sprouts are rich in phytoconstituents.
Antibacterial assay
Methanol and aqueous coconut sprouts extracts indicated a maximum zone of inhibitions of 35.66 ± 0.27 mm and 35.37 ± 0.29 mm at 80 µg mL-1 against Staphylococcus epidermidis and maximum zone of inhibitions of 34.89 ± 0.27 mm and 34.78 ± 0.25 mm at 80 µg mL-1 against Pseudomonas aeruginosa. Coconut meat extracts indicated a zone of inhibitions (28.59 ± 0.28 mm and 27.93 ± 0.23 mm) against Staphylococcus epidermidis. Remarkable variations were observed among the sample extracts (Figure 4).
In vitro bioassays
The antioxidant and anti-inflammatory potential of the sample extracts were determined based on the IC50. 100 µg mL-1 showed maximum bioactivities. In metal chelating activity, methanol and aqueous coconut sprouts extracts showed maximum per cent inhibition (85.22 ± 0.26 and 84.75 ± 0.28) with IC50 values, 33.01 and 35.13 µg mL-1. Methanol and aqueous coconut meat extracts revealed per cent inhibition of 54.57 ± 0.29 and 53.27 ± 0.27 with IC50 values, 87.72 and 90.35 µg mL-1. Na2EDTAindicated 86.24 ± 0.26 per cent inhibition with IC50 value, 31.0 µg mL-1. ABTS+ assay revealed that methanol and aqueous coconut sprouts extracts showed maximum per cent inhibition (88.39 ± 0.27 and 87.32 ± 0.27) with IC50 values, 31.29 and 32.96 µg mL-1. Methanol and aqueous coconut meat extracts revealed per cent inhibition of 52.66 ± 0.27 and 51.54 ± 0.29 with IC50 values, 96.67 and 99.88 µg mL-1. Ascorbic acid indicated 90.34 ± 0.26 per cent inhibition with IC50 value, 28.68 µg mL-1.
Concerning anti-inflammatory assay, methanol and aqueous coconut sprouts extracts showed maximum per cent inhibition (92.27 ± 0.25 and 91.78 ± 0.24) with IC50 values, 26.66 and 27.90 µg mL-1. Methanol and aqueous coconut meat extracts revealed per cent inhibition of 62.97 ± 0.23 and 61.88 ± 0.21 with IC50 values, 68.69 and 71.07 µg mL-1. Indomethacin indicated 94.46 ± 0.27 per cent inhibition with IC50 value, 21.85 µg mL-1. There were marked variations between the coconut meat and its sprouts, in which the sprout extracts had maximum antioxidant and anti-inflammatory activity on par with standard (Figure 5).
Gas Chromatography-Mass Spectrometry (GC-MS) analysis
Various peaks were observed in coconut sprouts extract representing the volatile compounds of the phytoconstituents such as flavonoids, terpenoids, phenols, proteins, amino acids, carbohydrates, vitamins, essential fatty acid esters when compared to the coconut meat which had phenols, alkaloids, fatty acid esters (Figure 6). 3',4',5,7-Tetrahydroxyflavone was found to be abundantly present in coconut sprouts with a peak area per cent of 88.2 (Table 1 & Table 2).
MTT assay
Methanol and aqueous coconut sprouts extracts (100 µg mL-1) showed maximum percent inhibition of infected AGS cells (93.92 ± 0.23 and 92.12 ± 0.27) with IC50 values, 20.23 and 22.11 µg mL-1. Methanol and aqueous coconut meat extracts revealed a percent inhibition of 67.11 ± 0.25 and 66.12 ± 0.26 with IC50 values, 67.66 and 68.98 µg mL-1. Cimetidine (100 µg mL-1) indicated 94.85 ± 0.29 percent inhibition with IC50 value, 18.83 µg mL-1. Methanol and aqueous extracts of the coconut sprouts were found to be cytotoxic to the infected AGS cells with gastric ulcers in a dose-dependent manner when compared to the coconut meat extracts (Figure 7). An increase in the concentration of sample extracts has increased the cytotoxic activity of the samples. There was a remarkable variation between the samples in which coconut sprouts extracts had maximum anti-ulcer activity on par with the standard.
DISCUSSION
Bioprospecting of natural plant-derived food products leads to the study of phytoconstituents and the identification of novel compounds with pharmaceutical properties.
Plant and plant-derived food products may be contaminated with toxic heavy metals or other residues resulting in health issues. Lead, cadmium, mercury, chromium in the food products cause gastric ulcer/cancer through the disruption of the gastric mucosa. These heavy metals along with arsenic were reported to be exogenous sources of ROS resulting in gastric mucosal tissue damage, epithelial, endothelial inflammation, where, cadmium affect E-cadherin function. Cobalt induces DNA damage, nickel modify the activity of catalase through ROS generation causing gastric ulcer/cancer.18 Hence, it is essential to analyze the toxicity of the samples. ICP-OES analysis was applied to metal concentrations in the samples. Present findings are clear evidence that the samples were found to be non-toxic and can be recommended for consumption as a natural edible product for the prevention and management of several diseases.
During germination, moisture content, nutrients released and the warm appropriate temperature are favourable for the growth of pathogens. Analyzing the microbiological quality of the samples signifies the importance of the study. The present study proves that the dried powdered samples were found to be pure and free from the microbial load with shelf-life extending up to 180 days. This reveals that the samples were found to be from a clean environment which can be best used for the preparation of nutraceuticals.
Flavonoids are potent bioactive compounds with a polyphenolic structure occurring in various natural edible plant-derived food products with health-promoting benefits having nutraceutical and pharmaceutical applications. These tend to possess biochemical, antioxidant, anti-inflammatory, anticancer activities due to which the use of flavonoids in the commercial production of nutraceutical and pharmaceutical drugs are in increasing demand. Several reports have indicated that flavonoids possess gastroprotective, cytoprotective and anti-secretory activities.19 Ascorbic acid or vitamin- C, a water-soluble vitamin is responsible for reducing the bleeding in gastric ulcers, in addition to the reduction of the NSAIDs related gastric mucosal destructions or damage and Helicobacter pylori suppression. Lipids include fats, phospholipids, sterols and glycolipids which are almost found in all living cells. Glycolipids are found in edible parts of the plant. Increased lipid content may lead to gastric ulcers and carcinomas. The present finding is scientifically validated that the coconut sprouts are enriched bioactive compounds and reduced level of lipids than the coconut meat. Thus, coconut sprouts are an alternative source of coconut meat with high cholesterol. It has solved the issue as a natural edible product found to be enriched with potent phytoconstituents used in the prevention and management of ulcers and other diseases with no side effects. Elevated levels of amylase can cause acute gastritis. Amylase activity in the coconut sprouts was found to be at a permissible level and it helps in the breakdown of complex substances. Hence, it is considered safe for different age groups of people to consume coconut sprouts.
Developing resistance-breaking natural antimicrobial agents are the need of the hour in the present scenario. Current findings prove that when compared to coconut meat, the coconut sprouts with a prominent shelf-life period, enriched flavonoids, and ascorbic acid act as a natural antibacterial agent. Bioactive flavonoids act against pathogenic bacteria by inhibiting the synthesis of nucleic acids, functions of the cytoplasmic membrane, and energy metabolism resulting in potent antibacterial activity.20
In the metal chelating assay, ferrozine chelate with Fe2+ and form a complex. ROS induce gastric mucosal damage.21 Antioxidants in the sample extracts form a coordinate complex with metal ions, inhibit electron transfer and no free radicals are produced. Suppression of ABTS+ ions is essential to reduce the release of free radicals resulting in healthy tissue damage. Flavonoids and essential phytoconstituents in the coconut sprouts might be responsible for this antioxidant activity. The present study has proved that when compared to coconut meat extracts, the coconut sprouts had maximum antioxidant activity with minimal IC50 value.
The inflammatory process involves the activity of inflammatory mediators (ROS, nitric oxide, neutrophil-derived free radicals, cytokines and prostaglandins). Increased levels of these mediators lead to injury of the tissues by damaging the macromolecules, lipid peroxidation of the membrane. Lipoxygenases contain non-heme iron dioxygenases mostly involved in leukotrienes synthesis which are essential for inflammation and hence these are the most promising inflammatory target.22 Present findings have proved that the anti-lipoxygenase activity was found to be in maximum in the coconut sprouts than the coconut meat which indicated that the sprouts are natural bioactive anti-inflammatory agents enriched with essential flavonoids.
In GC-MS analysis, coconut sprouts have maximum flavonoids constituting flavanones, flavonols, flavones, anthocyanidins and isoflavones indicating a promising role in preventing/healing peptic ulcers leading to a cytoprotective shield in the gastrointestinal region. It can be an alternative for the reduction of peptic ulcers associated with Helicobacter pylori infection/NSAIDs7 thereby contributing to therapeutic biological effects.
Human gastric adenocarcinoma (AGS) cell line with mucus-secreting epithelial cells used as an in vitro model is an appropriate cell line related to peptic ulcers/gastric cancers. Indomethacin (NSAID) is considered an instant gastric ulcer-causing agent which inhibits the synthesis of prostaglandins and thereby causes gastric ulcers. Prostaglandins are protective factors that prevent mucosal damage. Cimetidine, a modern commercial anti-ulcer drug heals gastric ulcers. Decreasing absorbance in the cells treated with the methanol and aqueous extracts of the coconut sprouts suggests cytotoxicity to AGS infected cells with gastric ulcers. MTT assay proved that the coconut sprouts were found to be cytotoxic to the infected AGS cell line with a gastric ulcer in a dose-dependent manner. The minimum IC50 value of the coconut sprouts extracts has indicated that the sprouts are possessing promising bioactive potential due to enriched phytoconstituents which are involved in various metabolic pathways leading to the inhibition of ulcers.
Significant findings and novelty of the present study include (i) First report of bioprospecting study of sprouts of Cocos nucifera L. (haustorium) revealing potent anti-ulcer activity through in vitro analysis using AGS cell line; (ii) Presence of flavonoids proves that coconut sprouts can be recommended as a natural edible product; (iii) Commercial production of nutraceuticals for the prevention and management of peptic ulcers; (iv) Presence of specific secondary metabolites in coconut sprouts are found to be advantageous over coconut meat; (v) Hesitation in consumption of coconut meat due to its rich cholesterol and lipid content finds the consumption of coconut sprouts with less cholesterol as an alternative source.
CONCLUSION
A bioprospecting study revealed that coconut sprouts are enriched with maximum flavonoids, vitamin- C and permissible amylase activity with minimum lipids when compared to coconut meat. Cocos nucifera L. sprouts possess promising antibacterial, antioxidant and anti-inflammatory activities. GC-MS and MTT assay indicated the presence of essential bioactive compounds responsible for the cytotoxic activity of the sprouts against the AGS cell line with gastric ulcer. Thus, coconut sprouts can be recommended as an economically potent natural product for the commercial production of nutraceuticals in the food industry. Further, it can be used as a nutrient supplement in the prevention and management of gastric ulcers with a cost-effective approach as well can be recommended to the pharmaceutical industries for novel drug development and drug discovery.
CONFLICTS OF INTERESTS
None.
SOURCE OF FUNDING
Our sincere thanks to the Directorate of Collegiate Education, Department of Higher Education, Government of Tamil Nadu, India for the PhD. Merit Scholarship and Ethiraj Centre for Research, Innovation & Creativity (ECRIC), Ethiraj College for Women (Autonomous), Chennai for the PhD. Research fellowship.
ACKNOWLEDGEMENT
The authors thank Principal & Secretary, Ethiraj College for Women (Autonomous), ECRIC, Head, Former and Present, Faculty members, supporting staff of the Department of Plant Biology and Plant Biotechnology, Ethiraj College for Women, Chennai for their valuable support, encouragement throughout the entire period of research. We would also like to express our sincere thanks for the facilities extended by the Central Instrumentation Centre of Ethiraj College for Women and Sophisticated Analytical Instrument Facility (SAIF), IIT Madras, Chennai, Tamil Nadu, India.
AUTHOR’S CONTRIBUTION
S. Abiraami Valli performed the experiments, drafted the manuscript, analysed and interpreted the data.
Dr. S. Uma Gowrie, proposed the concept, designed the experiments, supervised, analysed, interpreted the data, technically supported, critically revised and finally approved the manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=4226http://ijcrr.com/article_html.php?did=4226
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Assessing the Risk Factors of Malnutrition in Uttar Pradesh
English4349Mishra SEnglish Dubey AEnglish Srivastava MEnglish Singh REnglishEnglishChi-square test, Logistic regression, NFHS, Stunting, Underweight, Wasting
INTRODUCTION:-Malnutrition, according to the World Health Organization (WHO), refers to deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients. Malnutrition among under-five children is a topic of major concern for the health authorities in India. According to a study, low birth weight is the major factor among all indicators of malnutrition. The World Bank reported India as one of the highest-ranking countries in the world is malnutrition. The prevalence of underweight children in India is nearly double that of Sub-Saharan Africa which have a serious effect on mobility, mortality, productivity and economic growth. 1 According to the 2019 Global Hunger Index (GHI) report, out of 117 countries India ranked 102th with a serious issue of child wasting. Nearly 20% of children under five years of age in India are wasted.
Uttar Pradesh, with a population of nearly 200 million, is the most populous state of India. According to census 2011, Uttar Pradesh is contributing 16.50% of India’s total population. So our state’s poor performance in health indicators can affect our country a lot. That’s why it is a cause of concern for the country. According to the NitiAayog Health indicator report of 2019, the overall score of Uttar Pradesh in health declined from 33.69 in 2015-16 to 28.61 in 2017-18. 2 One of the important causes of this decline is low birth weight. The lack of the right amount of nutritional intake leads to various forms of malnutrition. Studies show that Uttar Pradesh is one of the highest malnutrition states in the country. There is no improvement in the nutritional status of children in Uttar Pradesh over the years. Though the percentage of stunted declined over the year in U.P. however it is higher than the national average.
Mother's nutritional status, lactation behaviour, women's education, and sanitation are some factors responsible for malnutrition in the country. Here we will analyze our data using three indicators of malnutrition, termed stunting, wasting and overweight. According to a study done by Dessie et al. (2019) in Ethiopia, it was found that maternal education, nutritional status, anaemia, place of delivery, and preceding birth interval were associated with malnutrition among children of age 6-59 months.3 The studies of Rao and Rao (1994) also showed that there is some association of malnutrition with socio-economic factors, nutritional intake, mother’s education, climate, and religion.4 The study of Hong et al. (2006) on children of Bangladesh showed that household wealth inequality has a strong association with childhood adverse growth rate stunting.5 In their study Saha et al. (2008) showed that the current infant feeding practices have a positive effect on the growth of infants and young children.6 In this paper, we will analyze the nutritional status of under 5 age children in Uttar Pradesh through height-for-age, weight for age and weight for height.
AIM: - The present paper aims to assess the risk factors associated with malnutrition among under five-year children in Uttar Pradesh.
OBJECTIVE:-The objectives of the study are:
(1) To assess the category-wise prevalence of stunting, wasting and underweight in children of 0-5years of age in Uttar Pradesh,
(2) To analyze the associations of socio-economic and demographic factors at the individual and household level with child malnutrition.
LITERATURE REVIEW: -One of the most important public health problems in India is malnutrition in children. Malnutrition harms future human performance. A recent study estimated that about 53% of all deaths in young children are attributable to being underweight.7According to a study on the nutritional status of school-age children, the risk of malnutrition was significantly higher among children living in joint families, children whose mother's education was (less than or equal to) 6th standard and children with working mothers.8In their study Best C. et al. found that underweight and thinness was most prevalent in populations from South-East Asia and Africa, whereas in Latin America, it was generally below 10%.9The anthropometric results of a study in QwaQwa also indicated that 2.8% of the total group of respondents was severely stunted and that 11.3% were stunted.10 In South Africa, stunting and underweight remain a public health problem in children, with a prevalence of 20% stunting and almost 10% underweight. 11 Inthe Dietary Diversity and Nutritional Status of Adolescent Girls in Selected Urban Slum of Dhaka City, A study was conducted to assess the relationship between nutritional status and individual dietary diversity. It was found that about 80% had normal weight, 3.3% of the girls were severely thin, 10% of the girls were moderately thin, and 6.7% were overweight. Again 10% of the girls were found severely stunted and 24% of girls were found to be mild to moderately stunt. The nutritional status and individual dietary diversity of the adolescent girls were positively related. 12
METHODOLOGY:-
DATA SOURCE:-
This analysis is based on the data from the National Family Health Survey (NFHS-4, 2015-16) which is fourth in the series of NFHS. International Institute for Population Sciences (IIPS), Mumbai conducts this survey in collaboration with many other organizations as ORC Macro, Calverton, Maryland, USA and the East-West Center, Honolulu, Hawaii, USA. The International Institute for Population Sciences (IIPS) acts as the nodal agency for this project by the Ministry of Health and Family Welfare, Govt. of India New Delhi which provides coordination and technical guidance for NFHS.
The NFHS-4 sample is a stratified two-stage sample. Four rounds of NFHS has been done till now NFHS-1 for 1992-93, NFHS-2 for 1998-99, NFHS-3 for 2005-06 and NFHS-4 for 2015-16. Unlike NFHS-3, NFHS-4 provided data on Human Immunodeficiency Virus (HIV) prevalence for all 29 states and union territories including 640 districts. NFHS-4 also collected data from a slum population of 8 big cities, namely Delhi, Chennai, Hyderabad, Mumbai, Kolkata, Indore, and Meerut. The NFHS-4 sample covered 699,686 women aged 15-49 and 112,122 menage 15-54 residing in all the states and union territory. The survey collected data on men and women’s background characteristics e.g., age, literacy, schooling, religion, caste/tribe, etc. the Information on nutritional status, maternal factors of fertility, marriage, family planning, and women’s empowerment, HIV or Acquired Immune Deficiency Syndrome (AIDS) etc. is also provided by NFHS-4.
Mothers having at least one child of fewer than 5 years of age were taken as units for our study. The survey collected data on the height and weight of children of less than 60 months. The socio-economic and demographic factors influencing child malnutrition which we have taken in our study are Age group: "=1" years; Place of residence: Rural, and urban; Religion: Hindu, Muslims, and others; Caste: SC, ST, and others; Sex: male and female; Breastfeeding: more than 6 months and up to 6 months; Preceding birth interval: "=24 months"; Mother's education level: >=primary, secondary and higher; Wealth index: low, medium, high; Working status: Currently working, and not currently working; Place of residence: Rural, and urban; Religion: Hindu, Muslims, Christian and others; and Caste: SC/ST, OBC and others.
METHOD: The present study focuses on the effect of all socio-economic and demographic factors on child stunting, wasting and underweight. In this study, the nutritional status of the children is analyzed using three indicators of malnutrition: stunting, wasting and underweight. Stunting is measured by height-for-age z-scores (HAZ), wasting is measured by weight-for-height Z-score (WHZ) and underweight is measured by weight-for-age Z-score (WAZ). According to WHO criterion based on standard deviation(SD) units, a child is termed as ‘severely stunted’ if the children’s height for age Z-score below–3, ‘moderately stunted’ if the child has Z-scores greater than or equal to –3 and less than –2. ‘Well nourished’ children are those whose height for age Z-scores are greater than or equal to –2. A child is said to be severely wasted if the children’s weight for height Z-score is below –3SD, moderately wasted if the child weights height Z-scores greater than or equal to –3 and less than –2. Otherwise, he/she will be termed as normal. Similarly, a child is termed as underweight if he/she weights age z-score below -2 SD, overweight if the weight for height Z score is above +2SD. Otherwise, he/she will be termed as normal.
In the second step of the analysis, the logistic regression technique is used to estimate the odds of being malnourished of the groups that have a higher or lower risk of malnutrition in the study population. An odds ratio (OR) measures the strength of the association between two events. The odds ratio represents the ratio of the odds of an outcome in the presence of a particular exposure and the odds of that outcome in the absence of that exposure. In the logistic regression table, the exponential function of the regression coefficient (EXPB) is the odds ratio associated with a one-unit increase in exposure. To create the dependent variable, children whose z-scores are below–2 are coded 1 and those with z-scores of –2 or higher are coded 0. The predictor (independent) variables are entered into the regression equation, thus the results obtained are compared with the reference category. In this paper statistical software package SPSS (20 version) is used for the statistical analysis. P< 0.05 is considered statistically significant.
RESULT: - In NFHS-4, 41751 children (from Uttar Pradesh) under the age of 5 years were surveyed out of which 5286 were missing cases. In our study, 78.1% of the cases belonged to the rural area and 21.9% belonged to the urban area. The percentage of males was 52.5% and females were 47.5%. 57% of the mothers had ≤primary education and 10.2% of the mothers had higher education. The percentage of children who belong to poor families was 55.3%. 78.1% of the children belong to the Hindu religion.
Table 1 displays the age-wise distribution of stunted, wasted and underweight children. The overall percentages of stunting, wasting and underweight children in Uttar Pradesh were 45.9%, 17.8%, and 38.9% respectively which means the prevalence of stunting in children was higher than wasting and underweight. An increasing trend in the percentage of stunted children in Uttar Pradesh was observed up to the age of 24 months and thereafter it decreased. The same trend was found in the case of underweight children up to the age of 24 months after that it oscillates. The percentage of wasted children showed a decreasing trend throughout the ages. Prevalence of stunting and underweight was found to be the highest in the age group 18-24 months (56.1% and 42.7% respectively) whereas the maximum prevalence of wasting was found in the age group 0-3 months (31.1%).
Differentials of malnutrition among 0-5 year children in Uttar Pradesh had been observed by taking child, mother and household level factors. Here we had seen the relationship of these factors with height for age, weight for height and weight for age. Table 2 shows the percentage distribution of 36465 children of less than 60 months by selected child, mother, and household-level characteristics. Table 2 clearly shows that there was no difference between females and males in terms of percentage of stunted and underweight but wasting was higher for males (19%).
Percentage of stunted, wasted and underweight children in Uttar Pradesh among illiterate or primary level educated mothers were 53.4%, 18.1% and 44.8% respectively which dropped rapidly to 24%, 16.9% and 22.2% among higher-educated mothers. Children living in rural areas had a higher prevalence of stunting (47.9%), wasting (17.9%) and underweight (40.4%) as compared to children of the urban area. Similarly, the children having a low wealth index had a percentage of 54.2% stunted, 18.6% wasted and 45.5% underweight which falls to 31.1%, 16.3% and 27.6% respectively among children having a higher wealth index. Schedule caste and schedule tribe had higher stunting (51.8%), wasting (19.2%) and underweight (44.1%) percentages. The prevalence of stunting and underweight were highest in Muslims which is 46.8% and 39.1% respectively whereas wasting was highest in Hindu (18%). This clearly shows that the percentage of stunted, wasted and underweight children decreases with an increase in levels of mother's education, household condition index and changing the place of residence.
Table 3 shows the results of the logistic regression of stunting, wasting and overweight respectively on the socio-economic and demographic characteristics of the children aged less than 60 months in Uttar Pradesh. The table gives standard errors, odds ratio and the level of significance along with the coefficients. It shows that among all individuals and household level factors, the age of children, preceding birth interval, mother’s education level, and household condition index are the most important factors affecting malnutrition.
It was found that there was a significantly higher risk of stunting and underweight among children with the increasing age, children with preceding birth interval Englishhttp://ijcrr.com/abstract.php?article_id=4227http://ijcrr.com/article_html.php?did=4227
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5. Hong R, Banta JE, Betancourt JA. Relationship between household wealth inequality and chronic childhood under-nutrition in Bangladesh. Int J Equity Health [Internet]. 2006;5(1):15. Available from: https://doi.org/10.1186/1475-9276-5-15
6. Saha KK, Frongillo EA, Alam DS, Arifeen SE, Persson LA, Rasmussen KM. Appropriate infant feeding practices result in better growth of infants and young children in rural Bangladesh. Am J Clin Nutr [Internet]. 2008 Jun;87(6):1852–9. Available from: https://pubmed.ncbi.nlm.nih.gov/18541577
7. Bharati S, Pal M, Bharati P. Determinants of Nutritional Status of Pre-School Children in India. J Biosoc Sci [Internet]. 2008/11/01. 2008;40(6):801–14. Available from: https://www.cambridge.org/core/article/determinants-of-nutritional-status-of-preschool-children-in-india/DA0E8F55A5A4F0DC103044C3EB7AA57F
8. Srivastava A, Mahmood SE, Srivastava PM, Shrotriya VP, Kumar B. Nutritional status of school-age children - A scenario of urban slums in India. Arch Public Heal [Internet]. 2012;70(1):8. Available from: https://doi.org/10.1186/0778-7367-70-8
9. Best C, Neufingerl N, van Geel L, van den Briel T, Osendarp S. The Nutritional Status of School-Aged Children: Why Should We Care? Food Nutr Bull [Internet]. 2010 Sep 1;31(3):400–17. Available from: https://doi.org/10.1177/156482651003100303
10. Oldewage-Theron W, Egal A. Nutrition knowledge and nutritional status of primary school children in QwaQwa. South African J Clin Nutr [Internet]. 2010 Jan 1;23(3):149–54. Available from: https://doi.org/10.1080/16070658.2010.11734329
11. Labadarios D, Swart E, Maunder E. Executive summary of the National Food Consumption Survey Fortification Baseline (NFCS-FB-I) South Africa, 2005. South African J Clin Nutr. 2008 Jan 1;21:245–300.
12.Alam S, Rahman N, Mia A, Islam K, Rahman MN. Dietary Diversity and Nutritional Status of Adolescent Girls in Selected Urban Slum of Dhaka City in Bangladesh. 2018.
13. Kaur H, Biswas M, Malik P. Assessment of Nutritional Status of Under-5 Children Using WHO Growth Standards. Int J Sci Res. 2018 Jul 1;7:30.
14. Chuc D Van, Hung NX, Trang VT, Linh DV, Khue PM. Nutritional Status of Children Aged 12 to 36 Months in a Rural District of Hungyen Province, Vietnam. Tran BX, editor. Biomed Res Int [Internet]. 2019;2019:6293184. Available from: https://doi.org/10.1155/2019/6293184
15. Martorell R, Young MF. Patterns of stunting and wasting: potential explanatory factors. Adv Nutr [Internet]. 2012 Mar 1;3(2):227–33. Available from: https://pubmed.ncbi.nlm.nih.gov/22516733
16. Conde-Agudelo A, Belizán JM, Breman R, Brockman SC, Rosas-Bermudez A. Effect of the interpregnancy interval after an abortion on maternal and perinatal health in Latin America. Int J Gynecol Obstet [Internet]. 2005 Apr 1;89(S1): S34–40. Available from: https://doi.org/10.1016/j.ijgo.2004.08.003
17. Gribble JN, Murray NJ, Menotti EP. Reconsidering childhood undernutrition: can birth spacing make a difference? An analysis of the 2002–2003 El Salvador National Family Health Survey. Matern Child Nutr [Internet]. 2009 Jan 1;5(1):49–63. Available from: https://doi.org/10.1111/j.1740-8709.2008.00158.x
18. Som S, Pal M, Bharati P. Role of individual and household level factors on stunting: A comparative study in three Indian states. Ann Hum Biol [Internet]. 2007 Jan 1;34(6):632–46. Available from: https://doi.org/10.1080/03014460701671772
19. Dubey P, Tiwari N, Jha R. Regional Disparity in Nutritional Status in India: An Examination. 2018 Jun 1;8.
20. Abuya BA, Ciera J, Kimani-Murage E. Effect of mother’s education on child’s nutritional status in the slums of Nairobi. BMC Pediatr [Internet]. 2012;12(1):80. Available from: https://doi.org/10.1186/1471-2431-12-80
21. Kasaye HK, Bobo FT, Yilma MT, Woldie M. Poor nutrition for under-five children from poor households in Ethiopia: Evidence from 2016 Demographic and Health Survey. PLoS One [Internet]. 2019 Dec 20;14(12):e0225996. Available from: https://doi.org/10.1371/journal.pone.0225996
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Perceived Stress and Sleep Quality of First Year Medical Students
English5054Jena SKEnglish Panigrahi AKEnglish Pattnaik MEnglish
Background: In the past few decades stress has been considered a major problem in medical students’ life. Sleep abnormality is associated with cognitive function abnormalities. Stress is one of the prevalent factors which worsen sleep quality. Aim: This study aimed to estimate the sleep quality of first-year medical students owing to perceived stress. Method: This study was conducted after due approval from the institutional ethics committee. It was a cross-sectional study that included 144 subjects including 87 male and 57 female. Stress was assessed by perceived stress scale (PSS) and sleep quality was assessed by indicators designed by National Sleep Foundation (NSF). A P-value less than 0.05 was considered to be significant. Result: 70.8% of subjects perceived moderate stress, 19.2% of subjects perceived low stress and 16% of subjects perceived high stress. On analysis, we found that some subjects sleep quality was inappropriate and most of them perceived severe stress. Conclusion: Poor sleep quality was associated with severe stress in first-year medical students. This may affect the cognitive function that affects the carrier building.
EnglishPerceived stress, Sleep quality, Medical students, Cognitive dysfunction
INTRODUCTION
Stress has been one of the most prevalent and important issues for medical students around the world for the past few decades. In very simple language it is the reaction of body and mind to challenges and threats.1For any particular stressor, a person can experience either eustress (favourable stress) or distress (unfavourable stress). Various studies have reported that eustress has good effects on physiological functioning and facilitates the learning process, whereas distress has negative effects on physical and mental health. A higher level of stress for a prolonged period always has a detrimental effect on the body and mind.1 In a medical college contributing factors to the stressful environment are curriculum load, peer pressure, environmental factors and various types of examinations.2,3The substantial negative effects of psychological stress contribute to poor performance of students in the classroom and clinical practices, the deficit in cognitive functions, illness, psychological disorders like anxiety, depression, and sleep disorders.4, 5, 6 High-grade stress in students is also associated with poor health behaviours like eating unhealthy food, minimal exercise practices and inadequate sleep. Therefore in a single sentence, it can be explained, stress is responsible for poor physical, mental, behavioural health and academic performance.5 Sleep plays a vital role in the enhancement of working memory capacity and consolidation of memory.7In a meta-analysis the researchers proposed their view that acute sleep deprivation is responsible for deficit in most cognitive domains like attention, working memory, and short-term memory.8Insomnia is a sleep disorder reported by college students who experience psychological deficits.9 Delayed circadian rhythm is also a factor for poor sleep quality, especially during examination periods and both have been found to hurt academic performance.10,11 Stress is also another prevalent factor among medical students that worsens sleep quality.12 Considering the factors cited this study was proposed to estimate the sleep quality of the first year medical students owing to perceived stress.
MATERIAL AND METHOD
This cross-sectional study was conducted in the Department of Physiology in a health institute in the eastern part of India between September 2019 and February 2020. The study was approved by the institutional ethics committee vide letter no 20006/Dt. 25.09.2000/IFO-9/20. Total 144 first-year MBBS students were included as study subjects among which 87 were male and 57 were female. Students were explained about the study protocol and its output. Healthy students were selected as subjects for this study. Students with a history of any disease, alcoholics were excluded from the study. For the selection of subjects 158 students were screened and finally, 149 subjects were selected. During the collection of data 5 subjects provided incomplete data for which they were excluded from the study. So finally 144 subjects were selected for data analysis.
A study tool in form of a questionnaire was designed and it was distributed among the students. Students were instructed properly to fill up the form honest and should not provide any wrong information. The questionnaire included sections A, B and C. Section A included demographic data, section B included the Perceived Stress Scale (PSS) questionnaire and section C included indicators of sleep quality according to the National Sleep Foundation (NSF).13,14 Proper instruction was given in each section of the questionnaire for the understanding and how to fill up the questionnaire. 20 min was given to them to fill up the questionnaire in presence of the principal investigator.
All questionnaires were put on data analysis. Subjects were between 19 to 23 years old. Among 144 subjects 87 were male and 57 were female. The stress score was calculated according to the instruction of PSS. PSS included 10 questions and each question had 5 options i.e. 0=never, 1=almost never, 2=sometimes, 3=fairly often and 4=very often. According to instruction in the PSS score of questions 4, 5, 7 and 8 was reversed in the following manner i.e. 0=4, 1=3, 2=2, 3=1 and 4=0. Then the final score of each subject was calculated. Corresponding to their score perceived stress was categorized into low, moderate and high as shown in table 1.13
NSF derived four sleep quality indicators to assess the sleep quality and these are “sleep latency (min)”, “Awakening after 5 minutes (episode)”, “Wake after sleep onset (min)” and “sleep efficiency (%)”. Among the four indicators, each indicator can be used to assess sleep quality independently. NSF categorized sleep quality into appropriate, uncertain and appropriate taking into account the indicators of sleep as shown in table 2.14
Data analysis was done by statistical software SPSS 20. The significance of data was tested by the Chi-square test. A P-value less than 0.05 was considered to be significant. Generation of tables was done by Microsoft word.
RESULT
This study was completed among 87 male and 57 female subjects. Table 3 depicts the frequency distribution of subjects owing to perceived stress. 70.8% perceived moderate stress, 19.2% perceived low stress and 16% perceived high stress.
Table 4 depicts “sleep latency” as an indicator of sleep quality and analyzed with stress. From this analysis we found sleep quality of 96 (66.6%) subjects was appropriate, 18 (12.5%) subjects were uncertain and 30 (20.8%) was inappropriate. Among the subjects having inappropriate sleep quality, 53.3% perceive high stress. This distribution was found to be significant.
Table 5 depicts “sleep efficiency” as an indicator of sleep quality and analyzed with stress. From this analysis we found sleep quality of 94 (65.2%) subjects was appropriate, 24 (16.6%) subjects were uncertain and 26 (18%) was inappropriate. Among the subjects having inappropriate sleep quality, 50% perceive high stress. This distribution was found to be significant.
Table 6 depicts “awakening after 5 min” as an indicator of sleep quality and analyzed with stress. From this analysis we found sleep quality of 96 (66.6%) subjects was appropriate, 30 (20.8%) subjects were uncertain and 18 (12.5%) was inappropriate. Among the subjects having inappropriate sleep quality, 66.6% perceive high stress. This distribution was found to be significant.
Table 7 depicts “wake after sleep onset” as an indicator of sleep quality and analyzed with stress. From this analysis we found sleep quality of 98 (68%) subjects was appropriate, 22 (15.2%) subjects were uncertain and 24 (16.6%) was inappropriate. Among the subjects having inappropriate sleep quality, 87.5% perceive high stress. This distribution was found to be significant.
DISCUSSION
First-year medical students when joining the MBBS course, have a lot of ambitions and expectations. The curriculum is designed such that they have to adapt a lot of things during their whole period of study. Vast course burden, peer pressure, routine assessment and many more stressors put them in a situation that is not avoidable.15,16 Students having better coping mechanisms adapt to stress but those who are unable to cope with the situation, their body physiology is disturbed. In this study, we analyzed how perceived stress affect sleep quality in first-year medical students.
This study suggested that 16% of subjects perceive high stress, 70.8% moderate stress and 19.2% low stress. Sleep quality was analyzed by four indicators i.e. sleep latency (min), sleep efficiency (%), awakening after 5 minutes (episode), wake after sleep onset (min). Each indicator was used to analyze sleep quality owing to stress and we found that most of the subjects perceived high stress had inappropriate sleep. So this study suggested that increase stress level was associated with poor sleep quality.
Several studies observed that stress level and sleep quality are associated in the linear fashion that is when the stress level is high sleep quality is poor or sleep is inappropriate. They reported those persons to experience high-stress levels their sleep is inappropriate.17,18 Insomnia is a sleep disorder quite common nowadays. More stressed persons are more prone to develop insomnia.18Many researchers did their studies on students and found that students having inappropriate sleep or poor sleep quality and perceived severe stress face problem in their academic achievement. They suggested that for students whose sleep quality is inappropriate their academic performance is poor.11,12,19 Some other studies reported a negative correlation between sleep disorder and the academic performance of students.20,21 When a person faces a challenge or stressor certain physiological response occurs leading to increased secretion of stress hormones. Stress response includes activation of hypo-thalamopituitary-adrenal axis and release of adrenaline and cortisol.22,23 Cortisol is a steroid hormone secreted from the adrenal cortex is under the control of circadian rhythm. Persons whose sleep quality is poor or inappropriate their circadian rhythm of cortisol secretion is affected. So a vicious cycle is generated and a negative impact is observed on the mental health of students.23 Adjustment in academic load, fear of failure in carrier, repetitive assessments and examinations could be the possible cause of sleep deprivation in medical students.23
LIMITATION
This study could be more effective if the sample size was more. We could not analyze the gender difference in sleep quality. This study was conducted in a single institute and further studies are essential including multiple institutions. We could not able to include other confounding factors like the socioeconomic status of subjects that influence the stress.
CONCLUSION
A low grade of stress is essential for performance but the high and severe grade of stress is always harmful. This study concluded that students who perceive severe grades of stress experience poor sleep quality which is harmful to their carrier. So necessary counselling is required to cope with the stress and to maintain a healthy life.
CONFLICTS OF INTEREST
No conflicts of interest
SOURCE OF FUNDING
Nil
ACKNOWLEDGEMENT
The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful authors and publishers of all those articles, journals and books from where the literature for the article has been reviewed and discussed.
AUTHOR CONTRIBUTION
Jena SK – Conceive and design the study, data collection and analysis, manuscript writing.
Panigrahi SK – Statistical analysis, manuscript writing.
Pattnaik M – Manuscript writing, final correction of the manuscript
Englishhttp://ijcrr.com/abstract.php?article_id=4228http://ijcrr.com/article_html.php?did=4228
Behere SP, Yadav R, Behere PB. A comparative study of stress among students of medicine, engineering, and nursing. Indian J Psychol Med. 2011;33(2):145–148.
Waqas A, Khan S, Sharif W, Khalid U, Ali A. Association of academic stress with sleeping difficulties in medical students of a Pakistani medical school: a cross-sectional survey. Peer J. 2015;3:e840.
Sreeramareddy CT, Shankar PR, Binu VS, Mukhopadhyay C, Ray B et al. Psychological morbidity, sources of stress and coping strategies among undergraduate medical students of Nepal. BMC Med Educ. 2007;7(1):26.
Malathi A, Damodaran A. Stress due to exams in medical students- the role of yoga. Indian J. Physiol. Pharmacol. 1999;43(2):218-224.
Brougham RR, Zail CM, Mendoza CM, Miller JR. Stress, sex differences, and coping strategies among college students. Curr Psychol. 2009;28(2):85-97.
Azim SR, Baig M. Frequency and perceived causes of depression, anxiety and stress among medical students of a private medical institute in Karachi: a mixed-method study. J Pak Med Assoc. 2019;69(6):840-845.
Fenn KM, Hambrick DZ. Individual differences in working memory capacity predict sleep-dependent memory consolidation. J. Exp. Psychol. Gen. 2012;141(3):404?410.
Lim J, Dinges DF. A meta-analysis of the impact of short?term sleep deprivation on cognitive variables. Psychol Bull. 2010;136(3):375?389.
Chang PP, Ford DE, Mead LA, Cooper?Patrick L, Klag MJ. Insomnia in young men and subsequent depression. The Johns Hopkins precursors study. Am J Epidemiol. 1997;146(2):105?114.
Phillips AJK, Clerx WM, O’Brien CS, Sano A, Barger LK et al. Irregular sleep/wake patterns are associated with poorer academic performance and delayed circadian and sleep/wake timing. Sci Rep. 2017;7(1):3216.
AhrbergK, DreslerM, NiedermaierS, SteigerA, GenzelL. The interaction between sleep quality and academic performance. J Psychiatr Res. 2012;46(12):1618?1622.
Åkerstedt T, Orsini N, Petersen H, Axelsson J, Lekander M et al. Predicting sleep quality from stress and prior sleep – A study of day?to?day covariation across six weeks. Sleep Med. 2012;13(6):674?679.
Cohen S, Kamarck T, Mermelstein, R. A global measure of perceived stress. J Health Soc Behav. 1983;24(4),385-396.
Hirshkowitz M, Whiton K, Albert SM, Alessi C, Bruni O et al. National Sleep Foundation's sleep time duration recommendations: methodology and results from the summary. Sleep Health. 2015;1(1):40–43.
Dahlin M, Joneborg N, Runeson B. Stress and depression among medical students: A cross-sectional study. Med Educ. 2005;39(6):594-604.
Castaldelli-Maia JM, Martins SS, Bhugra D, Machado MP, Andrade AG et al. Does ragging play a role in medical student depression—cause or effect? J Affect Disord. 2012;139(3):291-297.
Morin CM, Rodrigue S, Ivers H. Role of stress, arousal and coping skills in primary insomnia. Psychosom Med. 2003;65(2):259?267.
Zunhammer M, Eichhammer P, Busch V. Sleep quality during exam stress: The role of alcohol, caffeine and nicotine. PLoS One. 2014;9(10):e109490.
Stewart SM, LamTH, BetsonCL, WongCM, WongAM. A prospective analysis of stress and academic performance in the first two years of medical school. Med. Educ. 1999;33(4):243?250.
Bahammam AS, Alaseem AM, Alzakri AA, Almeneessier AS, Sharif MM. The relationship between sleep and wake habits and academic performance in medical students: a cross-sectional study. BMC Med. Educ. 2012;12:61
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Leproult R, Copinschi G, Buxton O, Van Cauter E. Sleep loss results in an elevation of cortisol levels the next evening. Sleep 1997;20(10):865-870.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Evaluation of the Neuroprotective Effect of Extract of Cleome viscosa Linn. Against Intracerebroventricular Colchicine-Induced Dementia in Rats
English5560K. Usha S PaiEnglish Yadav D BodkeEnglish Jayant Singh BhardwajEnglish K Sreedhara Ranganath PaiEnglishEnglishDementia, Morris Water Maze, Cleome viscosa, intracerebroventricular (ICV), Neuroprotection, Acetylcholinesterase inhibitor
INTRODUCTION
Alzheimer’s disease (AD) is a chronic neurodegenerative disorder in which there is memory loss which results in the poor societal and personal life of the patients. AD is a type of dementia involving the chronic reduction in the cognitive and intellectual functioning of a person. As the disease progresses, the nerve cells involved in thinking, learning becomes damaged followed by eventual damage of neurons associated with basic functions of the body like walking and swallowing. The late phase of AD comprises of loss of ability to think, plan and difficulty in problem-solving skills, and difficulty in walking and swallowing leading to the requirement of close care and bed-bound situation.1 It is chiefly caused by the production & accumulation of abnormal amyloid proteins also known as β amyloids outside the neurons leading to the formation of Senile plaques. Secondly, the hyperphosphorylation of Tau proteins and their accumulation inside the neurons result in neurofibrillary tangles thereby blocking the conduct of nutrients and essential molecules required for a healthy neuron. Hyperphosphorylated tau results in dissociation of tau protein from microtubules, misfolding and aggregation to form paired helical filaments, which enhance Aβ toxicity. A reduced level of neurotransmitters occurs in AD which leads to neurodegeneration and loss of memory. 2
Currently, only four FDA approved drugs in two categories namely: Acetylcholine esterase, AchE inhibitor (rivastigmine, galantamine, donepezil) and NMDA antagonist (memantine) are available for the symptomatic management of AD. None of the currently available pharmacological therapies slows down or prevent the disease. AchE inhibitors act by blocking acetylcholinesterase (not butyryl choline esterase) and is more potent than any other drugs under the class of cholinesterase inhibitors.3 Memantine prevents the overstimulation of receptors and prevents neuronal damage. These drugs are primarily used for the symptomatic treatment of dementia. Plant-based natural drugs have immense potential to be used as an alternative for the treatment of AD. The natives and traditional healers of India use Cleome viscosa Linn. (CV) for various therapeutic purposes. 4,5 In the traditional system of medicine, this plant is used to treat various disorders such as diarrhoea, fever, inflammation, liver diseases, bronchitis, skin diseases and malarial fever. The juice is useful in piles, lumbago, and earache 4. CV leaves possess high phenolic and flavonoid contents which show potential antioxidant activity, and free radical scavenging activity. 6 Currently, in this study, we have evaluated the neuroprotective potential of CV extract in Colchicine induced sporadic dementia model of AD.
Colchicine has been proven to induce behavioural, biochemical and pathological changes as that of sporadic AD. Colchicine when given by the intracerebroventricular (ICV) route destroys hippocampal cells leading to loss of cholinergic neurons and loss of memory. It is cytotoxic that binds irreversibly to the dimer of tubulin and prevent microtubule assembly. 7,8 The neuroprotective potential of extracts has not been explored in the colchicine-induced sporadic model of AD. Hence, in this current study, for the first time, the neuroprotective role of extracts has been investigated in the ICV colchicine induced cognitive deficit and oxidative stress model of AD in rats.
MATERIALS AND METHODS
Preparation of methanol extract of plant Cleome viscosa Linn.
The whole plant of Cleome viscosa Linn. belonging to the family Capparidaceae was collected from the district of Udupi, Karnataka in October. The plant was authenticated by Dr K. Gopalakrishna Bhat, Head, Department of Botany, Poornaprajna College, Udupi, Karnataka. The authenticated sample was submitted to the Manipal College of pharmaceutical sciences herbarium. The plant material (2kg) was shade dried, powdered coarsely was extracted using soxhlet apparatus for 24h by methanol. The crude methanol extract was concentrated in a rotary evaporator under reduced pressure for solvent recovery and the collected concentrated extract was dried and preserved in a desiccator for later use. The yield was 4.3% for crude methanol extract.
Animals
The male Wistar rats of 150-200 g used in the study were obtained from the Central Animal Research Facility, Manipal Academy of Higher Education and housed in propylene cages (3 animals per cage). The temperature and humidity were maintained at 23 ± 3oC and 55 ± 5% respectively. The animal handling and care were carried out according to the Committee for Control and Supervision of Experiments on Animals (CPCSEA) guidelines and the study was approved by the Institutional Animal Ethics committee, Manipal. (IAEC/KMC/104/2018).
Preparation of vehicle Carboxymethyl cellulose (CMC)
0.25g of CMC was weighed accurately into a 200ml beaker and 40ml of distilled water was added. This solution was sonicated for about 45 minutes and volume was made up to 100ml with distilled water.
Preparation of Cleome viscosa extract
The methanol extract of CV was weighed accurately and triturated with Tween80 until a clicking sound was heard. The resulting mixture was suspended in 0.25% CMC. The animals were given doses according to their body weight. [100mg/kg (Test treatment 1), 200mg/kg (Test treatment 2)]
Treatment regimen
The animals were divided into six groups with six animals in each group namely, Normal control, Sham control with artificial cerebrospinal fluid 5 μL, Disease control where intracerebroventricular injection of colchicine in artificial cerebrospinal fluid was done 7,8. The treatment of various drugs, surgery and the conduct of the experiment was done as per the regimen shown in Table 1 and Figure 1. (Schematic diagram for representing drug/Extract treatment plan, disease induction and evaluation of parameters).
Intracerebroventricular administration of Colchicine
Before the beginning of the surgical procedure, the frame of the apparatus was cleaned properly using 70% ethanol. Thiopental sodium (45mg/kg) was administered to anaesthetize the rats. The animal’s head was then fixed properly into the frame of the apparatus and an incision was carefully made along the midline of the scalp. The administration of colchicine was done in the lateral ventricle at the coordinates 0.8 mm posterior to bregma (AP), 1.8 mm lateral to sagittal suture (ML) and 3.6 mm below the cortical surface (DV) 9. The rat was infused with colchicine 15μg in 5 μL of artificial cerebrospinal fluid (in mM; 147 NaCl, 2.9 KCl, 1.6 MgCl2, 1.7 CaCl2 and 2.2 dextroses) using a quintessential stereotaxic injector and the microsyringe was left there for 2 minutes to avoid backflow. In the Sham group, only ACSF was administered without Colchicine. The scalp was closed by suturing and the antibacterial betadine was applied on the area where the incision was made using sterile cotton to prevent any infection.
Evaluation of spatial memory using Morris water maze
Spatial memory was evaluated with Morris water maze 10 consisting of a circular pool of 150 cm diameter and height of 40 cm divided into four North-east, North-west, South-east, South-west quadrants 15. The animals were placed in either of the quadrants alternating for each trial. The water in the pool was made opaque with non-fat milk and a platform of 10 cm diameter was placed 2 cm immersed, hidden in the water. Animal use external/extra-maze cues to find the platform. 16 A tracking software system with a camera was placed to capture the behaviour and movements of the animal. Water maintained at a temperature of 26 ± 1ºC was changed every day. The experiment was performed in the dim light intensity was kept constant throughout the trial.
Acquisition trial: After 16 days of colchicine administration (15μg, ICV) training was provided for four consecutive days to all animals. For 60 seconds, animals were allowed to swim freely to find the platform. If the animal does not find a platform, they are directed to the platform manually and held on it for 30 seconds. This training was conducted as four trials a day with a 5-minutes interatrial interval. The path efficiency, time spent in each quadrant, escape latencies, were recorded.
Probe trial: After the training phase, the retention trial was done on the 5th day for the 60s Post-acquisition trial. The platform was removed in this trial, without altering other external/extra-maze conditions. The animals were kept with the head facing to the wall in the quadrant opposite to the one containing platform and were allowed to explore the pool wherein parameters like escape latency, path efficiency, time in all zones, and total distance were considered and recorded using ANY-maze software with the camera fixed above the pool.
Locomotor activity evaluation by Actophotometer
The locomotor activity of each animal was evaluated on days 3, 7, 14 after colchicine administration (15μg, ICV), using a digital actophotometer. The animals were placed on the actophotometer that contains light-sensitive infrared photocells to monitor the movement of animals. The animals were acclimatized for 3 minutes and then were kept in the instrument for 10 minutes to record their locomotor activity 9.
Brain isolation and homogenization of hippocampus and frontal cortex
After the end of the probe trial, the rats were euthanized by administering a high dose of thiopental. Perfusion was done by injecting 20mL of ice-cold normal saline. The brain was removed from the cranial vault and then two lobes of the frontal cortex and hippocampus were isolated, stored at -20°C. 10% w/v of the tissue homogenate was prepared in 0.1M ice-cold Phosphate buffer (pH 7.4) using an Ultra-Turrax T25 homogenizer at the speed of 6000 rpm for 15 minutes and the tissue homogenates were measured for the following biochemical parameters.
Estimation of acetylcholinesterase enzyme (AChE) activity
Ellman’s method was followed for the estimation of acetylcholinesterase activity, which is a cognitive marker that indicates loss of cholinergic neurons 11. To the 5 µL acetylthiocholine iodide 25 µL of 5,5'-dithiobis-2-nitrobenzoic acid (DTNB) was added followed by 650 µL of 0.1M phosphate buffer and finally 100 µL of homogenate was added. The absorbance was then checked for 180 secs at 412 nm in UV spectrophotometer.
Statistical Analysis:
Graph Pad Prism software was used to analyse the results. Two Way ANOVA followed by Tukey’s multiple compartment test was used to analyse locomotor activity. All of the other tests were analysed using One Way ANOVA followed by Tukey’s multiple compartment test and expressed as Mean±SEM. Experimental results after analysis were considered significant at the p value less than 0.05.
RESULTS
Impact of extract of Cleome viscosa on the locomotor activity:
The locomotor activity of rats was evaluated using actophotometer after ICV injection of Colchicine. The mean counts of locomotor activity per 10 minutes were normal and stable without significant variation as shown in Figure 2 (Effect of extract of Cleome viscosa on locomotors activity). This indicates that there was no detrimental effect on locomotion due to surgery. The locomotive operation had no significant difference in all groups compared to normal and disease control.
Effect of extract of Cleome viscosa on AChE levels of the brain:
Injection of colchicine ICV in the brain showed a significant rise in the level of AChE compared to the normal group and sham control group. A significant reduction in AChE activity in the frontal cortex and no significant reduction in the hippocampal AChE activity was observed in the Donepezil treated groups compared to the Colchicine only treated disease group. The AChE activity in the hippocampal region was significantly elevated in the Donepezil treated group as compared to the normal and sham control rats. There is no significant reduction in AChE activity in the frontal cortex and hippocampal was observed in the extract of CV (100 and 200 mg/kg) treated groups compared to the Colchicine only treated disease group. (Figure 3: Effect of extract of Cleome viscosa on acetylcholinesterase).
Effect of extract of Cleome viscosa in the spatial memory:
Escape latency refers to the time taken to find the hidden island located in D-quadrant. ICV Colchicine treatment increased the escape latency compared to the vehicle control. Treatment with the standard Donepezil showed a significant decreased latency period as compared to the disease group. The dose of an extract of CV (100 and 200mg/kg) did not show a reduction in the Escape latency period when compared with rats of the disease group. Administration of ICV colchicine significantly decreased the path efficiency in disease control animals subjected to the Morris water maze test. There was no significant change in the path efficiency among all groups. Similarly, rats treated with ICV Colchicine took a longer time to cross the D quadrant as compared to normal and Sham control rats. A significant reduction in the Latency to D quadrant was observed in Donepezil treated group and insignificant reduction for the extract of CV (100 and 200mg/kg) treated groups (Figure 4: Effect of extract of Cleome viscosa on Path efficiency, Escape Latency, D quadrant latency).
DISCUSSION:
Alzheimer’s disease is a neurodegenerative disorder identified by a reduction in cognition abilities. It is observed that colchicine injection into the brain precipitates condition like Alzheimer’s disease 7. Colchicine is a compound that binds to tubulin proteins resulting in dephosphorylation and destabilization. This leads to the accumulation of amyloid beta (Aβ) and generates tangles similar to neurofibrillary tangles. Consequently, it triggers excessive oxidative stress and neuro-inflammation. Neuro-inflammation has been considered as one of the pathological cause for AD 12,13.
In the current study, extract of Cleome viscosa (100 and 200mg/kg) is evaluated for its neuroprotective activity against colchicine-induced dementia in rats. The Cholinergic hypothesis signifies the role of Acetylcholine in memory and has led to the identification and use of acetylcholinesterase inhibitors for enhancing memory and cognition 14,15. Increased AChE activity has been observed in the plasma, human liver, red blood cells, cerebrospinal fluid and brain from Alzheimer’s patients. Donepezil, a cholinesterase inhibitor was selected as a standard drug for the current study. In this study, the increased level of AChE was found in the frontal cortex and Hippocamus of the rat brain after ICV Colchicine administration 16. An insignificant reduction in the level of AChE was seen after treatment with dementia in rats as compared to the disease control rats. Cleome viscosa has been reported to have antioxidant property showing its potential to scavenge free radicals 17. In this study, extract of CV treatment in the ICV Colchicine induced cognition impaired rats, the AChE level of the brain had no significant AChE inhibitor effect in the frontal cortex and the hippocampal region of the brain.
The ICV administration of Colchicine leads to the memory impairment indicated by elevated D-quadrant latency and escape latency and significantly decreased the path efficiency in disease control animals in the Morris water maze test. Donepezil, a standard drug showed a reduction in the latency time. Both the dose of the extract (100 and 200 mg/kg) was not capable to reduce the latency period effectively. There was no significant reduction in the latency period in both of the treatment groups. There was no change in the locomotor activity as observed in the results of actophotometer among the rats of different groups. This removes the possibility of Colchicine toxicity and experimental errors affecting locomotion in the rats.
CONCLUSION:
In the current study, the neuroprotective activity of extract of Cleome viscosa (100 and 200 mg/kg) was evaluated against ICV colchicine-induced dementia in the rat model. The extract was reported as antioxidant property but the extract showed insignificant activity for AChE level. Treatment with extract at 100 and 200 mg/kg failed to exert any protective effect against colchicine-induced dementia in rats.
ACKNOWLEDGEMENT
The authors would like to thank the Department of Industrial Chemistry, Kuvempu University and Manipal College of Pharmaceutical Sciences and Manipal Academy of Higher Sciences for providing the facility and support to carry out the research work.
Authors’ Contribution:
Concept, study supervision: Bodke, Yadav D, and Pai, K Sreedhara Ranganath
Design, data acquisition and interpretation: Pai, K Usha S, Bhardwaj, Jayant Singh
Source of Funding: This studies as no fund from any authorities
Conflict of Interest: None to declare
Englishhttp://ijcrr.com/abstract.php?article_id=4229http://ijcrr.com/article_html.php?did=4229
1. Alzheimer’s Association. Race, Ethnicity and Alzheimer’s in America. 2021.
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3. Kaur S, DasGupta G, Singh S. Altered Neurochemistry in Alzheimer’s Disease: Targeting Neurotransmitter Receptor Mechanisms and Therapeutic Strategy. Neurophysiology. 2019 Jul 4;51(4):293–309.
4. KR K, BD B. Indian medicinal plants. 2nd ed. Singh B, Singh MP, editors. Periodical Experts. New Delhi: Periodical Experts; 1975. 183–205 p.
5. T P. Medicinal plants in India. Vol. 1, Indian Journal of Medical Research. New Delhi: Regency Publication; 2002. 168 p.
6. Singh H, Mishra A, Mishra AK. The chemistry and pharmacology of Cleome genus: A review. Biomed Pharmacother. 2018 May;101:37–48.
7. Veerendra Kumar MH, Gupta YK. Intracerebroventricular administration of colchicine produces cognitive impairment associated with oxidative stress in rats. Pharmacol Biochem Behav. 2002 Oct;73(3):565–71.
8. Kumar A, Sehgal N, Kumar P, Padi SSV, Naidu PS. Protective effect of quercetin against ICV colchicine-induced cognitive dysfunctions and oxidative damage in rats. Phyther Res. 2008 Dec;22(12):1563–9.
9. Kumar A, Dogra S, Prakash A. Protective effect of naringin, a citrus flavonoid, against colchicine-induced cognitive dysfunction and oxidative damage in rats. J Med Food. 2010 Aug;13(4):976–84.
10. Vorhees C V., Williams MT. Morris water maze: Procedures for assessing spatial and related forms of learning and memory. Nat Protoc. 2006 Aug 27;1(2):848–58.
11. Ellman GL, Courtney KD, Andres V, Featherstone RM. A new and rapid colorimetric determination of acetylcholinesterase activity. Biochem Pharmacol. 1961 Jul;7(2):88–95.
12. Heneka MT, Carson MJ, Khoury J El, Landreth GE, Brosseron F, Feinstein DL, et al. Neuroinflammation in Alzheimer’s disease. Lancet Neurol. 2015 Apr;14(4):388–405.
13. Kinney JW, Bemiller SM, Murtishaw AS, Leisgang AM, Salazar AM, Lamb BT. Inflammation as a central mechanism in Alzheimer’s disease. Alzheimer’s Dement Transl Res Clin Interv. 2018 Jan 5;4(1):575–90.
14. Sharma K. Cholinesterase inhibitors as Alzheimer’s therapeutics (Review). Mol Med Rep. 2019 Jun 11;20(2):1479–87.
15. Bartus RT, Dean RL, Beer B, Lippa AS. The cholinergic hypothesis of geriatric memory dysfunction. Science (80- ). 1982 Jul 30;217(4558):408–17.
16. García-Ayllón MS, Riba-Llena I, Serra-Basante C, Alom J, Boopathy R, Sáez-Valero J. Altered levels of acetylcholinesterase in Alzheimer plasma. Kursula P, editor. PLoS One. 2010 Jan 14;5(1):e8701.
17. Gupta PC, Sharma N, Rao C V. Comparison of the antioxidant activity and total phenolic, flavonoid content of aerial part of Cleome viscosa L. Int J Phytomedicine. 2011;3(3):386–91
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Clinicopathological Study of Bone Marrow Infiltration in Lymphoma
English6167Yeresime SurekhaEnglish Belurkar SushmaEnglish
Background: Trephine biopsy plays a critical role in the routine staging of lymphoma. Bone marrow involvement by lymphoma confirms advanced-stage disease and may affect both treatment and prognosis. Therefore bone marrow examination has an important role in staging and predicting prognosis in lymphoma Objective: To study the Incidence and Pattern of bone marrow infiltration in lymphoma, correlate bone marrow morphology with lymph node biopsy and assess the clinical prognosis according to bone marrow involvement. Methods: This is a 4-year retrospective study of 86 diagnosed cases of lymphoma with marrow infiltration. The clinical data were retrieved from the medical records and the bone marrow (aspiration and biopsy) slides, lymph node biopsy slides were reviewed. Results: A total of 135 cases of lymphoma were diagnosed on lymph node biopsy, out of which 106 cases (78.5%) were of Non - Hodgkin lymphoma and 29 cases (21.4%) were Hodgkin lymphoma. The overall incidence of marrow infiltration in lymphoma was 63.7 % (86/135). The incidence of marrow infiltration by NHL (71.7%) was higher when compared to HL (34.5%). Only 86 cases that had marrow infiltration by lymphoma were analyzed in this study. The most common type of NHL with marrow infiltration was follicular lymphoma (36.8%), followed by DLBCL (27.6%). In Hodgkin lymphoma, the equal incidence of marrow infiltration was found in Mixed cellularity, Lymphocyte - depleted and unclassified Classical Hodgkin lymphoma each accounting for 30%. The predominant pattern of marrow infiltration was-Mixed type (30.2%), followed by a diffuse pattern (27.9%). Morphological discordance between lymph node and trephine biopsy was seen only in 13 cases (15.1%), all of which were Non-Hodgkin Lymphoma. Conclusion: Overall marrow infiltration by Non-Hodgkin Lymphoma is higher compared to Hodgkin Lymphoma. The most common pattern associated with poor prognosis was the diffuse pattern.
EnglishLymphoma, Bone marrow aspiration, Bone marrow biopsy, Incidence, Bone marrow involvement, Pattern of infiltration
INTRODUCTION
Lymphoma is cancer that occurs due to the malignant transformation of lymphocytes in the lymphatic system. Incidence of Bone marrow infiltration in Non-Hodgkin Lymphoma (NHL) varies from 15% to 75% due to heterogeneous inclusion criteria used by different studies.1Follicular lymphoma is most common to involve the marrow followed by diffuse large B-cell lymphoma. In the adult population, the estimated incidence of marrow infiltration by Hodgkin lymphoma (HL) is around 2-32% with an average of 10%,2 whereas the incidence in the pediatric population is low accounting for 1.8 %.3The involvement of the marrow in a patient with lymphoma represents stage IV disease. The clinical significance of bone marrow involvement can vary based on the type of lymphoma.
Trephine biopsy is more useful in detecting bone marrow infiltration. Trephine biopsy help in assessing the presence or absence of infiltration, the pattern of infiltration and any morphological discordance with primary lymphoma. It has an important role in the routine staging of Hodgkin and Non-Hodgkin lymphoma.
Bone marrow involvement by lymphoma confirms advanced-stage disease and may affect both treatment and prognosis. Therefore bone marrow examination has an important role in staging and predicting prognosis in lymphoma.
MATERIALS AND METHODS:
This is a 4 year retrospective study of 86 diagnosed cases of lymphoma with marrow infiltration conducted in the Department of Pathology, Kasturba Medical College and Kasturba Hospital, Manipal.
The clinical data were retrieved from the medical records and the bone marrow (aspiration and biopsy) slides, lymph node biopsy slides were reviewed. Peripheral smears and all bone marrow aspirates were stained with Leishman stain as per the standard procedure. All trephine biopsy sections and lymph node biopsies were stained with Hematoxylin and Eosin stain as per the standard procedure.
INCLUSION CRITERIA:
All cases of Lymphoma show bone marrow involvement.
EXCLUSION CRITERIA:
Diagnosed cases of lymphoma for which bone marrow aspiration or biopsy was not done.
Cases of lymphoma with inadequate bone marrow biopsies.
RESULTS:
During the study period, a total of 135 cases of lymphoma were diagnosed on lymph node biopsy, out of which 106 cases (78.5%) were of Non - Hodgkin lymphoma and 29 cases (21.4%) were Hodgkin lymphoma. Out of the 106 Non - Hodgkin lymphoma cases, 76 cases (71.7%) showed marrow infiltration and out of 29 cases of Hodgkin lymphoma, 10 cases (34.5%) showed marrow infiltration. Overall marrow infiltration by Non - Hodgkin lymphoma is higher compared to Hodgkin lymphoma. The Overall incidence of marrow infiltration in NHL and HL was 63.7 % (86/135). Only 86 cases that had marrow infiltration by lymphoma were analyzed in the study. The results of various variables of the study are as follows:
In Non-Hodgkin lymphoma - Follicular lymphoma (36.8%) was the most common, followed by Diffuse large B-cell lymphoma (27.6%). Among 10 cases of Hodgkin lymphoma with marrow infiltration, there were 3 cases of Mixed cellularity, 3 cases of Lymphocyte - depleted classical Hodgkin lymphoma and 1 case of Nodular sclerosis. Further, 2 Cases of Non-Hodgkin lymphoma and 3 cases of Classical Hodgkin lymphoma were not subclassified, as IHC was not done.
The age of patients with marrow involvement ranged from 19-84 years, with the median age being 51years, with a peak age incidence observed between 55 to 64 years. Male preponderance was seen with a male to female ratio of 2.45:1.
The most common presenting symptom was cervical or inguinal lymphadenopathy (100%), the next most common presenting symptom was giddiness due to anaemia (34.8%), followed by fever (33.7%). Splenomegaly was found in the majority of cases (67%), followed by hepatomegaly (45.3%).
Haemoglobin values in males ranged from 4.5-15.6g/dl, with the median value being 10.5 g/dl. In females, the haemoglobin values ranged from 5.9-12.1g/dl with the median value being 10.5 g/dl. WBC count ranged from 1.4 - 60.3 x 103/µL with the median value being 6.5 x 103/µL. Platelet count ranged from 11 – 913 x 103/µL with the median value being 174 x 103/µL.
Among cytopenias, anaemia (78%) was most common, followed by thrombocytopenia (45%) and Leucopenia (20%). Peripheral blood involvement by abnormal lymphoid cells accounted for 15% and was seen only in NHL cases. The most common lymphoma with peripheral blood involvement was Follicular lymphoma and DLBCL, each accounting for 4.6%.
Aspirate studies of only 43 (50%) cases showed abnormal lymphoid cells. Follicular lymphoma was the most common NHL picked up on aspiration studies, followed by DLBCL.
The predominant pattern of marrow infiltration on bone marrow biopsy in different subtypes of 76 Non-Hodgkin lymphoma cases was-Mixed type (32.8%), followed by diffuse pattern (23.6%). Among the Mixed type: Para trabecular and Interstitial (15.7%) was the most common. The obtained results for infiltration patterns in different types of lymphoma are tabulated in Table-1
In Hodgkin lymphoma, the most common pattern of marrow infiltration was diffuse-type accounting for 60%.
Common secondary changes seen in the bone marrow were fibrosis, necrosis and granuloma accounting for 11.6%, 5.8% and 2.3% of cases, respectively.
When bone marrow aspiration and bone marrow biopsy were compared, bone marrow biopsy was found to be more accurate for assessment of marrow involvement by lymphoma, with a sensitivity rate of 100% (Table-2).
Morphological discordance between lymph node and trephine biopsy was seen only in 13 cases (15.1%), all of which were Non-Hodgkin Lymphoma. No discordance was found in Hodgkin Lymphoma. Follicular lymphoma was the most common subtype with a discordant rate of 25%, followed by DLBCL (23.8%).
During treatment 51(59.3%) patients expired, 15 patients (17.4%) were lost for follow up, remission was seen only in 20 patients (23.2%). The commonest cause of death was septic shock accounting for 72.5%. The most common pattern associated with poor prognosis was a diffuse pattern, accounting for 45%, and the majority of Diffuse large B-cell lymphoma patients who expired had a diffuse pattern of marrow infiltration.
DISCUSSION:
The diagnosis and classification of lymphoma are made on tissue biopsy i.e. lymph node and bone marrow biopsy. In the present study, we discuss the incidence and pattern of marrow infiltration in Non-Hodgkin Lymphoma and Hodgkin Lymphoma and also correlate lymph node biopsy findings with the bone marrow biopsy morphology.
The overall incidence of marrow infiltration by lymphoma in our study was 63 %, which is very high when compared to studies conducted by Lambertenghi et al.4 (32%) and Shi et al.5 (16%). The difference may have been exaggerated as our study population is much smaller as compared to the other two studies. Another reason could be due to different spectrums of lymphoma occurring in different countries.
NON – HODGKIN LYMPHOMA
The incidence of Bone marrow infiltration varies from 15% to 75% due to heterogeneous inclusion criteria used by different studies. 1
The incidence of marrow infiltration by NHL in our study was 71%, which is similar to studies conducted by Bartl et al.6 (69%) and Georgii et al.7 (75%).In contrast, studies carried out by Shi et al.5 (18.1%), Bonadonna et al. 8 (16%), Jones et a1.9 (18%) and Conlan et al.10 (32%), showed a lower incidence of marrow infiltration. The difference in incidence could be attributed due to different types of lymphoma occurring at different places.
Hassan K et al.11 in his studies found anaemia to be the most common cytopenia, followed by thrombocytopenia and neutropenia, similar results were obtained in our study. The cause of cytopenia could be due to the replacement of marrow elements by lymphomatous cells at a later stage and due to the release of cytokines by malignant cells. This could be the reason why patients in our setup, who generally present late in the course of disease with the higher frequency of marrow infiltration, manifest cytopenias more frequently.
Peripheral smear involvement accounted for 17.1% of our study. Similarly, Kumar et al.12 reported a frequency of 7.4%. However, Studies conducted by Hassan K et al. 11, Arber etal.13, and Jeong et a.l.14 showcased a higher frequency of peripheral blood involvement. The presence of abnormal/atypical lymphoid cells in peripheral blood was found to be associated with an increase in total leucocyte count, similar observation was also found in other studies.
In our study, follicular lymphoma was the most common type of NHL with marrow infiltration accounting for 36.8%, followed by DLBCL -27.6%, these findings are comparable to studies done by Arber et al.13 as they also found follicular lymphoma to be the most common accounting for 39.8%, followed by DLBCL -16% (Table-3).
In contrast, studies carried out by Kumar et al.12 and Shi et al.5 found Lymphoblastic lymphoma (44.8%) and Mantle cell lymphoma (18.3%) respectively, to be the most common subtype of NHL to infiltrate the marrow. Variations in the incidence of marrow infiltration could be due to the inclusion of different proportions of various histologic subtypes of lymphoma in different studies, as the incidence of marrow pathology varies according to histologic subtypes.
Predominant histopathological patterns of marrow infiltration encountered in different subtypes of 76 NHL cases in our studies were -Mixed (32.8%), followed by diffuse (23.6%), interstitial (18.4%) and para-trabecular (14.4%) - Figure 1
Arber et al.13 also reported a higher incidence of marrow infiltration with a mixed pattern consistent with our study, as both our studies had a higher incidence of Follicular lymphoma cases which is associated with a mixed pattern of marrow involvement. These findings differ from studies conducted by Bolkainy et al.15 and Hassan et al.11 who found marrow infiltration to be predominantly Paratrabecular & Diffuse type respectively and in these the frequently occurring NHL was SLL.
Whereas Chen et al.16 in his studies found interstitial to be most common pattern followed by diffuse pattern. Studies conducted by Foucar et al.17 had Focal involvement as the predominant pattern.
HODGKIN LYMPHOMA
In the present study, the incidence of marrow infiltration by Hodgkin lymphoma accounted for 34.5%, in concordance with the study conducted by Ikram et al.18 (35%), Sharma et al.19 (36.2%) and Ayaz et al. 20 (38%). In contrast, a lower incidence of marrow infiltration was seen in studies conducted by Howell et al.21 (5. 2%), Franco et al.22 (10%), and Lambertenghi et al.4 (11.6%). Variations in incidence occur due to heterogeneous inclusion criteria used by different studies.
Out of 10 cases of Hodgkin lymphoma, all patients were anaemic accounting for 100%, whereas a study conducted by Ikram et al.18 found 66% of patients to be anaemic with marrow infiltration, he also observed leukocytosis and thrombocytosis accounting for 19% and 23% respectively, which they have attributed to reactive changes in the bone marrow of Hodgkin lymphoma cases. In contrast, the present study had no case with thrombocytosis or leukocytosis in Hodgkin lymphoma patients with marrow infiltration. In our study, Peripheral blood involvement in Hodgkin lymphoma was not observed.
The most common pattern of infiltration in Hodgkin lymphoma observed in our study was the diffuse type, followed by focal pattern, in contrast to studies conducted by Ayaz et al. 20 and Ikram et al.18 where they found the interstitial pattern to be more common and in the study conducted by Sultan et al. 23 focal pattern were more common followed by the diffuse type. This is attributed to the fact that the patients in our country seek medical help much later in the course of the disease by the time the patients will be in the more advanced stage of the disease.
In our study, among 86 cases with marrow infiltration only in 43 cases abnormal cells were detected on Bone Marrow Aspiration (BMA) giving a sensitivity rate of 50%. Whereas the sensitivity of detection of marrow infiltration on Bone Marrow Biopsy (BMB) was 100%. Hence it is essential to perform BMB for all cases of lymphoma so that cases with marrow involvement are not missed.
The detection rate of marrow infiltration on aspirate is low, the cause for this could be - dilution of bone marrow, the difference in a procedure performed or distortion of normal marrow architecture.
The discordant rate between lymph node and trephine biopsy in our study was 15.1%. Most of the other studies 4,12,13,24 have shown a higher percentage of morphological discordance between bone marrow biopsy and Lymph node biopsy compared to the present study.
In the present study, morphological discordance between lymph node and trephine biopsy was seen frequently in follicular lymphomas and diffuse large B-cell lymphomas, similar observations were made by Arber et al13 and Kumar et al.12 in their studies.
Present studies and other studies have also shown fibrosis and necrosis as the most common secondary change in bone marrow involved by lymphoma. A study done by Sovani et al. 24 has shown a higher incidence of granulomas, probably due to the higher number of Hodgkin lymphoma cases in their study.
Out of 51 patients - 37 patients (72%) died due to septic shock and due to chemotherapy-induced febrile neutropenia, which was the most common cause of death, followed by respiratory failure in 6 patients (11.7%), cardiac failure in 5 patients (9.8%), and rest 3 with renal failure (5.8%). Similarly, in study done by Ostrow et al.25 septic shock and respiratory failure was found to be most common cause of death.
Ethical clearance number: IEC 512/2015-KMC Manipal
CONCLUSION:
Overall marrow infiltration by Non-Hodgkin Lymphoma is higher when compared with Hodgkin Lymphoma. Variations in incidence occur, due to heterogeneous inclusion criteria used by different studies and due to different types of lymphoma occurring at different places.
Bone marrow aspiration is of mere importance in the diagnosis of marrow infiltration by lymphoma when compared to Bone marrow biopsy. As the sensitivity of Bone Marrow Aspiration is 50%, whereas the detection of lymphoma on Bone Marrow Biopsy is 100%. The causes for inadequate bone marrow aspiration could be fibrosis and technical errors during the procedure. Marrow infiltration by lymphoma is definite evidence of disseminated disease. Therefore knowledge about the presence or absence of marrow involvement is vital. As the specific pattern of bone marrow infiltration is associated with specific subtypes of lymphoma, hence study of patterns of marrow infiltration in lymphoma aids in accurate diagnosis when correlated with lymph node biopsy. A small proportion of lymphoma cases can show morphological disparity on bone marrow biopsy when compared to lymph node biopsy. Hence IHC is recommended for accurate subtyping of lymphomas.
ACKNOWLEDGEMENTS:
The authors gratefully acknowledge the Departments of Medicine & Oncology KMC Hospital, for referring their patients for research studies. The authors are also grateful to the staff of the Pathology Department of KMC, for their suggestions and histological analysis.
FUNDING: NIL
COMPETING INTERESTS: NIL
CONTRIBUTORS:
The authors certify that neither this manuscript nor one with substantially similar content under their authorship has been published or is being considered for publication elsewhere. The authors agree to allow the corresponding author to correspond with the editorial office, to review the uncorrected proof copy of the manuscript and to make decisions regarding the release of information in the manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=4230http://ijcrr.com/article_html.php?did=4230
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Bartl R, Frisch B, Burkhardt R. et al. Assessment of bone marrow histology in the malignant lymphomas (non-Hodgkin’s): Correlation with clinical factors for diagnosis, prognosis, classification and staging. Br J Haematol. 1982;51: 5 1 1-5 30.
Georgia A. Classification of non-Hodgkin’s lymphomas from biopsies of the bone marrow with special emphasis on their spread. Leukaemia and Non-Hodgkin-Lymphoma. Advances in Medical Oncology, Research and Education 1979; 7: 179-188.
Bonadonna G, Castellani R, Narduzzci C, Spinell P, Rilke F. Pathological staging in adult previously untreated non-Hodgkin lymphomas. Res Canc Res. 1978; 65: 41-50.
Jones SE, Rosenberg SA, Kaplan HS. Non-Hodgkin’s lymphomas - Bone marrow involvement. Cancer 1972;29: 954-960.
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Chen H, Qian L, Shen L. Clinicopathological studies on bone marrow involvement of non-Hodgkin lymphoma.Chinese J Oncol. 2000; 22(6): 513-15.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Effect of Combining Vacuum Massage and Shock Wave Therapy on the Post Burn Scar
English6872Mahmoud ElshazlyEnglish Abdelrazak A. AhmedEnglish Mohammed Ali SarhanEnglish
Introduction: Post burns hypertrophic scar is the most serious problem with the burned patient. There are different physical therapy modalities used in the rehabilitation of post-burn scars as pressure therapy, splinting stretching exercises, mechanical massage, and shock wave therapy. Aim: our study was applied to detect the efficacy of combining treatment vacuum massage and shockwave on the post-burn scar. Methods: Forty patients with post-burn scars, age 20-40 years old randomly divided into 2 groups. study group (group A) received manual physical therapy program in addition to combining therapy of shockwave and vacuum massage 3 times per week for 4 weeks, control group (group B) received manual physical therapy program) plus shockwave therapy, 3 times per week for 4 weeks. Results: Skin thickness and VSS decreased significantly in both groups after treatment compared with before treatment but the percent of decreasing of skin thickness and VSS in group A (44.25 and 46.45% respectively) was more than in group B (23.98 and 29.41% respectively). Conclusion: Shock wave treatment has a positive effect on the post-burn scar treatment but the positivity increase if combined with vacuum therapy.
EnglishVacuum therapy, Massage, Shock wave, Post-burn scar, Combining therapy, Hypertrophic scar
Introduction
A hypertrophic scar is the most serious functional problem that occurs after burn wounds. 1 Serious of the post-burn scar because it developed within few weeks after burning injury, its serious increase when it develops across a joint axis that is leading to limitation of joint range of motion. 2 The prevalence rate of post scars can be up to 60 % and the scar contracture up to 54 %. 3 Keloid is most serious than scar because it develops and grows beyond the burn wound boundaries. 4 High elastic skin areas (neck, anterior chest, and lower face) are common areas for post-burn scar development. 5 surgical removal of the scar and repair with flap or graft is one from scar treatments but there is a higher per cent for recurrence and tendency of scar formation in donor site of the graft or flap increase (in case of auto-graft). 2
Shockwave therapy is defined as a mechanical sound wave used originally in 1980 in the breakdown of kidney stones. Shockwave therapy causes micro-trauma during the breakdown of extra-collagen fibres in scar tissue and enhances the growth factor release for tissue remoulding and repair. 6 The breakdown effect of shockwave therapy is used in the treatment of calcaneal spurring, muscle fibrosis is also used in the improvement of wound healing and is nowadays used in the treatment of hypertrophic scar. 7
Vacuum massage (depression-massage or vacuum-therapy) is a non-invasive modality characterized by lifting layers of the skin by negative pressure (suction) effect and used to mobilize the skin folds.8 Vacuum massage as manual massage has a significant effect on scar properties but this effect lasts for short time (1-2 hours). 9
So our study was applied to clarify the efficacy of combining treatment vacuum massage and shockwave on the post-burn scar.
Methods & Materials:-
Forty patients with post-burn scars with age 20-40 years old were selected from outpatients clinics of physical therapy faculty, south valley university, Egypt, during the period from June 2020 to February 2021. Patients were randomly distributed into two equal groups, study group (group A) received a manual physiotherapy program (deep friction massage, stretching exercises) in addition to combining therapy of shockwave and vacuum massage 3 times/week for 4 weeks, control group (group B) received manual physiotherapy program (scar tissue mobilization, deep friction massage, pressure therapy, stretching exercises) in addition to shockwave therapy, 3 times/week for 4 weeks. Patients with skin abnormalities, immunodeficiency disorders, mature hypertrophic scars, diabetic patients, spinal cord injuries, peripheral paralysis, and pregnant female were excluded from this study.
Procedures:
Assessment procedures:
Ultrasonography:-
By using Toshiba Xario prime ultrasound machine.
U.S assessment applies to the higher point of the scar.
Then the ultrasonography assessment procedure was applied by the radiology specialist before treatment and after 4 weeks. (probe perpendicular to the skin).
The radiological specialist was the same person who applies the assessment each time
Vancouver scale:-
It was used to assess the scar tissue with parts (vascularity, pigmentation, pliability, and height) before and after 4 weeks of treatment and scored as follow:- 10,11
Treatment procedures:-
Deep friction massage, stretching exercise, and shock wave therapy was applied in both groups as follow:-
Deep friction massage:-
Put your fingertip pad perpendicularly on the scar tissue.
Then move across the scar band in the direction of surrounding normal fibres.
Then back and forth motion applied along the length of scar tissue. 12
Stretching exercises:-
Apply hot pack as preparation before stretching exercises for 10 min.
The apply stretching force in the anti-deformity direction for 1 min and relax for 30 sec. 12
Shockwave therapy:
Put the patient in a comfortable position that allows good vision for the treated area.
Apply shock wave therapy with 2500-3000 pulses.
In group A we applied vacuum massage therapy before application of shockwave therapy as follow:-
Vacuum massage therapy:-
Use PRUS device (Belgium)
The patient position should be comfortable and allow good vision for the area of application.
Set device parameters in intensity: 250-900 millibar, frequency: 0.25- 0.50 HZ for 10 min.
Then apply shockwave therapy directly after vacuum massage application.
Statistical analysis
Descriptive statistics and an unpaired t-test were applied to compare the age between both groups. Data Normal distribution was tested using the Shapiro-Wilk test for all variables. Variances homogeneity Levene’s test was applied to test the homogeneity between groups. Unpaired t-test was applied to compare the mean values of thickness and visual analogue scale (VSS) between group A and B. Paired t-test was applied to compare between before and after treatment in each group. The significance level for all statistical tests was set at p < 0.05. All statistical analysis was applied through the statistical package for social studies (SPSS) version 25 for windows (IBM SPSS, Chicago, IL, USA).
- Results
- Subject characteristics:
Forty subjects participated in this study. The mean ± SD age of study group (A) was 34.7 ± 6.86 years and that of group B was 35.55 ± 5.78 years. There was no significant difference between both groups in patients age (p = 0.67).
Effect of treatment thickness and VSS:
- Within-group comparison:
Thickness and VSS post-treatment compared with that pre-treatment in groups A and B significantly decreased (p > 0.001). The decreasing per cent in thickness and VSS in group A was 44.25 and 46.45% respectively, while that in group B was 23.98 and 29.41% respectively. (table 1, figure 1-2).
- Comparison Between groups:
Pre-treatment: there was no significant difference between groups (p > 0.05). Post-treatment: comparison between groups showed a significant decrease in thickness and VSS of group A compared with that of the group (p > 0.01). (table 1, figure 1-2).
Discussion:-
Our trial reported that patients with a hypertrophic scar treated with shockwave therapy and vacuum massage therapy in group A and patients treated with shockwave therapy in group B had a significant decrease in thickness & VSS after treatment compared with those before treatment (p > 0.001). But the decrease per cent in the thickness and VSS in group A (44.25 and 46.45% respectively) was more than in group B (23.98 and 29.41% respectively). So, the post-treatment groups Comparison revealed a significant decrease in thickness and VSS of group A compared with that of the group (p > 0.01).
Zaghloul et al. reported that post-burn hypertrophic scar thickness and appearance significantly decreased according to ultrasonographic measurement (42.55%) and VSS (48.57%) respectively post-application of shockwave therapy in addition to the physiotherapy program.1
Cho et al. revealed that scar pain decreased significantly after the application of shockwave therapy. Also, it was reported that hematological, molecular, microscopic and immunological responses in different cells and plasma decrease pain and induce tissue regeneration.13
Laura et al. reported that the destructive and stimulatory effects of shock waves are dose-dependent. They compared the effects of different doses of shock wave therapy on normal fibroblast proliferation in vitro. After 1 hour from the shock-wave application, the cell viability decreased related both to the energy and the shocks numbers applied: a constant decrease was observed to impulses number (300, 1,000, 2,000) with maximum viability decreasing at 2,000 impulses (18%) while there was no statistically significant association between energy levels and fibroblast viability. 14
Merete et al. reported that vacuum massage had a short-term effect on scar physical properties and there were significant changes in the density of the epidermal layer immediately after the treatment. The thickness of the dermal layer increased significantly immediately after the treatment; after 1 h, and decreased significantly after 2 h compared to baseline. The density of the dermal layer decreased significantly after treatment by vacuum massage, and even at 2 h after treatment, this decrease was still significant compared to baseline. 9
Serup et al. Myofibroblasts (cells responsible for pathological scar formation) were present in the pre-treated scars abundantly, but after application of mechanical pressure therapy myofibroblast activity was suppressed significantly and at the end, myofibroblasts disappeared by apoptosis and collagen fibre alignment improved. 15
Moortgat et al.8 in their review reported that vacuum massage therapy had a positive effect on physical as improvement of tissue hardness, skin elasticity16,17, skinfold thickness18, skin laxity19, skin roughness20, and decrease skin redness21. It also had a positive physiological effect as increasing numbers of fibroblast and collagen fibres.
Conclusion:-
From the gained results it could be concluded that shock wave therapy and vacuum massage therapy are effective in the treatment of the post-burn scar, but the combination treatment between vacuum massage and shock wave is more effective. This increase in effectiveness comes from the ability of vacuum massage to help the reorientation f collagen fibres and decrease the hardness of scar tissue, so it prepared the scar tissue before application of shockwave therapy.
Acknowledgement:-
The authors thank the members and staff of the faculty of physical therapy, south valley university and our colleagues in the department of burns in south valley university hospitals. Also great thanks to all patients who participated in our study.
Conflict of interest:
We have NO affiliations with or involvement in any organization or entity with any financial interest (such as honoraria; educational grants; participation in speakers’ bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
Individual author’s contribution:
Conceived the ideas and experimental design of the study. 1,3
Performed data collection.1,2
Data analysis and interpretation. 1,2,3
Primary author (wrote most paper) 1
Revision of scientific content of manuscript.2,3
Provide stylistic and grammatical revisions to the manuscript.1,3
Englishhttp://ijcrr.com/abstract.php?article_id=4231http://ijcrr.com/article_html.php?did=4231
Mahmoud SZ. et al. ‘Effect of Extracorporeal Shock Wave Therapy on Post Burn Scars’ /Int.J. PharmTech Res. 2016,9(3),p 78-85.
Chan SYJ.: “The effectiveness of extracorporeal shockwave therapy on hypertrophic scar appearance and hand mobility in a severe burn patient” Burns O.J. 4 (2020) 72–77.
Bombardo KM, Engrave LH, Carrougher GJ, Weichman SA, Faucher I, Costa BA, et al. 'extracorporeal shock wave therapy for the management of burn scars, Dermatol Surg 2012; 38: 778-82.
Roseborough, Mark A, Grevious and Raphael C Lee “Prevention and treatment of excessive dermal scarring”. J Natl Med Assoc. January 2004 96(1): 108– 116.
Cui HS., “Extracorporeal Shock Wave Therapy alters the expression of fibrosis-related molecules in fibroblast-derived from human hypertrophic scar” Int. J. Mol. Sci. 2018;19,124.
Fioramonti P; Cigna E; Onesti MG; Fino P; Fallico Ne; Scuderi N “Extracorporeal Shock Wave Therapy for the Management of Burn Scars” Dermatol surg., 2012; 38:778-82.
Z. Rezasoltani, S. Najafi, S. Azizi, B. Forough, N. Maleki and H. Fateh: “The comparison of Shock Wave therapy and Corticosteroid injection on the treatment of Plantar Fasciitis” Ann Mil Health Sci Res., 11 (2013), pp. 53-60.
Moortgat P. The physical and physiological effects of vacuum massage on the different skin layers": current status of the literature” Burns Trauma, (2016) 4:34.
Merete., "Short-term effects of vacuum massage on the epidermal and dermal thickness and density in burn scars: J Burn Care Res (2016) 4:27.
Sullivan T, Smith J, Kermode J, Mclver E, Courtemanche DJ. Rating the Burn Scar. J Burn Care Rehabil. 1990;11:256-260.
Truong PT, Lee JC, Soer B, Gaul CA, Olivotto IA. Reliability and validity testing of the Patient and Observer Scar Assessment Scale in evaluating linear scars after breast cancer surgery. Plast Reconstr Surg. 2007;119:487–494.
Zhang YT, Li-Tsang CWP, Au RKC. A Systematic Review on the Effect of Mechanical Stretch on Hypertrophic Scars after Burn Injuries" Hong Kong J Occup Ther., 2017; 29(1):1-9.
Cho D. Effect of extracorporeal shock wave therapy on scar pain in burn patients” A prospective, randomized, single-blind, placebo-controlled study. Medicine (2016) 95:32.
Laura B, Annamaria F, Anna MF, Patrizia ME, Maria GC and Roberto F. Acta Orthopaedica 2009, 80 (5): 612–617.
Serup J, Keiding J, Fullerton A, Gniadecka M, Gniadecki R. High-frequency ultrasound examination of the skin: introduction and guide. In: Serup J, Jemec GBE, Grove GL. Handbook of Non-Invasive Methods and the Skin. 2nd ed. 1995, p. 473–92.
Márquez-Rebollo C, Vergara-Carrasco L, Díaz-Navarro R, Rubio-Fernández D, Francoli-Martínez P, Sánchez-De la Rosa R. Benefit of endermology on indurations and panniculitis/lipoatrophy during relapsing-remitting multiple sclerosis long-term treatment with glatiramer acetate. Adv Ther. 2014;31: 904–14.
Majani UGO, Majani A. Tissue mechano-stimulation in the treatment of scars. Acta Medica Mediterr. 2013; 29:133–4.
Monteux C, Lafontan M. Use of the microdialysis technique to assess lipolytic responsiveness of femoral adipose tissue after 12 sessions of mechanical massage technique. J Eur Acad Dermatol Venereol. 2008;22: 1465–70.
Revuz J, Adhoute H, Cesarini J, Poli F, Lacarrière C, Emiliozzi C. Clinical and histological effects of the Lift 6 device used on facial skin aging. Les Nouv Dermatologiques. 2002; 21:335–42..
Bourgeois JF, Gourgou S, Kramar A, Lagarde JM, Guillot B. A randomized, prospective study using the LPG technique in treating radiation-induced skin fibrosis: clinical and profilometric analysis. Skin Res Technol. 2008;14:71–6.
Worret WI, Jessberger B. Effectiveness of LPG treatment in morphea. J Eur Acad Dermatol Venereol. 2004; 18:527–30.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Study of Incidence of Acute Kidney Injury in Acute Myocardial Infarction and its Impact on Hospital Outcome
English7379Deshpande AEnglish Shingade PEnglish Deshpande SEnglishEnglishAcute kidney injury (AKI), ST-segment elevation myocardial infarction (STEMI), Cardiogenic shock
INTRODUCTION-
Ischemic heart disease is the leading cause of death among adults in developed as well as in developing countries and accounts for a substantial fraction of the total disease burden globally. AKI (Acute kidney injury) is a common complication after acute myocardial infarction (AMI), affecting from 10 to 55% of the patients.1-4
AKI in STEMI has been consistently associated with a worse outcome, and namely with strikingly higher short-term and long-term mortality rates.3,5,6,
The overall survival of patients with ST-elevation myocardial infarction (STEMI) has significantly improved during the past two decades, due to the combined use of novel pharmacologic therapies and aggressive revascularization strategies.7 The interest of cardiologists is now shifting towards subsets of patients whose mortality remains very high, thus contributing to the overall mortality of STEMI. Those developing AKI represent a critical example of STEMI patients associated with a poor prognosis. A growing amount of data confirms the clinical and prognostic relevance of AKI in this clinical setting. However, it is worth noting that the current guidelines on the management of STEMI patients do not focus much attention on AKI. Surprisingly, while recommendations exist for the management of rare STEMI-associated complications, such as mitral valve rupture or Dressler pericarditis, no clear indications are provided on the management of this frequent complication.6,7Indeed, The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) Adding Insult to Injury AKI Study reported, in 2009, that only 50% of patients who died with AKI in different clinical contexts received good care. Therefore, this study was carried out to know the incidence of AKI in acute MI and its impact on hospital outcomes.
MATERIAL AND METHODS-
This prospective observational study was carried out on 224 patients of ST-elevation myocardial infarction (STEMI) in the intensive care unit of the tertiary care centre from December 2018-December 2020. Patients with acute ST-segment elevation myocardial infarction proven by ECG (ST-segment elevation > 0.1mV in at least 2 contiguous leads) and cardiac enzymes (Positive Troponin I or CPK-MB) were included in our study. Patients who presented with Non-ST Elevation MI (NSTEMI) /Unstable angina (UA), who had evidence of chronic kidney disease, who were on renal replacement therapy and any prior use of nephrotoxic drugs were excluded from the study. A complete history including sociodemographic characters and risk factors was taken. Detailed clinical examination and relevant investigations were done. Two groups were made according to the development of AKI based on KDIGO guidelines. Various complications and outcomes were compared between the two groups.
Statistical analysis- Collected data were entered into a Microsoft Excel spreadsheet. Tables and Charts were generated using Microsoft word and excel software. Continuous variables were presented as Mean ±SD. Categorical variables were expressed in frequency and percentages. Continuous variables were compared between with and without AKI by performing an independent t-test. Categorical variables were compared by performing a chi-square test. For small numbers, Fisher exact test was used. Multiple logistic regression analysis was performed to identify independent risk factors of acute kidney injury in patients of MI. Adjusted Odds ratio, 95%confidence interval & p-values were reported. P-value < 0.05 was considered as statistical significance. Statistical software STATA version 14.0 was used for data analysis.
RESULTS-
Out of 224 patients, 57 patients (25.45%) developed AKI and 167 patients (74.55%) did not develop AKI(Table-1). So, the incidence in our study was 25.45%. The mean age of patients in the AKI Group and Non-AKI Group was 59.97 ±10.96 and 53.97±10.96 respectively(Table-2). There was a statistically significant difference between mean age and incidence of AKI. Out of 224 patients, 137 were males (61.16%) and 87 were females (38.84%). Out of the total of 137 males, 41 males (29.93%) developed AKI. Out of the total of 87 females, 16 females (18.40%) developed AKI(Table-3). There was no significant difference between the two groups. When various risk factors were compared in both the groups, diabetes and higher BMI were found to be significantly associated with AKI. Alcohol, smoking, hypertension and dyslipidemia were not found to be significant(Table-4). The maximum number of patients is 41.9% who had AWMI (anterior wall myocardial infarction). There was no statistically significant difference in the area of myocardium involved and AKI. Various clinical parameters at the time of admission were compared between the two groups. Heart rate, systolic blood pressure, diastolic blood pressure and random blood sugar were found to be highly significant(Figure-1). Mean EF in the AKI group was found to be 38.85±6.65 and in the non-AKI group, it was 44.04±5.29(Table-5). This indicates that lower EF is significantly associated with the development of AKI. Patients of AKI were divided based on severity(Figure-2). Out of 57 patients, 23 patients were in mild, 22 is moderate and 12 in severe category respectively. Total 44 patients (19.64%) developed cardiogenic shock. 33 patients (75%) developed AKI and 11 patients (25%) did not develop AKI(Table-6). There was a statistically significant increase in the number of patients developing AKI who developed cardiogenic shock.
A total of 29 patients (12.94%) had evidence of LVF in the study. Out of the 29 patients, 25 patients (86.20%) developed AKI and 4 patients (13.80%) did not develop AKI. There was a statistically significant difference in both groups.
A total of 18 patients (8.03%) in the study developed arrhythmias. 15 patients (83.33%) developed AKI and 3 patients (16.67%) did not develop AKI. This difference was found to be statistically significant.
Total 7 patients (3.12%) in the study developed AV blocks. 1 patient (14.29%) developed AKI and 6 patients (85.71%) did not develop AKI. Statistically, there was no significant association of AV blocks with AKI.
Total 19 deaths (8.48%) occurred in the study. 16 deaths (28.07%) occurred in AKI and 3 deaths (1.79%) occurred in non-AKI(Table-7). This difference was statistically highly significant. It means that mortality was very high in patients who had AKI. A higher length of hospital stay was seen in deaths and discharge of the AKI group. Using multiple logistic regression age, history of diabetes, tachycardia, hyperglycemia, low EF, presence of cardiogenic shock and arrhythmias were independent risk factors for AKI (Table-8).
DISCUSSION-
In our study out of the total 224, 57 developed AKI (25.45%) and 167 patients did not develop AKI (74.55%). The incidence of AKI in our study was 25.45%. The overall incidence of AKI is reported 10 to 55 % in various studies.1-4 Wang et al. and Amit Amin et al. reported incidence of 26% and 22.5% respectively which was similar to the present study.8,9
The mean age in the AKI group was 59.97±10.96 and in the non-AKI group was 53.97±10.96 respectively. When compared statistically the difference was found to be significant. Rodrigues et al., Reinstadler et al. and Bruetto et al. reported similar findings.1,10,11 So higher the age higher the chance of developing AKI. The reason could be that in the absence of a specific disease, the kidney undergoes age-dependent structural and functional alterations leading to a significant decrease in renal mass, functioning nephron numbers, and baseline kidney function.12
Out of the total 224 patients of STEMI, there were 137 males (61.16%) and 87 females (38.84%).
Other studies like Yan Bei Sun et al. and Bruetto et al. also showed male preponderance.1,13
Various risk factors were compared between both the groups which included hypertension, diabetes, alcohol intake, smoking, BMI and dyslipidemia. Out of this diabetes and increased BMI were significantly associated with AKI.
Reinstadler et al. and Moriyama et al. also studied same factors. But the statistically significant difference was found only with diabetes.11,14 Various clinical and laboratory parameters on admission were considered which included heart rate(HR), systolic blood pressure(SBP), diastolic blood pressure(DBP), random blood sugar(RBS). So, tachycardia, low SBP, low DBP and increased RBS were found to be significantly associated with AKI.
Tachycardia was also found significant by Moriyama et al. and Fox et al.14,15
Increased heart rate could be explained by increased sympathetic activity in left ventricular failure and reactive tachycardia due to cardiogenic shock. Low SBP and DBP were found highly significant in the studies by Moriyama et al. and Wang et al.9,14
This is explained by the fact that reduction in blood pressure which could be a result of cardiogenic shock reduces renal perfusion thus leading to AKI.In our study stress hyperglycemia was associated with increased incidence of AKI. This fact was also supported by Yan Bei Sun et al.
Hyperglycemia may thus represent an epiphenomenon of the stress response mediated by cortisol and catecholamines, whose release is elicited by the hemodynamic compromise or myocardial damage. Hyperglycemia exerts a direct negative impact on renal function.16
When LV function was assessed by echocardiography there was a significant association of low EF with AKI. Reinstadler et al. showed a significant association of cardiac magnetic resonance (CMR) determined cardiac function and myocardial damage with the development of AKI.
Out of 224 patients, 44 patients (19.64%) had evidence of cardiogenic shock.
Out of 44 patients, 33 patients had AKI (75%) and 11 patients (25%) did not develop AKI. There was a significant association between cardiogenic shock and the development of AKI.
Cong Wang et al. reported 36 patients with cardiogenic shock. Out of which 32 patients (88.88%) had AKI and 4 patients (11.12%) did not have AKI. This indicates that the presence of cardiogenic shock increases the susceptibility to AKI. When LVF was considered in our study, 29 patients (12.94%) had LVF.Out of 29 patients, 25 patients (86.20%) developed AKI and 4 patients (13.80%) did not develop AKI. So, it shows that LVF plays a major role in the development of AKI. In the study by Cong Wang et al., 76.51% of patients with LVF developed AKI.So, their findings are comparable with our study.9
There was evidence of arrhythmia in 18 patients (8.03%) out of 224.
Out of them, 15 patients (83.33%) developed AKI and 3 patients (16.67%) did not develop AKI. So, the presence of arrhythmia makes the patient prone to the development of AKI.
The finding in our study was also supported by Cong Wang et al.9
The mortality in our study was 28.07% in the AKI group and 1.79% in the non-AKI group. So, the development of AKI in STEMI increases mortality. This observation was also supported by the study of Moriyama et al.14
CONCLUSION-
AKI developing in patients with acute myocardial infarction is associated with a higher rate of complications and in-hospital mortality.
Acknowledgment-authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of this manuscript. The authors are also grateful to the authors 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
ETHICAL CLEARANCE- Taken
Englishhttp://ijcrr.com/abstract.php?article_id=4232http://ijcrr.com/article_html.php?did=4232
1. Bruetto RG, Rodrigues FB, Torres US, Otaviano AP, Zanetta DMT, et al. Renal Function at Hospital Admission and Mortality Due to Acute Kidney Injury after Myocardial Infarction. 2012;PLoS ONE 7(4): e35496.
2. Goldberg A, Hammerman H, Petcherski S, Zdorovyak A, Yalonetsky S, et al. In-hospital and 1-year mortality of patients who develop worsening renal function following acute ST-elevation myocardial infarction. Am Heart J. 2005;150:330–337.
3. Parikh CR, Coca SG, Wang Y, Masoudi FA, Krumholz HM. Long-term prognosis of acute kidney injury after acute myocardial infarction. Arch Intern Med. 2008;168:987–995.
4. Marenzi G, Assanelli E, Campodonico J, De Metrio M, Lauri G, et al. Acute kidney injury in ST-segment elevation acute myocardial infarction complicated by cardiogenic shock at admission. Crit Care Med. 2008;38:438–444.
5. Anzai A, Anzai T, Naito K, Kaneko H, Mano Y, Jo Y, Nagatomo Y, Maekawa Y, Kawamura A, Yoshikawa T, Ogawa S. Prognostic significance of acute kidney injury after reperfused ST-elevation myocardial infarction: synergistic acceleration of renal dysfunction and left ventricular remodeling. J Cardiac Fail. 2010 May 1;16(5):381-389.
6. James MT, Ghali WA, Knudtson ML, Ravani P, Tonelli M, Faris P, et al; Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) Investigators. Associations between acute kidney injury and cardiovascular and renal outcomes after coronary angiography. Circulation. 2011;123:409-416.
7. Stewart JA. Adding insult to injury: care of patients with acute kidney injury. Br J Hosp Med. (Lond) 2009;70:372-373.
8. Amin AP, Salisbury AC, McCullough PA, Gosch K, Spertus JA, Venkitachalam L, et al. Trends in the incidence of acute kidney injury in patients hospitalized with acute myocardial infarction. Arch Intern Med. 2012;172:246-253
9. Cong Wang, Yuan-Yuan Pei. Risk factors for acute kidney injury in patients with acute myocardial infarction. Chinese Med J. 2019;132(14):1660-1665.
10. Rodrigues FB, Bruetto RG, Torres US, Otaviano AP, Zanetta DM, Burdmann EA. Incidence and mortality of acute kidney injury after myocardial infarction: a comparison between KDIGO and RIFLE criteria. PloS one. 2013 Jul 23;8(7):e69998.
11. Sebastian Johannes Reinstadler, Andreas Kronbichler. Acute kidney injury is associated with microvascular myocardial damage following myocardial infarction. Kid Int. 2017;92:743–750.
12. Rosner MH. Acute kidney injury in the elderly. Aging Health. 2009;5:635–647.
13. Sun YB, Liu BC, Zou Y, Pan JR, Tao Y, Yang M. Risk factors of acute kidney injury after acute myocardial infarction. Renal Fail. 2016 Oct 20;38(9):1353-1358.
14. N.Moriyama. Early development of acute kidney injury is an independent predictor of in-hospital mortality in patients with acute myocardial infarction. J Card. 2017;69:79–83.
15. Caroline S. Fox Shor-Term Outcomes of Acute Myocardial Infarction in Patients With Acute Kidney Injury. Circulation. 2012;125:497-504.
16. Persson PB, Patzak A: Renal hemodynamic alterations in contrast medium-induced nephropathy and the benefit of hydration. Nephrol Dial Transp. 2005;20(suppl 1):i2–i5.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Influence of Low Birth Weight and Preterm Birth on Morbidity, Mortality and Medication Use among Neonates in Resource-Limited Settings: A Prospective Observational Study
English8085Pradeepkumar BhupalamEnglish Sowjanya NalampatiEnglish CB. Jyostna AngielEnglish T. GowthamiEnglish Goruntla NarayanaEnglish Kanala Somasekhar ReddyEnglish Chintaginjala HaranathEnglish MV. Sunil KumarEnglish Abdul AhadEnglish
Introduction: The birth rate in India is estimated to be 26,932,586 per year. Of these 27 million babies born each year, 1 million babies die before the age of 1 month; India carries the highest share with 30% of global neonatal mortality. Three neonates are dying every minute in India and every fourth baby born has a low birth weight. Low birth weight directly or indirectly contributes to 60- 80% of all neonatal death. Aim: We aimed to assess the impact of preterm birth and low birth weight on medical conditions, medications use and mortality among neonates in a resource-limited setting. Methodology: A prospective observational study was conducted at the neonatal intensive care unit (NICU) over 6 months. Neonates of either sex admitted to NICU and who received at least one medication were enrolled in the study. Perinatal and demographic data, reasons for NICU admission, medications prescribed, and discharge status were documented and analysed. Result: Four hundred and four neonates were included in the study: 61.1% were boys, 38.9% were girls. Respiratory distress syndrome (n=120, 29.7%), neonatal jaundice (60, 14.85%), and sepsis (44, 10.9%) were the most commonly observed conditions and were significantly more common among preterm and low birth weight neonates. Nearly half of the medications prescribed were antibiotics (n=1113, 49.6%). The mean number of medications prescribed to each neonate is 5.5. The mortality rate was significantly higher in extremely preterm and very preterm when compared to term neonates. Conclusion: Medical conditions, medications prescribed and the mortality rate was significantly higher among preterm and low birth weight neonates admitted in the NICU that are included in the study.
EnglishLow birth weight, Preterm birth, Mortality, Medication use, Neonates, Resource limited setting
Introduction
As per WHO, birth before 37 weeks of gestation is defined as preterm birth (PTB) and less than 2500 grams of body weight as low birth weight (LBW). PTB and LBW babies are more prone to severe morbidity and mortality in the neonatal stage.1As per WHO estimate globally, 15 million preterm births per year, and India ranked with the highest number of preterm births of 3.5 million approximately.1,2As per UNICEF estimate globally 3.9 million infant deaths per year, 1 million deaths (Approximately 25.6%) carried by India.3,4Preterm birth complications are the leading cause of death among children under 5 years of age, responsible for nearly one million deaths in 2015. Three neonates are dying every minute in India and every fourth baby born has a low birth weight.5directly or indirectly contributes 60–80% of all neonatal deaths. On average, 12% of babies are born preterm in low-income countries compared to 9% in high-income countries. WHO identified that half of the babies born at or below 32 weeks (2 months early) die due to a lack of feasible and cost-effective care in low-income countries, such as warmth, breastfeeding support, and basic care for infections and breathing difficulties.2There is a scantiness of research on outcomes of PTB and LBW in India and no studies in rural recourse limited settings of India. In this context, this study was conducted with an aim to assess the impact of PTB and LBW on morbidity, drug usage, and mortality among neonates in a rural resource-limited setting.
Methods
A prospective observational study was conducted in a neonatal intensive care unit (NICU) at a rural recourse limited setting of Anantapur district, Andhra Pradesh, India over six months from April 2019 to September 2019. The study was initiated after clearance from the ethics committee (Approval No: RIPER/IRB/PP/2019/06). Irrespective of gender, neonates admitted in NICU were included in the study after taking consent from guardian/parent. Neonates under observation, fluid replacement, nutritional supplements, vaccination and phototherapy without one or more medication use were excluded from the study. The sample size was calculated as 404 using Epi-info 7 das software version 7.2.3.1 (CDSCO, Atlanta, USA) with the assumption of 50% probability, design effect 1, error 5%, CI 95% and 5% non-response rate. Study participants were categorised based on gestational age (GA) as extremely preterm (EPT: Less than 28 weeks), very preterm (VPT: 28-32 weeks), moderate to late preterm (MLPT: 33-37 weeks) and term (More than 37 weeks). Study participants were classified based on birth weight as extremely low birth weight (ELBW: Less than 1000 Grams), very low birth weight (VLBW: 1000-1499 Grams), low birth weight (LBW: 1500-2499 Grams) and normal birth weight (NBW: Equal or more than 2500 Grams). All required data was collected by using a data collection form which consists of demographic details which include name, age, gender, patient ID, birth weight, gestational age, medical condition, medications prescribed including dose, frequency, duration of therapy, route of administration and discharge status of the patient. Graph Pad Prism 3.0 software (San Diego, California, USA) software was used for the statistical analysis. Descriptive statistical analysis for categorical variables was performed by calculating the frequencies and percentages; the chi-square test was used to compare categorical variables. An unpaired t-test was used to compare continuous variables. p-value < 0.05 was considered statistically significant.
Results
A total of 404 neonates were included in the study with a mean (SD) age of 8.06 (7.46) days and a median of 6 days. 66.1% were boys, preterm 35.15 %, and 40.1 % were underweight as shown in Table 1.
A major reason for NICU admission was respiratory distress syndrome (RDS) 29.7%, neonatal jaundice 14.85%, sepsis 10.9%, and birth asphyxia 8.4% as shown in Table 2.
Compared to term neonates, RDS and birth asphyxia were significantly higher in very preterm and moderate to late preterm neonates. Compared to normal birth weight neonates, RDS and seizures were significantly higher in very low birth weight and low birth weight, birth asphyxia was significantly higher in very low birth weight neonates as shown in Table 3.
At the time of discharge, out of 404 participants included in study 298 (73.8%) were clinically active and feeding well. The mortality rate was 32 (7.92%), 30 (7.4%) of neonates were discharged against medication and 44 (10.9%) neonates were discharged at a request. Overall death rates in extremely preterm (16.7%) and very preterm (4.34%) were significantly higher compared to term (10.7%) neonates as shown in Table 4.
A total of 2,243 medications were prescribed to all neonates included in the study, on average, each neonate has prescribed 5.5 medications. Of all the medications prescribed 1113 (49.6%) were antibiotics and the remaining 1130 (50.4 %) were non- antibiotics as shown in Table 5. According to the ATC classification system, most of the antibiotics were prescribed for systemic use followed by oral and topical use. Analysis based on the WHO core indicators revealed that an average of 5.5 medications was prescribed per encounter. Among all the medications prescribed 90% of medications were prescribed by generic name and all the medications prescribed among all the neonates included in the study were on the National essential medication list and on the WHO essential medicines list for children.
SD: Standard deviation, LBW: Low birth weight VLBW: Very low birth weight, ELBW: Extremely low birth weight.
Discussion
The main objective of this study is to assess the impact of preterm birth and low birth weight on medical conditions, medications use and mortality among neonates. Our study revealed that out of 404 patient’s majority of them are baby boys 247(61.1%) and baby girls157 (38.9%). A similar pattern was observed in studies conducted in Central India (59.3%) baby boys and East India (62.5%) baby boys.[5,6] The prevalence of preterm (35.1%) and low birth weight (40.1%) babies in our study were lower compared to a study conducted in Central India (54.8% and 73%, respectively) and higher compared to a study conducted in east India.5,6
The most common condition for NICU admission was RDS (Respiratory distress syndrome), followed by sepsis and neonatal jaundice and the most reason was Tachypnoea. RDS was the commonly observed condition among all categories of neonates according to the GA and birth weight.
The majority of neonates in extremely preterm, very preterm and moderate to late preterm categories experience RDS and neonatal jaundice.
The mean number of medications prescribed to neonates in our study was 5.5 medications per neonate and was consistent with published data between 3.7 and 8.6 medications per neonate.7,8 Majority of the medications prescribed to neonates included in our study were antibiotics. Gentamycin was the most commonly prescribed antibiotic among neonates and a similar pattern was observed in previous studies conducted in the UK, USA, Australia and Germany.7,9
The most commonly prescribed off-label drugs in NICU were Gentamycin, Ampicillin, Amikacin, Cefotaxime etc. was observed in our study is similar to the studies conducted in NICU, Iran 2019. The choice of antibiotic regimens varies to different hospitals according to their hospital policies.
The overall neonatal mortality rate in our study was 7.9% (32/404). The babies born extremely preterm had the highest mortality rate (16.7%) compared to others. Systematic analysis of Indian data identified that preterm birth complications cause 43.7% of neonatal deaths.10,11
The strengths of the present study include the systematic follow-up of neonates admitted in NICU to identify the medication utilization and to assess the prevalence and impact of preterm birth and low birth weight and medical conditions, medication use and neonatal mortality.12,13 Our study provides data about health outcomes and medication use among neonates in NICU in a secondary care hospital serving patients mainly of low socio-economic backgrounds. As this study is a single-centred study, our results may be different from outcomes at other hospitals of Andhra Pradesh and Telangana 8,14,15.
Conclusion: Respiratory distress syndrome was the most commonly observed medical condition among neonates and associated with the prescribing of more medications especially antibiotics. The mortality rate was higher in birth asphyxia. Medical conditions, medications prescribed and the mortality rate was significantly higher among preterm and low birth weight neonates compared to term and normal weight neonates.
Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Conflict of Interest: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=4233http://ijcrr.com/article_html.php?did=4233
WHO.Pretermbirth.https://www.who.int/news-room/fact/sheets/detail/preterm-birth. [Last accessed 2018 December 11].
Krishna U, Bashar TSM, Parthasarathi G, Srinivasa MD. Impact of preterm birth and low birth weight on medical conditions, medication use, and mortality among neonates: A prospective observational study.World J Pediatr. 2019;15(3):281-8.
The World Counts. How many babies are born each day? http://www.the world Counts.Com/Stories/How-Many-Babies-Are-Born-Each-Day. [Last accessed 2018 December 11].
Med India. Indian population clock. https://www.medindia.net/patients/calculators/pop_clock.asp. [Last accessed 2018 December 11].
Chatterjee S, Mandal ALN, Mukherjee S, Singh AK. Drug Utilisation study in a neonatology unit of a tertiary care hospital in eastern India. Pharmacoepidemiol Drug is safe. 2007; 16: 1141-5.
Chautankar SA, Marathe PA, Potey AV, Nanavathi RN. Drug utilization in neonatal intensive care unit of a tertiary–care hospital in Mumbai, India. Indian paediatrics. 2017:54:931- 4.
Donnell CPF, Stone RJ, Morley CJ. Unlicensed off-label drug use in Australian intensive care unit. Pediatrics 2002; 110:52.
Kieran EA, Callaghan N, Connell CPF. Unlicensed and off-label drug use in an Irish neonatal intensive care unit: a prospective cohort study. Acta Paediatr. 2014:103;139-42.
Neubert A, Lukas K, Leis T, Dormann H, Brune K, Rascher W. Drug utilization on a preterm and neonatal intensive care unit in Germany: A prospective, cohort-based analysis. Eur J Clin Pharmacol. 2010;66:87-95.
Sankar MA, Neogi SP, Sharma J, Chauhan M, Srivastava R, Prabhakar PK, et al . State of newborn health in India. J perinatal. 2016; 36:3-8.
Vladislava Z, Megan RS, Kyungjoon L, Lina G, Monika AZ, Black MJ. Low Birth Weight due to Intrauterine Growth Restriction and/or Preterm Birth: Effects on Nephron Number and Long-Term Renal Health. Int. J. Nephr.2012;12: 1-13.
Cunha GS,Mezzacappa F,Riberiro JD.Maternal and neonatal factors affecting the incidence of bronchopulmonary dysplasia in very birth weight newborns.J Pediatr.2003:79:550-6.
Bhupalam P, Tawfeek A, Goruntla N, Reddy YP and Jinka D Assessment of antibiotic prescribing pattern in pediatric patients: A cross-sectional hospital-based survey. CHRISMED J Health Res. 2017;4:235-7.Citation metadata
Laforgia N. Nuccio MM, Schettini F, Dell’ Area M, Gasbarro AR, Dell’ Erba A, et al. Off-label and unlicensed drug use among neonatal intensive care unit in Southeren Italy. Pediatr Int. 2014; 56:7-9.
Warrier I, Du W, Natarajan G,SalariV,ArandaJ.Patterns of drug utilization in a neonatal intensive unit. J Clin Pharmacol.2006; 46:612-20.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Bisap Score and Ranson’s Score in Predicting Severity of Acute Pancreatitis: A Comparative Study
English8693Kommi SwethaEnglish Chakravarthy D J KEnglish Eli Lakshmi AdityaEnglish C RadhamaniEnglish Vallepalli RamakrishnaEnglish
Introduction: Acute pancreatitis is an inflammation of the pancreas, due to alcohol or gallstones. Severe pancreatitis may lead to higher morbidity and mortality. Early, an efficient and structured scoring system is required to know the potential outcome of the patient. Aims: The study aims to assess the accuracy of the bedside index for severity in acute pancreatitis (BISAP) and Ranson’s scoring system and to compare both in predicting the severity of acute pancreatitis. Methodology: This is a cross-sectional observational study of 90 patients with acute pancreatitis admitted to GSL medical college and general hospital, Rajahmundry. Results: The mean age of the study group was 38.34 ± 10.41 years. Of the total 90 patients, 47 patients had mild disease, 27 patients had moderately severe courses, and 16 patients had severe courses. Renal failure was the most common organ dysfunction in severe acute pancreatitis and the Mortality rate in this study was 1.1%. Ranson’s score had a sensitivity of 93.75% (95% CI 69.77%--99.84%), specificity of 94.59% (95% CI 86.73%--98.5%). BISAP score had a sensitivity of 87.5% (95% CI 61.65% -- 98.45%), specificity of 98.6% (95% CI 92.7% -99.97%). Conclusion: Ranson’s score had a higher sensitivity and BISAP had higher specificity in the prediction of severe pancreatitis. Components of the BISAP scoring system are easily available when compared to Ranson’s scoring system as the latter may require 48 hours for completion of the assessment.
EnglishAcute pancreatitis, BISAP score, Ranson’s score, Abdominal pain, Renal failure, Pleural Effusion
INTRODUCTION
Acute pancreatitis is a sudden inflammation of the pancreas, involving peripancreatic tissue and multiple organs. It results from a complex process with a variable aetiology and natural histories, and early identification of patients at high risk can be difficult.
Most episodes of acute pancreatitis (80%) are mild and self-limiting without sequelae. In 10-20% of cases of acute pancreatitis, necrosis will develop in various parts of the pancreas and the surrounding tissue. In such cases systemic inflammatory response syndrome and/or multiorgan failure is seen, may result in death.1,2 Unpredictable and variable individual responses are seen in pancreatic injury.
Pancreas has both exocrine and endocrine functions. Alcohol intake and biliary tract diseases account for the majority of cases (90%) of acute pancreatitis. In Europe and Asia, gallstone-associated pancreatitis predominates. Gallstones are responsible for 50 – 60 % and alcohol for 8 – 32 % of attacks of acute pancreatitis in the U.K.3 Moreover, females are more prone to gallstone pancreatitis, and males for alcohol-induced pancreatitis.
In more than 90% of patients, the predominant feature of acute pancreatitis is a pain in the abdomen. Pain is mostly in the epigastrium, constant, boring, or penetrating, and may radiate to the back. Pain starts 12-48 hours after a bout of alcohol or after a large meal in case of gallstone pancreatitis. Fever, vomiting, tachycardia, epigastric tenderness, hypoactive or absent bowel sounds, and abdominal distension are the other features. Other manifestations include pleural effusion (mostly left side), ascites, and elevation of left hemidiaphragm with tachypnoea, dyspnoea, and cyanosis. Painless pancreatitis, although uncommon, is a definite and well-recognized entity. The evaluation of pancreatic enzymes (Lipase and Amylase) released from the inflamed tissue is the cornerstone of a biochemical diagnosis of acute pancreatitis.4
The simultaneous determination of amylase and lipase offers sensitivity and specificity of 90 to 95 % for detecting acute pancreatitis in patients presenting with acute abdominal pain.5 Contrast-Enhanced Computed Tomography (CECT) is the imaging modality of choice.
Many multifactor scoring systems such as Ranson’s criteria, BISAP, APACHE-II (Acute Physiology and Chronic Health Enquiry) have been described in an attempt to accurately predict the outcome of the disease.
BISAP SCORING SYSTEM
In 2008, Wu et al.6 retrospectively developed a new scoring system, the bedside index for severity in acute pancreatitis (BISAP), to estimate the risk of in-hospital mortality in patients with acute pancreatitis.
Components of the BISAP score include
1. Age > 60 years
2. Bun > 25 mg/dl
3. Impaired mental status (Glasgow coma scale score < 15)
4. SIRS- is defined as two or more of the following:
Temperature of < 36 or > 38 ° c
Respiratory rate > 20 breaths/min or paco2 < 32 mm hg
Pulse > 90 beats/min
WBC < 4,000 or >12,000 cells/mm3 or >10% immature bands
5. Pleural effusion detected on imaging.
One point is assigned for each variable within 24 hrs of presentation. Score ≥3 is read as severe acute pancreatitis (SAP).
The severe disease should be predicted by careful clinical assessment, together with a multiple-factor scoring system and imaging studies.1 Several scoring systems can predict severe complications, but current methods of risk stratification of acute pancreatitis are complex as the data required is not collected at an early stage.17
The bedside index for severity in acute pancreatitis (BISAP) is a pretty simple and precise method for identifying the risk of in-hospital death.1 this study aimed to evaluate the usefulness of the BISAP scoring system as an early severity scoring system, to evaluate Ranson’s scoring system and to compare BISAP with Ranson’s scoring system.
MATERIALS AND METHODS
The present study was carried out in the department of General medicine, GSL Medical College and General Hospital, Rajahmundry from 1st October 2018 TO 30th June 2020 with the approval of the Institutional Ethics committee (485-EC/485-09/18). It is a cross-sectional observational study. A total of 90 cases were studied.
All patients aged more than 20 years with history and clinical findings suggestive of acute pancreatitis with evidence of elevated pancreatic enzymes serum amylase, lipase and bulky oedematous pancreas on USG abdomen were included in the study. Patients having structural abnormalities of the pancreas, chronic pancreatitis, recurrent acute pancreatitis and carcinoma of the head of the pancreas were excluded.
All the selected patients were subjected to detailed clinical examination, laboratory investigations and radiological imaging. The BISAP score was calculated using data of the first 24-hours from admission and the Ranson's score using data from the first 48 hours of hospitalization. Computed Tomography (CT) or Magnetic Resonance Imaging (MRI) or Ultrasound imaging of the abdomen was obtained at any time in the first seven days of hospitalization was used to differentiate necrotizing from interstitial pancreatitis. The scores were compared with the clinical severity, which was graded according to the revised Atlanta classification. Persistent organ failure was graded by the Modified Marshall scoring system.
All the patients were graded as having mild, moderately severe, and severe acute pancreatitis based on the revised Atlanta classification. Patients with mild acute pancreatitis had no local complications or organ failure. Patients with moderately severe acute pancreatitis had transient organ failure or local or systemic complications or both, whereas patients with severe acute pancreatitis had persistent organ failure.
According to Marshall score, Organ failure is defined as the involvement of ≥ 2 organ systems in one or more of the three (respiratory, renal, and cardiovascular) out of the five. For all patient’s organ failure scores were calculated every 24 hours.
Patients with acute oedematous pancreatitis were managed in the general ward while those with severe disease (Ranson’s and BISAP score > or =3) were admitted to an intensive care unit. Standard management protocols were followed for treating all patients till discharge.
Data were analysed using SPSS software version 17. Different scores on Ranson’s and BISAP were compared to vital signs, haematological parameters, and biochemical parameters that denote organ failure using one-way ANOVA. Ranson’s and BISAP scores were compared in assessing organ failure, pleural effusion using Pearson’s chi-square test for proportions. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for both BISAP and Ranson’s scores. Receiver operator curves (ROC) for SAP and pancreatic necrosis were plotted for Ranson’s score and BISAP score. Ranson’s score and BISAP score was compared along with organ failure using Kendall’s coefficient of concordance. Linear regression for organ failure as an outcome variable was carried out using biochemical parameters, Ranson’s, and BISAP score, pleural effusion as predictor variables.
RESULTS
A total of 90 persons with features of acute pancreatitis, 81(90%) males and 9(10%) females who fulfilled the inclusion criteria were enrolled in this study after obtaining informed consent. The mean age of the study group was 38.34 ± 10.41 years. The cause of acute pancreatitis was gallstones in 15 patients (16.7%), alcohol in 57 patients (63.3%), hypertriglyceridemia in one patient (1.1%) and idiopathic in 17 patients (18.9%). Abdominal pain was present in 78 (86.7%) patients and vomiting in 25 (27.8%) patients (Table-1). There was a significant difference in the means of various Ranson’s scores with Respiratory rate (RR) (p=0.001), mean Glasgow coma scale (GCS) (p=0.00), mean systolic blood pressure (p= 0.005), mean Total leucocyte count (TLC) (pEnglishhttp://ijcrr.com/abstract.php?article_id=4234http://ijcrr.com/article_html.php?did=4234
Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, Slivka A et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010 Feb;105(2):435-41
Pezzilli R, Zerbi A, Di Carlo V, Bassi C, Delle Fave GF; Working Group of the Italian Association for the Study of the Pancreas on Acute Pancreatitis. Practical guidelines for acute pancreatitis. Pancreatology. 2010;10(5):523-35.
Poston GJ, Williamson RC. Surgical management of acute pancreatitis. Br J Surg . 1990 Jan;77(1):5-12.
Tenner S, Baillie J, DeWitt J, Vege SS; American College of Gastroenterology. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013 Sep;108(9):1400-15; 1416.
Klaus M, John B.Acute Pancreatitis. BMJ 1998; 316: 44-8.
Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, Banks PA. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut. 2008 Dec;57(12):1698-703.
Banday IA, Tattoo I, Khan AM, Javeed J, Gupta G, Latief M. Modified Computed Tomography Severity Index for Evaluation of Acute Pancreatitis and its Correlation with Clinical Outcome: A Tertiary Care Hospital Based Observational Study. J Clin Diagn Res. 2015 Aug;9(8): TC01-5.
Khanna AK, Meher S, Prakash S, Tiwary SK, Singh U, Srivastava A et al. Comparison of Ranson, Glasgow, MOSS, SIRS, BISAP, APACHE-II, CTSI Scores, IL-6, CRP, and Procalcitonin in Predicting Severity, Organ Failure, Pancreatic Necrosis, and Mortality in Acute Pancreatitis. HPB Surgery: 2013 ;2013:367581.
Harshit Kumar A, Singh Griwan M. A comparison of APACHE II, BISAP, Ranson's score and modified CTSI in predicting the severity of acute pancreatitis based on the 2012 revised Atlanta Classification. Gastroenterology Report. 2018 May;6(2):127-131.
Tarique S, Sarwar S, Iqbal F. Validity of Ranson's Score for Predicting Mortality and Morbidity in Acute Pancreatitis. Proceedings S.Z.P.G.M.I. 2003;17(2):67-70.
Arif A, Jaleel F, Rashid K. Accuracy of BISAP score in prediction of severe acute pancreatitis. Pak J Med Sci. 2019 Jul-Aug;35(4):1008-1012.
Yadav J, Yadav SK, Kumar S, Baxla RG, Sinha DK, Bodra P et al. Predicting morbidity and mortality in acute pancreatitis in an Indian population: a comparative study of the BISAP score, Ranson’s score and CT severity index, Gastroenterology Report, 2016 Aug;4(2):216-220.
Lalithkumar J, Chitra T, Kodieswaran N. Comparative study between BISAP and Ranson’s score in predicting the severity of acute pancreatitis. IAIM, 2016; 3(9): 23-33.
Karki S, Karki B, Thapa S, Shrestha R, Poudel BN, Shrestha R. Accuracy of bedside index for severity in acute pancreatitis ‘BISAP’ score in predicting the outcome of acute pancreatitis. JPAHS 2020Aug;7(2):70-76.
Cho JH, Kim TN, Chung HH, Kim KH. Comparison of scoring systems in predicting the severity of acute pancreatitis. World J Gastroenterol. 2015 Feb 28;21(8):2387-94.
Garg PK, Madan K, Pande GK, Khanna S, Sathyanarayan G, Bohidar NP et al. Association of extent and infection of pancreatic necrosis with organ failure and death in acute necrotizing pancreatitis. Clin Gastroenterol Hepatol. 2005 Feb;3(2):159-66.
Simoes M, Alves P, Esperto H, Canha C, Meira E, Ferreira E et al. Predicting Acute Pancreatitis Severity: Comparison of Prognostic Scores. Gastroenterology Res. 2011 Oct;4(5):216-222.
Chatterjee R, Parab N, Sajjan B, Nagar VS. Comparison of Acute Physiology and Chronic Health Evaluation II, Modified Computed Tomography Severity Index, and Bedside Index for Severity in Acute Pancreatitis Score in Predicting the Severity of Acute Pancreatitis. Indian J Crit Care Med. 2020 Feb;24(2):99-103.
Zhang J, Shahbaz M, Fang R, Liang B, Gao C, Gao H et al. Comparison of the BISAP scores for predicting the severity of acute pancreatitis in Chinese patients according to the latest Atlanta classification. J Hepatobiliary Pancreat Sci. 2014 Sep;21(9):689-94.
Kim BG, Noh MH, Ryu CH, Nam HS, Woo SM, Ryu SH et al. A comparison of the BISAP score and serum procalcitonin for predicting the severity of acute pancreatitis. Korean J Intern Med. 2013 May;28(3):322-9.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Nutritional Composition and Sensory Properties of Value-Added Health Mix for Undernutrition and Better Cognition
English9499Anitha REnglish PA RaajeswariEnglish
Introduction: The incidence of undernutrition among children is high in India, which will pave its way to the occurrence of frequent infection, reduced learning capacity, poor academic performance and cognitive deficit. The health mix is the most popular, convenient, easy to prepare and healthy dish for the children. Objective: To develop a cheaper and nutritious health mix for improving the nutritional status and cognitive function in children. Method: The raw ingredients were procured, processed, powdered and mixed into 5 variations of health mix. The developed health mixes were analysed for their nutritional and sensory qualities. Result: The results stated that the health mix 3 with the combination of multi-grain such as red rice (25g), Bajra (25g), Green gram (20g), Soybean (10g), Rice flakes (10g), Jaggery (8g) and Brahmi leaves (2g) received significantly higher scores and also selected as best in having a high amount of essential nutrients namely, protein (14.9 g), fat (1.68 g), iron (6.52 g), zinc (1.91 mg), selenium (445 mg) required for the improvement of nutritional status and cognitive function. Health 3 has got the highest rating in many sensory qualities and also the results were similar to the control sample. Conclusion: Our study indicates the importance of a healthy mix, prepared from the combination of multi-grains with Brahmi leaves, as one of the most convenient food formulas for supplementation to undernourished children. Future studies on such supplementation to improve the nutritional status and cognitive function of undernourished children is recommended.
EnglishUndernutrition, Health mix, Nutritional quality, Sensory evaluation
INTRODUCTION
Undernutrition is a multidimensional issue holding back development with unacceptable human consequences. The burden of this across the world remains unacceptably high and progress unacceptably slow.1 In India, nearly every second young child is undernourished.2 National Family Health Survey 4 reported that both chronic and acute undernutrition was high in many states of India. Undernutrition weakens the immune system, putting children at higher risk of more severe, frequent and prolonged bouts of illness. It is also a consequence of repeated infections, which may further worsen the child’s nutritional status at a time of greater nutritional needs.1
Children who fail to grow optimally during this crucial period may not make up for the loss in growth even on an excellent diet in later life.3 Inadequate intake of nutrients leads to serious during periods of rapid growth, physical and cognitive development of children.4 The diets of children today increasingly reflect the global ‘nutrition transition’, which is seeing communities leave behind often more healthy, traditional diets in favour of modern diets often missing whole grains, fruits, nuts and seeds, vegetables, and omega-3 fatty acids.5,6 Foods that are nutritionally balanced, energy-dense, easily digestible, and have functional benefits, are needed for the food formulation.7
Cereals being the staple foods of the majority of the population in India, the combination of cereal with an appropriate proportion of pulses and oilseeds complement each other and result in improved nutritional qualities.8 bowls of cereal, millets and legumes also form a good source of macro and micronutrients, phytochemicals and prepare nutritionally balanced composites of high biological value.9 Nutrition can be redesigned to improve cognitive development, and micronutrient supplementation can help those at risk of cognitive impairment avoid deficiencies.10 Vitamins B1, B2, B3, B6, B12, C, folic acid, and minerals like iron, iodine, and zinc are the micronutrients most closely linked to cognitive function.11,12
In addition to micronutrients, several plant-based extracts, particularly ‘Brahmi’ have recently been shown to improve cognition. It was proved that eight out of nine clinical double-blind, placebo-controlled Brahmi trials in humans demonstrated improvements in cognition.13 Hence, the present study was aimed to formulate a value-added nutritious health mix with the combination of cereals, millet, legumes and Brahmi leave to alleviate undernutrition and help to improve the cognitive function of school children.
MATERIALS AND METHODS
Selection of ingredients
The ingredient cereals, millets and pulses such as Red rice, Wheat, Bajra, Thinnai and rice flakes, soya bean, green gram and roasted Bengal gram was chosen for their higher potential dietary sources and Brahmi leaves (Vallarai Keerai) were added for the enhancement of brain function and memory. Jaggery was used for its sweet taste, palatability and high amount of iron.
Procurement and processing of selected ingredients
Raw ingredients were procured from the local market. They were cleaned of impurities. Bajra, ragi, soya bean and green gram were washed and sprouted individually for 24 hours for the up-gradation of nutrients. Sprouted and non-sprouted ingredients were dried, roasted for moisture reduction and flavour enhancement. Roasted grains were milled into a fine powder separately. Vallarai Keerai was purchased from the local agricultural farm and the leaves were cut from thin branches. The good quality leaves were selected and washed thoroughly, blanched for 3 minutes to kill the microorganism on the surface and within the leaves and also to remove if there are any volatile compounds. Then they were shade dried by placing them in a white muslin cloth for five days. Dried leaves were powdered by using a mixer grinder and sieved to get a fine powder. All the ground ingredients were stored in an airtight container until used for formulation.
Development of health mix
About five variations of health mix were developed by mixing the processed ground flours to select one best variation in sensory and nutritional quality. The proportions of the health mix are presented in Table 1.
Preparation of value-added Health Mix Ladoo (HML)
About six variations of health mix Ladoos were prepared by mixing 25 gm of each health mix variation with hot water. The control health mix porridge was prepared by using sathumavu provided by the Government of Tamilnadu through Anganwadi centres.
Organoleptic evaluation of the health mix Ladoo
Evaluation of sensory attributes is a science by using human senses for measuring appearance, flavour, colour, texture and taste.14 Acceptability testing was carried out by 20-panel members for the prepared health mix porridge using nine points hedonic rating scale with the highest score as liked extremely (9) to dislike extremely (1). The panel members were instructed about the evaluation procedure and score ratings were obtained in the sensory evaluation sheet.
Evaluation of nutritional qualities of the health mix
Nutrients such as calories, protein, fat, carbohydrate, ash, moisture, total fibre, iron, calcium, zinc and selenium were analyzed using standard procedure.15 Estimation of nutrients such as ash by the incineration method in a muffle furnace at 550oC, the moisture content in a hot air circulating oven, crude fat by soxhlet extractor, protein (N X 6.25) in Kjeldahl method, carbohydrate content by difference, crude fibre by digestion, minerals such as iron by calorimetrically, calcium by precipitation and titration against potassium permanganate, zinc and selenium were evaluated by atomic absorption spectrophotometer.16,17
Anti-nutritional content of the health mix
A highly accepted health mix was evaluated for anti-nutritional factors since they may hinder the absorption of some of the essential nutrients during metabolism. Secondary metabolites such as oxalic acid, tannins, phytic acid and alkaloids were evaluated.
RESULTS AND DISCUSSION
Different health mix was prepared by combining raw ingredients in the proportion as 2 bowls of cereal, 1 millet, 2 legumes and 1 green and they were tested for nutritional qualities and sensory acceptability.
Nutritional qualities of the developed health mix
The mean and standard deviation value derived from the triplicate analysis of nutrients such as energy, protein, fat, total fibres, ash, moisture, iron, zinc, calcium, selenium present in various combinations of composite flour is displayed in Table. 2
The prepared health mixes were nutritionally adequate and comparable to standard recommended allowances. Health Mix 3 has got the highest in protein (14.89g) and fat (1.68g) carbohydrate (74.14g), iron (6.52mg), zinc (1.91mg) and selenium (444.7mg) when compared to other health mix variations. The calorie (393 kcal), fibre (2.34g) and calcium content were higher in health mix 5 since ragi was added one of the ingredients in the combination. Many nutrients are essential for brain development, particularly protein for cell proliferation and differentiation, synthesis of growth factors, the role of iron in myelination, essential fatty acids in synaptogenesis, and zinc for DNA synthesis. Dietary protein is providing an amino acid source for neurotransmitter production, namely, serotonin and catecholamines.19
Consumption of carbohydrates is necessary and at least 130 grams of carbohydrates per day is required to keep the blood glucose at a balanced level and adequate carbohydrates should be taken regularly for better cognitive functions.20 Though health mix 1,2,4,5 was adequate in some nutrients, HM 3 has been selected as best due to its superior quality of many important nutrients, namely protein, fat, carbohydrate, iron, zinc and selenium for the improvement of undernutrition and cognition.
Anti-nutritional contents of the health mix
Table.3 represents the quantitative determination of anti-nutritional content, namely, tannins, phytic acid and oxalic acid in the developed health mix. A gradual rise in the result of the sample when increasing concentration indicates a better outcome of the study. Mean tannin, phytic acid and oxalic acid content of the processed and developed health mix was 24mg, 36mg and 50 mg respectively. One of the major problems of plant-based flours is the presence of anti-nutritional contents such as phytate, oxalate, and tannin may usually have a negative effect on protein digestibility and other nutrient availability.21 The anti-nutritional contents of the current sample were within an acceptable limit and did not have an adverse effect on health. This shows that the developed health mix could be used extensively since it possesses very limited anti-nutritional factors and there would not be any interference with other nutrient bioavailability. Many researchers have reported that processing methods improved the nutritional quality of foods prepared from legumes and cereals by a reduction in their anti-nutritional factors.22
Organoleptic evaluation of the prepared Health Mix Ladoo (HML)
The mean scores of five variations of health mix Ladoo in appearance, flavour, taste, texture, colour and overall acceptability are presented in Table 4. The comparison of sensory attributes between different health mixes. The results showed that HML 3 has reached the maximum scores in many sensory qualities and also it was almost similar to that of the control sample (HML 0). The HML 3 has secured the highest in flavour (8.5±1.1) and colour (8.9±1.1) when compared to other variations. The mean score of appearance (8.5±1.2) and taste (8.3±1.3) of HML 3 was very nearer to the mean score of the control sample. The mean score of texture was maximum in HML 4 (8.4) due to the combination of ingredients, namely, wheat, Italian millet and green gram since these ingredients give the coarse structure. It was observed during sensory evaluation that the flavour of the Health Mix Ladoo-3 (HML 3), Health Mix Ladoo-1 (HML 1) and control sample [Health Mix Ladoo-0 (HML 0)] were very good and highly appreciable when compared to other variations. Health Mix Ladoo 4 has obtained the lowest in overall acceptability scoring than others. Figure 1 stated the results of mean scores of overall acceptability of all variations of the prepared health mix. Though all variations of the developed health mixes were accepted by the panel members one has to be selected for further processes. However, HML 3 was being selected as best based on the overall rating for further supplementation to improve the nutritional status and cognitive function of the children. Many researchers prepared health mix by using multiple ingredients with the combination of roasted flours of wheat, soybean and chickpea flour, and with malted and roasted grains of wheat, barley, green gram and jaggery.23,24
CONCLUSION
Health mix, prepared from the combination of different multigrain added to Brahmi leaves was one of the versatile and most convenient food formulas for supplementation to the undernourished children. It can be concluded from the results that the nutritional content and sensory qualities of health mix 3 was superior. Hence, considering the nutritional analysis and sensory acceptability trail, it is strongly recommended that the health mix 3 can be considered optimal for further future studies as supplementation to improve the nutritional status and cognitive function of the undernourished children.
ACKNOWLEDGEMENT
The authors are thankful to all the study participants for their kind cooperation. Authors are also grateful to authors/ publishers of all those articles from where the literature for this article has been reviewed and discussed.
Conflict(s) of Interest: Nil
Source(s) of funding: Nil
Ethical consideration: The study was approved by the Institutional Review Board of The Human Ethical Committee, Avinashilingam Institute for Home Science and Higher Education for Women, Coimbatore (AUW/IHEC-18-19/FSN/FHP-07).
Englishhttp://ijcrr.com/abstract.php?article_id=4235http://ijcrr.com/article_html.php?did=4235
UNICEF. Levels and trends in child malnutrition UNICEF-WHO-World Bank Group joint child malnutrition estimate key findings of the 2015 edition. New York: UNICEF, WHO, World Bank Group. 2015.
Initiatives D. Global Nutrition Report 2018: Shining a light to spur action on nutrition. Retrieved from Bristol. The UK. Available online at https://globalnutritionreport. org/reports/global-nutrition-report-2018.
Kamath SM, Venkatappa KG, Sparshadeep EM. Impact of nutritional status on cognition in institutionalized orphans: a pilot study. JCDR. 2017 Mar; 11 (3): CC01.
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World Health Organization. The state of food security and nutrition in the world 2019: safeguarding against economic slowdowns and downturns. Food Agric Org. 2019 Jul 15.
Afshin A, Sur PJ, Fay KA, Cornaby L, Ferrara G, et al. Health effects of dietary risks in 195 countries, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. The Lancet. 2019 May 11; 393(10184):1958-72.
Murugkar DA, Gulati P, Gupta C. Effect of sprouting on physical properties and functional and nutritional components of multi-nutrient mixes. Int J Food Nut Sci. 2013 Apr 1; 2(2):8.
Shilpa G, Pushpa B. Formulation and evaluation of cereal based health mix for preschool children. Asian J Home Sci. 2014; 9(1):44-9.
Gorinstein S, Pawelzik E, Delgado?Licon E, Haruenkit R, Weisz M, et al. Characterisation of pseudocereal and cereal proteins by protein and amino acid analyses. J Sci Food Agri. 2002 Jun; 82(8):886-91.
Bryan J, Osendarp S, Hughes D, Calvaresi E, Baghurst K, et al. Nutrients for cognitive development in school-aged children. Nutri Rev. 2004 Aug 1; 62 (8):295-306.
Huskisson E, Maggini S, Ruf M. The influence of micronutrients on cognitive function and performance. J Int Med Res. 2007 Jan; 35(1):1-9.
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Pase MP, Kean J, Sarris J, Neale C, Scholey AB, et al. The cognitive-enhancing effects of Bacopa monnieri: A systematic review of randomized, controlled human clinical trials. The J Alt Comple Med. 2012 Jul 1; 18(7):647-52.
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Reda TH, Atsbha MK. Nutritional composition, anti-nutritional factors, antioxidant activities, functional properties, and sensory evaluation of cactus pear (Opuntia ficus-indica) seeds grown in the Tigray region, Ethiopia. Int J Food Sci. 2019;5 (2): 391-394.
Ochanda SO, Akoth OC, Mwasaru AM, Kagwiria OJ, Mathooko FM. Effects of malting and fermentation treatments on group B-vitamins of red sorghum, white sorghum and pearl millets in Kenya. ). J Food Proc Tech .2010; 2(2): 182-184
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Alloxan-induced diabetes, Prenalon, Small intestine, Sucrase, Lactase, Maltase, Glucose levels
English100104Karimova IIEnglish Kuchkarova LSEnglish Ergashev NAEnglish Tursunboeva HOEnglish Rakhmatova MJEnglish Khidirova NKEnglish
Introduction: It is known that the activity of intestinal enzymes involved in the digestion of carbohydrates increases in diabetes mellitus. An increase of intestinal brush bolder maltase, sucrase, and lactase activity was shown in experimental diabetes and hyperglycemia. To reduce the activity of intestinal carbohydrates various herbal preparations are used. Objective: This work aims to study the effect of prenatal on the activity of intestinal disaccharidases in alloxan-induced diabetic rats. Material and Methods: White outbred rats were divided into the control and experimental groups to receive a single injection of saline, or alloxan monohydrate (150 mg/kg) (intraperitoneal) respectively. Further, experimental animals with high glucose levels were divided into the experiment I and experiment II groups. Control and experiment 1 group rats were injected with saline. Experiment 2 group rats were injected with prenatal (5mg/kg/24 h) for 30 days. The glucose level and intestinal disaccharidases activity were determined by using a glucometer and special kits (Human, Germany) respectively. Results: It was found that in experimental diabetes, the activity of the small intestine carbohydrates sharply increased. Injection of prenalon to alloxan-induced diabetic rats resulted in stabilizes of glucose level and normalizing of the activities of intestinal sucrase, maltase, and lactase. Conclusion: Administration of prenatal to the alloxan-induced diabetic rats led to the restoration of blood glucose levels and the activity of intestinal disaccharidases.
EnglishAlloxan-induced diabetes, Prenalon, Small intestine, Sucrase, Lactase, Maltase, Glucose levels
INTRODUCTION
Diabetes mellitus is one of the most common metabolic diseases, characterized by increased glucose levels, insulin deficiency, or low insulin sensitivity. A diabetic syndrome is also expressed changes in the activity of lipid, protein, and carbohydrate enzymes metabolism.1,2,3An increase of pancreatic and intestinal carbohydrases activity was shown in alloxan-induced4,5and in streptozotocin-induced diabetic rats.6,7
Currently, harmless plant substances which affect the activity of enzymes of glycolysis, gluconeogenesis, lipid peroxidation, and carbohydrate assimilation attract the attention as antidiabetic preparations.8,9,10To reduce the causing hyperglycemia activity of digestive carbohydrasesturkesteron4,5, acarbose6, quercetin7, black chokeberry extract11 and other preparation were used. Antidiabetic and hypoglycemic properties were also shown for a complex of substances from Alcea rosea. seed extract.12It has been suggested that obtained from the leaves of A. nudiflora prenalon, including various biologically active compounds with high activity13, might be effective for diabetes treatment.
This work aims to study the effect of prenalon on the activity of intestinal disaccharidases in alloxan-induced diabetic rats.
MATERIALS AND METHODS
Animals
In the experiments, white outbred laboratory male rats weighing 200-220 g were used. Animal procedures were performed according to Helsinki Declaration of the World Medical Association (WMA) "Ethical Principles for Medical Research with Human Participation as Research Subjects", adopted at the 18th WMA General Assembly in June 1964, and revised at the 64th WMA General Assembly in 2013 The rats were kept in well-ventilated, clean and bright rooms in separate plastic cages 50×30×28 cm3in size 4 animals in each. The room temperature was 22-24 °?, the relative air humidity was 40-60%. Access to food and drinking water was not restricted. The rat’s diet was included the following components: grain feed, sunflower seeds, milk, meat, wheat bread, vegetables, dry soups.
Experimental design
At the first stage of the observation, the animals were divided into control and experimental groups. Before modelling diabetes rats of experimental groups have been fasting for two days with unlimited access to water. Then the animals of the experimental group were injected intraperitoneally with a solution of alloxan monohydrate (DIAEM, OOO, Russia, 150 mg/kg) and the animals of the control group were injected with an equal volume of saline at the same time in the same manner. On the 12th day of observation, blood from the tails was analyzed for glucose levels in all animals. Only experimental rats with a blood glucose level of around 200 mg% were taken for the next stage of observation. Further, animals with high glucose levels were evenly divided into two groups (experiment I and experiment II). During 30 days the control and alloxan-induced diabetic rats of the first experimental group (experiment I) were injected subcutaneously with saline. The alloxan-induced diabetic rats of the 2nd experimental group (experiment II) were also injected subcutaneously with the same volume of prenalon solution (5.0 mg/kg/24 h) in the morning between 8-10 hours for 30 days. The day when the rats began to receive prenalon was accepted as the 0th day of the experiment. Animals were sacrificed by decapitation in the morning between 8 and 10 o'clock on 5th, 10ht, 20th, and 30th days after prenalon administration. Before sacrification, the animals were starved for 24 hours. Immediately after decapitation and opening of the abdominal cavity, the small intestine was removed, cleaned from the mesentery, and washed with 20-30 ml of Ringer's solution (pH-7.4). Then, the intestine was cut open and the mucosa was separated with a plastic spatula and placed in the tube. Ringer's solution was poured into each containing mucosa tube in a ratio of 1:9. Obtained samples were homogenized using a Teflon/glass homogenizer within 1 minute at 300 rpm. All processes were performed in cold conditions.
Biochemical analysis
The blood glucose level was determined using a glucometer (Accu-Chek active (Roche Diagnostics, Switzerland).
To determine the activity of intestinal enzymes, 2% solutions of lactose, sucrose, and maltose (Reagent, Sigma) were used as a substrate. The activities of lactase (EC 3.2.1.23), sucrase (EC 3.2.1.48), and maltase (EC 3.2.1.20) of the small intestine were determined using a complex of reagents (Human, Germany) by the glucose oxidase method.14 The enzyme activity was calculated per gram of tissue concerning the amount of reducing glucose (µmol) for 1 minute.
Statistical Analysis
The arithmetic mean (M), standard error (m), t coefficient, and statistical significance value (P) were determined. If the P-value was less than 0.05, the difference between the two groups was considered statistically significant.
RESULTS
Glucose level
It is turned out that the level of glucose in the rat blood was increased 3.5, 3.3, 4.1and 3.1-fold on the 5th, 10th, 29th, and 30th days observation respectively in alloxan-induced diabetic rats compared with the non-diabetic rats. Administration to alloxan-induced diabetic animals prenalon (5.0 mg/kg/24 h) led to a markedly decrease of blood glucose level although it remained above the control values. However, in the experiment I group of rats, the blood glucose level was decreased by 45.1% on the 5th day, by 62.6% on the 10th day, by 64, 6% on the 20th, and by 53.8% on the 30th day of observation compared to the experiment I group (Table 1).
Experiment I - alloxan diabetes group; Experiment II - alloxan diabetes + prenalon group, P - statistical significance between control and experimental groups.
Maltase activity
In alloxan-induced diabetic rats maltase activity was increased by 32.6%, 95.3%, 81.2%, and 68.0% on the 5th, 10th, 20th, and 30th days of the experiment, respectively, compared to the control group. Administration of prenalon to alloxan-induced diabetic rats led to a normalization of the enzyme activity by the end of the experiment. The decrease of the intestinal maltase activity in the experiment II group on the 5th, 10th, 20th 30th days of the treatment with prenalon was 4.1%, 16.5%, 24.6%, and 35.5% respectively compared to the experiment I group (Table 2).
Experiment I - alloxan diabetes group; Experiment II - alloxan diabetes + prenalon group, P - statistical significance between control and experimental groups.
Sucrase activity
It was noted that the intestinal sucrase activity in the 1stexperimental group animals significantly increased in comparison with control animals. Increase of sucrase activity in alloxan-induced diabetic rats was 31.7% on the 5th day, 39.3% on the 10th day, 42.2% on the 20th day, and 40.6% on the 30th day of the experiment in comparison with control. Administration of prenalon resulted in a gradual approximation of sucrase activity to control value. On the 30th day of the experiment, the sucrase activity in diabetic rats treated with prenalon was identical to those in the control one. In the experiment II group rats, a decrease of intestinal sucrase activity compared to the experiment I group was statistically significant on the 20th and 30th days of the experiment (Table 3).
Experiment I - alloxan diabetes group; Experiment II - alloxan diabetes + prenalon group, P - statistical significance between control and experimental groups
Lactase activity
Small intestine lactase activity in alloxan-diabetic animals was increased by 45.6%, 87.7%, 62.7%, and 55.6%, respectively, on the 5th, 10th, 20th, and 30th days of the experiment compared to the control group (Table 4). Treatment of diabetic rats with prenalon also led to a gradual decrease of enzyme activity which was reached the control value by the end of observation. After administration of prenalon to the 2nd experimental group rats, the lactase activity was decreased by 14.1% on the 5th day, by 18.0% on the 10th day, by 14.6% on the 20th day, and by 23.5% on the 30th day of observation compared to the experiment I group rats (4).
Experiment I - alloxan diabetes group; Experiment II - alloxan diabetes + prenalon group, P - statistical significance between control and experimental groups
So, by the end of the experiment, the activity of all brush border disaccharidases was significantly decreased in treated with prenalon diabetic rats compared with untreated diabetic rats.
DISCUSSION
In this study, the possibility of the correcting effect of prenalon on the activity of intestinal enzymes involved in the final stage of carbohydrate digestion in alloxan diabetes of male adult rats was studied. Obtained data show an increase in blood glucose level as well as activity of intestine disaccharidases in alloxan-induced diabetic rats. Simultaneous changes of both blood glucose level and intestinal disaccharidase activity supposed, the increase of disaccharidases activity is contributing to the hyperglycemia in alloxan-induced diabetic rats. An increase in the activity of enteral disaccharidases in experimental diabetes was also identified in streptozotocin-induced diabetes.7 However, the authors did not describe the possible mechanisms of enteral disaccharidases activity induction in diabetes or hyperglycemia. In diabetes despite the increased glucose level in the blood, its level is lowered in other body tissues.15 Probably glucose hunger of the major body cells leads to an increase in the activities of intestinal disaccharidases through a nervous and humoral feedback mechanism. However, this assumption requires additional experimental researches. An endocrine system including the hypothalamus, pituitary, adrenal, thyroid, parathyroid, and other glands is impaired in diabetes mellitus.16Diabetes-related deficiency of thyroid-stimulating and/or thyroid hormones could also lead to an increase in intestinal lactase activity.17,18. The change in the hydrolytic activity of brush bolder disaccharidases could be also due to structural disorders in the mucous membrane of the small intestine in alloxan-induced diabetes rats.8,19Many plant compounds attract the attention of specialists because concerning the human or animal organism they have a wide spectrum of biological activity, due to the diversity of their chemical structure3,8,20. Medicinal plants which possess antioxidants activity usually has hypoglycemic activity because oxidative stress plays a major part in diabetes development and treatment.4-13,20Taken from A. nudiflora leaves prenalon includes polyphenols, tocopherols, carotenoids, sterols, terpenoids, and other substances with pharmacological effects on the metabolic processes.13According to the obtaining results prenalon has a certain corrective effect on the reduction of blood glucose level and activities of intestinal disaccharidases in alloxan-induced diabetic rats. Taking all these data together, it is suggested that the prenalon could be a potential therapeutic agent for a decrease of glucose level and disaccharidases activity against diabetes.
CONCLUSION
Association between increase of blood glucose level and activity of intestinal disaccharidases in diabetic rats shows the efficiency of sugar hydrolysis in the small intestine contributes to the increase of blood glucose level. Administration of prenalon to alloxan-induced diabetic rats results in a decrease in both blood glucose level and intestinal disaccharidases activity. It also confirms the regular functional relationships between blood glucose level and the ability of the small intestine to assimilate carbohydrates. In addition, these data indicate that prenalon could be a candidate for a decrease of blood glucose level and/or enteral disaccharidases activity.
These positive results were obtained in animal studies. Therefore, further research is needed to identify the mechanisms through which prenalon works to acceptably address safety concerns. It is hoped that this study will revive interest in the hypoglycemic properties of prenalon and serve as an impetus for broader research.
Authors’ Contribution
Karimova II, Tursunboeva HO conceived, planned, and carried out the experiments. Kuchkarova LS and Ergashev NA analyzed data and wrote the manuscript. Akhmatova MJ, Khidirova NK got the prenalon preparation from extract A. All authors discussed the results and contributed to the final manuscript.
ACKNOWLEDGEMENTS
The authors acknowledge the immense help received from the scholars whose articles are cited and included in the references of the manuscript. The authors are also grateful to the authors/editors, publishers of all those articles and journals where the literature for this article has been reviewed and discussed.
Conflict of interest: There is no conflict of interest associated with this article.
Source of funding: There is no external funding agency associated with this article.
Englishhttp://ijcrr.com/abstract.php?article_id=4236http://ijcrr.com/article_html.php?did=4236
Kharroubi AT, Darwish H M. Diabetes mellitus: The epidemic of the century. World J Diabetes 2015;6(6):850-67.
Khawandanah J. Double or hybrid diabetes: A systematic review on disease prevalence, characteristics and risk factors. Nutr Diabetes. 2019;4;9(1):33.
Hamden K, Mnafgui K, Amri Z, Aloulou A, Elfeki A. Inhibition of key digestive enzymes related to diabetes and hyperlipidemia and protection of liver-kidney functions by trigonelline in diabetic rats. Sci Pharm 2013;81(1):233-46.
Kuchkarova LS, Rokhimova SO, Syrov VN. Effect of Turkesterone on the Pancreas Histology and Function in Diabetic Rats. Inter J Cur Res Review 2020;12 (21):1-5.
Kuchkarova LS, Rokhimova SO. Intestinal carbohydrate digestion in rat alloxan diabetes. Scientific review.Biological sciences 2020; 3:56-60 (in Russian).
Jureti? D, Bernik S., Cop L, Hadzija M, Petlevski R, Lukac-Bajalo J. Short-term effect of acarbose on specific intestinal disaccharidase activities and hyperglycemia in CBA diabetic mice. Anim Physiol Anim Nutr 2003;87(7-8): 263-8.
Ramachandra R, Shetty AK, Salimath PV. Quercetin alleviates activities of intestinal and renal disaccharidases in streptozotocin-induced diabetic rats. Mol Nutr Food Res. 2005; 49(4):355-60.
Giacco F, Brownlee M. Oxidative stress and diabetic complications. Circ Res 2010;107(9):1058-70.
El-Salam NA, Radwan MM, Wanas AS, Shenouda ML, Sallam SM, Piacente S, Ghazy NA. Phytochemical and Biological Evaluation of Alcea Rosea L. Growing In Egypt. Planta Med 2016;82(5):83.
Rajendiran D, Packirisamy S, Gunasekaran K. A review on the role of antioxidants in diabetes. Asian J Pharm Clin Res 2018;11(2):223-41.
Jurgo?ski A, Ju?kiewicz J, Zdu?czyk Z. Ingestion of black chokeberry fruit extract leads to intestinal and systemic changes in a rat model of prediabetes and hyperlipidemia. Plant Foods Hum Nutr 2008;63(4):176-82.
Dar PA, Ali F, Sheikh IA, Ganie SA, Dar TA. Amelioration of hyperglycemia and modulation of antioxidant status by Alcea rosea seeds in alloxan-induced diabetic rats. Pharm Biol 2017;55(1)1849-55.
Rakhmatova MZ, Karimova II, Gayibov UG, Khidyrova NK. Polyprenolsthe leaves of the plant alceaenudifloral and their antioxidant activity. East Eur Sci J 2020; 6(58):53-6.
Dahlqvist A. Assay of intestinal disaccharidases. Scand J Clin Lab Invest 1984;44(2):884–92.
Holst JJ, Gribble F, Horowitz M, Rayner CK. Roles of the gut in glucose homeostasis. Diabetes care 2016;39:884–92
Alrefai H, Allababidi H, Levy S, Levy J. The Endocrine System in Diabetes Mellitus. Endocrine 2002;18(2):05-119.
Schlienger JL, Anceau A, Chabrier G, North ML, Stephan F. Effect of Diabetic Control on the Level of Circulating Thyroid Hormones. Diabetologia 1982; 22(6):486-8.
Hewitt JE, Smith MW. Thyroid hormone effects on lactase expression by rat enterocytes. J Physiol 1986;376(6): 253–65.
Zhao M, Liao D, Zhao J. Diabetes-induced mechano-physiological changes in the small intestine and colon. Diabetes 2017;8(6):249-69.
Firdous SM. Phytochemicals for treatment of diabetes. Expt J. 2014;13:451-3.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
A Study of Knowledge, Attitude & Practices of Family Planning Methods among Married Women of Reproductive Age Group
English105109Kinnari AminEnglish Heena RajputEnglish Bhamini KadikarEnglish Nilesh ShahEnglish
Introduction: Studies from various parts of developing countries reveal that the knowledge of contraception in women is very low. Also use of contraceptive methods varies in various countries and is probably related to local belief. To increase the awareness and actual practice of contraception among married couples, understanding the knowledge and attitude of the patient towards contraception is very much necessary. Aims and Objectives: To assess the knowledge and attitude regarding family planning methods and contraceptive practices among married women of the reproductive age group. Methodology: 500 women in the reproductive age group (15-45 years) attending. Nootan General Hospital, Visnagar, Gujarat, India from 1st December 2020 to 28th February 2021 were interviewed with a predesigned questionnaire after taking informed consent. Results: Most of the women interviewed fall in the age group of 21-30 years (48.6%). 67.4% were married for 5 years. 48.4% were illiterates and only 18.6% had primary education. 477 (95.4%) had heard/aware of the family planning method (permanent/ temporary). About 311 (65.19%) got information from social circles. The importance of and use of contraception has been ex-plained by health personnel to 95 (19.91%) and 71 (14.88%) got it through mass media. 278 (55.6%) were practising different contraceptive methods. 172 (61.87%) women resort to tubal ligation as a contraceptive method of choice and the reason being the completion of their family. None of their husband underwent tubectomy. Only 69 (24.82%) women used various methods for spacing. Conclusion: According to our study, though knowledge of at least one method of contraception was wide among the women still actual practice was very low. More programs are required to combat the influence of various factors on contraception usage and to emphasize the positive effects of the use of contraception.
EnglishAttitude, Knowledge of contraception, Practice of contraception, Condom, Tubectomy, Awareness of contraception
INTRODUCTION
In the world population numbers, India is at second rank. Very soon India will overtake China, which at present is the most popular country in the world.1 National economy has been adversely affected due to the rapid increase of population. The health of the women is also adversely affected due to the increasing number of childbirth. Both these factors have a direct effect on the social and economic uplift of the family.2 Family welfare programme was launched by the government of India in the 1950s, to accelerate social and economic development by reducing population growth. However, this program has met with only marginal success. Though the permanent methods have been successful in our country, the spacing methods lag and unwanted, unplanned pregnancies continue to be high.3 Modern methods of contraception are oral pills, male and female condoms, intrauterine devices, implants, male and female sterilization, injectables, diaphragm and emergency contraception. Periodic abstinence, withdrawal and folk methods are traditional methods.4 There are many social factors, taboos, myths & ignorance which are responsible for the underutilization of contraceptive services.
This leads to many unwanted pregnancies causing maternal morbidity and mortality.3 In India, women virtually have no role to play or are allowed to play a very limited role in making reproductive decisions. Socio-economic factors and education play a vital role in family planning acceptance. Studies from various parts of developing countries reveal that the knowledge of contraception in women is very low. Also use of contraceptive methods varies in various countries and is probably related to local belief.5To increase the awareness and actual practice of contraception among the married couple, understanding the knowledge and attitude of the patient towards contraception is very much necessary. We are doing the present study to know the knowledge, attitude and practices regarding contraceptive usage.
METHODS
A cross-sectional study was conducted in the Department of Obstetrics and Gynecology, Nootan General Hospital, Visnagar, Gujarat from 1st December 2020 to 28th February 2021. A total of 500 women in the reproductive age group who visited our hospital were evaluated with the predesigned questionnaire.
The study was aimed to study
(1) the socio-demographic parameters
(2) knowledge and awareness regarding contraception
(3) contraceptive practices.
Inclusion criteria
Women in the reproductive age group
Women living with their husbands
Exclusion criteria
Women who have had medical disorders
Women who refused to give consent
Descriptive analysis was done to obtain the percentage. Women who satisfied the inclusion criteria were interviewed after taking informed consent. The questionnaire revealed information regarding different parameters of the study like age, occupation, educational status, number of children, source and knowledge of contraceptive methods and attitude of females towards contraception. The practice of family planning methods and the attitude of females towards contraception. Data compilation was done by simple tabulation.
RESULTS
Out of 500 women interviewed, 243 (48.6%) were in the age group of 21-30 years. 187 (37.4%) women were primipara and 212 (42.4%) women had Englishhttp://ijcrr.com/abstract.php?article_id=4237http://ijcrr.com/article_html.php?did=4237
1. World Health Organization. Family planning 2012 July www.who.int/mediacentre/factsheets/fs351/en/index.html.
2. Sharma V, Mohan U, Das V, Awasthi S, Sharma J. Socio-Demographic Determinants and Knowledge, Attitude, Practice: Survey of Family Planning. Int J Reprod Contracept Obstet Gynecol 2015;4(3):750-754.
3. Nigar A. Contraceptive awareness and practices among rural women in Lucknow. Indian J Obstet Gynecol Res 2018;5(4): 454-457.
4. Rankawat S, Nuninarayannappa N.V, Chaudhary R. Knowledge and practice of contraceptive methods in rural eligible couple, Moradabad. J Harmoniz Res Med HlthSci 2016;3(4):217-222.
5. Ghike S, Joshi S, Bhalerao A, Kawthalkar A. Awareness and contraception practices among women- an Indian rural experience. J. SAFOG 2010;2(1):19-21.
6. National family health survey (NFHS-4). Available from: http://www.nfhsindia.org/NFHS-4%20Data/ VOL-1/ Summary%20of%20 Findings% 20 (6868K).pdf.
7. Onwuzurike BK, Uzochukwu BS. Knowledge, attitude & practice of family planning amongst women in a high-density low income urban of Enugu, Nigeria. Afr J Reprod Health. 2001 Aug;(5):83-9. PMID:12471916.
8. Mao J. Knowledge, Attitude and Practice of Family Planning: A Study of Tezu Village, Manipur (India). Internet j. biol. Anthropol. 2006;1(1).
9. Agarwal M, Samanta S, Bhusan D, Anant M. Assessing knowledge, attitude, and practice of contraception: a cross-sectional study among patients in a semi-urban tertiary hospital. Int J Reprod Contracept Obstet Gynecol 2017;6:720-4.
10. Lavanya KS, PNSL. A study on contraceptive knowledge, attitude and practice among reproductive age group women in a tertiary institute. Int J Res Health Sci. 2014 Apr 30;2(2):577-80.
11. Jirange U, Relekar M, Gulsha M. Contraceptive awareness in a rural area, Pune. ?Int J Curr Res. 2019;11(04): 2778-2780.
12. Sunita TH, Desai RM. Knowledge, Attitude and Practice of Contraception among Women attending a tertiary care hospital in India. Int J Reprod Contracept Obstet Gynecol 2013;Jun:2 (2):172-176.
13. Jahan U, Verma K, Gupta S, Gupta R, Mahour S, Kirti N, et al. Awareness, attitude and practice of family planning methods in a tertiary care hospital, Uttar Pradesh, India. Int J Reprod Contracept Obstet Gynecol 2017;6:500-6.
14. Thapa P, Pokharel N, Shrestha M. Knowledge, Attitude and Practices of Contraception among the Married Women of Reproductive Age Group in Selected Wards of Dharan Sub-Metropolitan City. J Contracept Stud 2018;3(3):18.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Autopsy Findings in Covid-19 in a Tertiary Care Teaching Hospital - Case Series
English110114Sofiah CSEnglish Swaminathan KEnglish Merla JEnglish Shantaram KEnglish
Introduction: Post-mortem studies provide important information for understanding the new disease pathogenesis and clinical outcomes. Methods: Post-mortem examinations were performed according to WHO guidelines brought dead at tertiary care hospital, Tamilnadu, India. Tissues from the lung, heart, liver, kidney, spleen, and brain were examined. Results: Lung findings revealed early-stage DAD in 6 out of 10 cases and late-stage DAD in 4 cases, atypical pneumocytes and bronchopneumonia also noted. There is no evidence of myocarditis, hepatitis or encephalitis. Microvascular injury and thrombosis were also detected. Conclusion: The SARS-CoV-2 infection causes multisystem disease and significant pathological changes seen in most organs in patients with and without comorbidities irrespective of age.
EnglishAutopsy, COVID-19, SARS–CoV-2, Comorbidities, Pathology
INTRODUCTION
The pandemic outbreak caused by a new coronavirus infection (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) disease was reported first in China and spread to many countries worldwide from December 2019. In India, Kerala's state reported the first case of coronavirus infection on 30 January 2020 and had a travel history from Wuhan, China. The new coronavirus, severe acute respiratory syndrome coronavirus-2 (SARS–CoV-2), has infected 37.4 million and caused more than 1.08 million deaths worldwide in India 7.12 million cases and 109K death were reported. However, very little is known about the causes of death and the virus's Pathologic features.
The clinical spectrum of SARS-CoV-2 disease (COVID-19) is reported with mild, moderate and severe symptoms. The main symptoms include, a disease with fever, cough, difficulty in breathing, chest pain, vomiting, giddiness, loose stools and 15% of the symptomatic patients develop pneumonia & ARDS.1,5 SARS-CoV-2 is the seventh member of the coronavirus family identified to cause disease in humans. Coronaviruses are enveloped, positive-sense, single-stranded RNA viruses. Two other family members, severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), cause acute diffuse alveolar damage, pneumocyte hyperplasia, and interstitial pneumonia.2
Autopsy plays an important role in understanding and explaining the disease processes and their effects on different organ systems for many centuries. Autopsy helps and enhances the clinical practitioners, about the treatment and management of new diseases such as COVID-19.3,4
METHODS
This is a case series of autopsies conducted in the pathology department at a tertiary care hospital. The hospital recorded ten sudden deaths in community settings and was brought to this teaching hospital's casualty in rural south Tamil Nadu, south India. The post-mortem was carried to find out the cause of death. The chronological evolution of the event leads to the death, time of its occurrence, previous medical history related to the deceased, details of medical therapy, treatment regimen (current and prior) and previous surgical procedures or interventions, and family history of cardiac illness were recorded. Examination of the heart and blood vessels was done as per the standard procedure.
Inclusion criteria: Person dead of sudden cardiac death received in the morgue
Exclusion criteria: No histological changes related to COVID-19
Post-mortem examination
With the recently published WHO guidelines for suspected COVID-19 cases, Post-mortem examinations were performed in line with it. The autopsy was carried out at the Tirunelveli Medical College, Tamilnadu, India, to establish the cause of death, as all these cases were unexpected deaths of unknown cause.
Diagnostic testing for COVID-19
To test for COVID-19, swabs were obtained from the trachea, lung parenchyma, pericardium, and pleural cavity. As directed, collected specimens were forwarded to the lab for a real-time reverse transcriptase PCR.7
Histology
Representative samples were obtained from the brain, lung, liver, kidney, spleen and heart submitted in standard tissue cassettes. These were fixed in formalin for 72 hours as per the Centers for Disease Control and Prevention guidance. The virus is rendered inactive by formalin.8Samples were prepared, paraffin-embedded, sectioned, mounted on glass slides, and stained with H&E, immunohistochemical staining for inflammatory infiltrate and cellular components (including staining with antibodies against CD68, CD3, CD20, CD34) and Special stain Reticulin was performed to demonstrate basement membrane and all slides were examined.
Data were collected using proforma and presented as frequency and percentage.
RESULTS
Patients were 8 Male and 2 Female, with a mean age of 38.2 years (SD 13; range 16-60)
Clinical Summary:
The hospital recorded ten sudden deaths in community settings, most of whom had various respiratory symptoms with fever immediately before death. Still, it was not tested for or diagnosed with COVID-19 (Table 1). One case had a significant underlying disease with chronic obstructive pulmonary disease and another case was with type 2 diabetes mellitus.
Microscopic Findings:
Histological examination of lungs given in Table 1 revealed features are corresponding to an early stage of Diffuse Alveolar Damage (DAD) in 6 cases and 4 cases with advanced DAD lesion (Fibroblastic proliferation within interstitial alveolar spaces) and all cases consisted of interstitial and intra alveolar oedema (Fig 1) with variable amounts of haemorrhage (Fig 2) and fibrin deposition (Fig 3), hyaline membrane thickening (Fig 4) with minimal interstitial inflammatory infiltrates (Fig 5) mainly composed of CD3 & CD20lymphocytes located predominantly in the interstitial spaces and around larger bronchioles with focal neutrophils, CD20lymphocytes (Fig 6)seen in aggregates around small vessels and type 2 pneumocyte hyperplasia (Fig 7), CD3 positive T cells (Fig 8), CD68 macrophages (Fig 9), were seen in intra alveolar space, Microthrombi was noted in 4 cases, 2 cases had bronchopneumonia, and one had atypical pneumocytes, and one case had multinucleated giant cells.
Histological examination of liver Table 2 shows sinusoidal congestion in 7 cases and extravasation of RBC into the space of Disse. In 6 cases, there was congestion of small veins, steatosis was seen in 7, portal triad lymphocytic infiltration was seen in 6 cases. Spleen, in all cases, showed congestion.
Histological examination of the kidney in Table 3 showed renal tubules, which are distorted/atrophied and haemorrhage noted in all cases. Glomeruli and interstitium showed haemorrhage and congestion and focal fibrosis was also noted in 3 cases.
Histological examination of the brain showed only congestion no evidence of vasculitis, necrosis and perivascular lymphocytes infiltration was noted.
Histological examination of the heart did not show any areas of myocyte necrosis; there was no significant lymphocytic infiltrate consistent with viral myocarditis.
DISCUSSION
Whole-body autopsies provide various advantages using biopsies and tissues obtained from post-mortem5,9,10. A full-body autopsy study was conducted for these cases that were brought dead to establish the cause of death. The case study illustrates the histological changes observed in the COVID-19 infection. Various degrees of lung injury with diffuse alveolar damage associated with multisystem involvement and significant pathology in most body organs where microvascular injury and thrombosis were also seen. Significant histopathological hallmarks of widespread vascular injury are seen in the liver, kidney and spleen. It was also found that type 2 pneumocyte hyperplasia and shedding was prominent in these cases, which were similar to recent studies on SARS-CoV-1and SARS-CoV-2.11,12, 13
A case report from China also described findings in a post-mortem biopsy specimen, which showed diffuse alveolar damage and interstitial mononuclear inflammatory infiltrates14. Our autopsy study found that COVID-19 predominantly causes acute lung injury and diffuse alveolar damage, associated with multisystem involvement and significant pathology across most body organs in patients with and without the comorbid disease. All deaths were due to cardiorespiratory failure, and all cases had extrapulmonary manifestations. Microvascular injury and thrombosis were also detected. The 3 young patients without pre-existing medical conditions also had similar findings despite the absence of comorbidities. They displayed all the histopathological hallmarks of widespread vascular injury, including liver, kidney and spleen15.
It is well recognized that older age increases the risk of severe disease or fatality, with 95% of deaths in those aged over 60.18 In this study, all but cases were with (age Englishhttp://ijcrr.com/abstract.php?article_id=4238http://ijcrr.com/article_html.php?did=4238
Huang C, Wang Y, Li X, Ren L, Zhao J, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The lancet. 2020 Feb 15;395(10223):497-506.
Carsana L, Sonzogni A, Nasr A, Rossi RS, Pellegrinelli A, et al. Pulmonary post-mortem findings in a series of COVID-19 cases from northern Italy: a two-centre descriptive study. Lancet Infect Dis. 2020 Oct 1;20(10):1135-1140.
Youd E, Moore L. COVID-19 autopsy in people who died in community settings: the first series. J Clin Pathol. 2020 Dec 1;73(12):840-844.
Schaller T, Hirschbühl K, Burkhardt K, Braun G, Trepel M, et al. Postmortem examination of patients with COVID-19. Jama. 2020 Jun 23;323(24):2518-2520.
Xu Z, Shi L, Wang Y, Zhang J, Huang L, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020 Apr 1;8(4):420-422.
Fox SE, Akmatbekov A, Harbert JL, Li G, Brown JQ, Vander Heide RS. Pulmonary and cardiac pathology in African American patients with COVID-19: an autopsy series from New Orleans. Lancet Respir Med. 2020 Jul 1;8(7):681-6.
Wang D, Hu B, Hu C, Zhu F, Liu X, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. J Am Med Ass. 2020 Mar 17;323(11):1061-1069.
Healthcare Workers [Internet]. Centres for Disease Control and Prevention. 2020 [cited 10 April 2020]. Available from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-postmortem-specimens.html
Tian S, Xiong Y, Liu H, Niu L, Guo J, et al. Pathological study of the 2019 novel coronavirus disease (COVID-19) through post-mortem core biopsies. Mod Pathol. 2020 Jun;33(6):1007-1014.
Konopka KE, Wilson A, Myers JL. Postmortem lung findings in a patient with asthma and coronavirus disease 2019. Chest. 2020 Sep 1;158(3):e99-101.
Su H, Yang M, Wan C, Yi LX, Tang F, et al. Renal histopathological analysis of 26 post-mortem findings of patients with COVID-19 in China. Kidney Int. 2020 Jul 1;98(1):219-227.
Xu Z, Shi L, Wang Y, Zhang J, Huang L, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med. 2020 Apr 1;8(4):420-2.
Franks TJ, Chong PY, Chui P, Galvin JR, Lourens RM, et al. Lung pathology of severe acute respiratory syndrome (SARS): a study of 8 autopsy cases from Singapore. Hum Pathol. 2003 Aug 1;34(8):743-748.
Tian S, Xiong Y, Liu H, Niu L, Guo J, et al. Pathological study of the 2019 novel coronavirus disease (COVID-19) through post-mortem core biopsies. Mod Pathol. 2020 Jun;33(6):1007-1014.
Falasca L, Nardacci R, Colombo D, Lalle E, Di Caro A, et al. Postmortem findings in Italian patients with COVID-19: a descriptive full autopsy study of cases with and without comorbidities. J Infect Dis. 2020 Dec 1;222(11):1807-1815.
Barton LM, Duval EJ, Stromberg E, Ghosh S, Mukhopadhyay S. Covid-19 autopsies, Oklahoma, USA. Am J Clin Pathol. 2020 May 5;153(6):725-733.
Lupia T, Scabini S, Pinna SM, Di Perri G, De Rosa FG, et al. 2019 novel coronavirus (2019-nCoV) outbreak: A new challenge. J Glob Antimicrob Resist. 2020 Jun 1;21:22-27.
Statement – Older people are at the highest risk from COVID-19, but all must act to prevent community spread [Internet]. Euro.who.int. 2020 [cited 19 April 2020]. Available from: https://www.euro.who.int/en/health-topics/health-emergencies/coronavirus-covid-19/statements/statement-older-people-are-at-highest-risk-from-covid-19,-but-all-must-act-to-prevent-community-spread
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Prevalence and Risk Factors for Malnutrition among Rural School Children in Anantapur District, Andhra Pradesh, India
English115120Goruntla NarayanaEnglish Dudekula Ruha ThasmiyaEnglish Poluru Prasuna ChowdaryEnglish Kasturi Vishwanathasetty VeerabhadrappaEnglish Madhale Milka DEnglish Kandula UsharaniEnglish Murugesan ReethaEnglish
Introduction: There was a scarcity of evidence on malnutrition-related factors among school-going children ≥ 5 years in rural India. Objective: To assess the prevalence of stunting, underweight, wasting, and associated factors in school children of Anantapur district. Methods: This was a cross-sectional study conducted in a primary and secondary school located in rural settings of Anantapur district, Andhra Pradesh, India. A multi-stage random sampling technique was used to select the children for our study. The study was approved by the institutional review board and registered in the clinical trial registry of India. A suitable data collection form was used to collect information about socio-demographics, utilization of government nutritional programs, physical activity, and WHO anthropometric parameters. Chi-square Fisher exact test was used to associate predictors with malnutrition measures. The height-for-age z-score for stunting, weight-for-age z-score for undernutrition, and weight-for-height z-score for wasting were computed in WHO anthroplus software. Results: A total of 390 children have participated in the study with a mean age of 11.8±2.4. The prevalence of stunting, underweight, and wasting among school children was 25.4%, 11.5%, and 17.7%, respectively. There was no significant difference in the nutritional measures among male and female children. Predictors like illiteracy of parents, joint family, and non-healthcare occupations were significantly associated with malnutrition characteristics among school-going children. Conclusion: The study concludes that the prevalence of stunting, underweight, wasting was existing among rural school-going children. Even government provides nutritional schemes to overcome malnutrition disorders in school children, there was still a gap to prevent nutritional disorders. Targeted educational programs on the importance of child nutrition and malnutrition complications towards mothers are required to improve nutritional status among school-going children
EnglishAnthropometry, Children, Nutrition, Stunting, Under-weight, Wasting
Introduction
Globally, including in India, health complications associated with undernutrition and deficiency of vitamins is a significant public health problem.1 Nutritional status during school age is a major predictor of nutritional and health status in adult life. The quality of life of the children residing in rural settings is inferior compared to the urban settings of India.2
School-age is the dynamic period for the physical growth and mental development of the child. Evidence shows that poor nutritional status is the primary cause of low school enrolment, absenteeism, early dropouts, and low performance.3 In the current scenario, the nutritional status of children was very unsatisfactory in India. According to the National Family Health Survey (NFHS) report, about 45.5% of children are suffering from disorders associated with malnutrition in India.4 Even though India has a higher Gross National per capita income (US$1070) than other Asian countries (Bangladesh=US$570; Nepal=US$400), yet undernutrition is high in India compared to these countries.5 Therefore, poverty alone does not entirely explain the burden of undernutrition, but it also relates to parental education, awareness, lack of sanitation, low food intake, family size, suffering from infectious diseases, social, cultural, and political aspects regarding nutrition recommendations.6
There was less attention among health providers/policymakers towards evaluating the nutritional needs of school-age children than under-five age groups.7 Most of the time, maternal and child health programs/schemes cover nutritional requirements of children under five years of age only.8 School age is also very crucial to identify health problems associated with undernutrition and treat them early. So, our study aims to assess the prevalence of stunting, underweight and wasting, and associated factors among school-going children in rural school settings of Anantapur District, Andhra Pradesh, India.
Materials and Methods
A cross-sectional, descriptive-analytical study was conducted in primary and secondary schools located in rural settings of Anantapur District, Andhra Pradesh, India. The study was conducted for a period of six months, from April 2019 to September 2019.
Study criteria
Children aged more than or equal to five years and less than are equal 15 years, irrespective of gender, and who attended school at the survey time were included in the study. The physically challenged children and having spinal deformities were excluded from our study due to difficulty in measuring the anthropometric parameters. Also, children suffering from any chronic disorders are not considered for inclusion in our study.
Registration and Ethical considerations
The trial was registered in the Clinical Trial Registry of India (CTRI/2019/11/022144) before enrolment of the participants. The study was conducted after getting ethical clearance from Institutional Review Board (RIPER/IRB/PP/2019/009). Verbal and written consent was taken from the parents or guardians to enrol their children in our study. Confidentiality of the data and anonymity of the participants was maintained during and after completion of the study.
Sample size and sampling technique
The sample size was calculated using Epi-Info 7 statistical software given by the Centre for Disease Control, USA. The sample size was determined by considering the proportions of underweight, stunting, and wasting reported by Srivastava et al. study in Uttar Pradesh, India. (1) The parameters used in sample size determination, calculated sample size, and the final sample size was represented in Table 1.
By considering the expected proportion of 38.4%, precision 5%, confidence level 95%, and non-response rate of 10%, the final sample size was determined as 400.
A simple random sampling technique was used to select the required number of children from the selected two primary and two secondary schools present in rural settings of Anantapur District. From each school, 100 children were selected randomly from the total school strength using a table of random numbers. Children who satisfy the study criteria were subjected to collect data about demographics and anthropometric parameters.
Data collection
A total of 390 children and their parents or caregiver were enrolled in our study after getting oral and written informed consent. All parents or caregivers were explained about study objectives and protocol in the local language before getting informed consent. A suitable data collection form was used to collect the socio-demographic and anthropometric parameters of the study participants.
Socio-demographic details like children's age, gender, parents’ education, religion, type of family, socio-economic status, physical activity, utilization of government nutrition programs, and parents belonging to healthcare jobs were collected from the parents by face-to-face interviews and medical records. The socio-economic status of the family was assessed by using a modified Kuppuswamy classification.
Anthropometric measurements (weight and height) for all children aged between five and 15 years were assessed using standard equipment for height and weight. Nutritional assessment was carried out by using World Health Organization (WHO) 2006 child growth standards. height-for-age z-score for stunting, weight-for-age z-score for underweight, and weight-for-height z-score for wasting were computed in WHO anthroplus software. The threshold points for the determination of undernutrition measures were given below;
Underweight: weight-for-age z-score ≤ 2 standard deviations (SD) of the WHO child growth standards median.
Stunting: height-for-age z-score ≤ 2 standard deviations (SD) of the WHO child growth standards median.
Wasting: weight-for-height z-score ≤ 2 standard deviations (SD) of the WHO child growth standards median.
Statistical Analysis
Data analysis was performed by using Epi-Info 7 statistical software given by the Centre for Disease Control, USA. Descriptive statistics like proportion, frequency, mean, and standard deviation were used to represent the socio-demographic and anthropometric parameters of the study participants. Inferential statistics like the Chi-square test was used to associate the socio-demographics with stunting, underweight, and wasting. P< 0.05 was considered as a statistically significant value.
Ethical clearance: The study was conducted after getting ethical clearance from Institutional Review Board (RIPER/IRB/PP/2019/009).
Results
A total of 390 children (male=59; female=231) have participated in the study with a mean age of 11.8±2.4 years. The majority of the children were physically active (357; 91.5%), Hindus (354; 90.7%), lower socio-economic family group (213; 54.6%), and utilizing government nutritional scheme (390; 100%). The majority of the parents were non-healthcare jobs (345; 88.5%), and illiterates (77.2% of Mothers and 50.3% of Fathers) as represented in Table 2.
The study findings revealed that the prevalence of stunting, underweight, and wasting were found to be 25.4%, 11.5%, and 17.7%, respectively. There was no significant difference among male and female children concerning undernutrition measures. Undernutrition measures associated with age and gender were represented in Table 3.
Above 10 years of age, many children experience the pubertal growth spurt and appear to have more weight concerning the weight-for-age score. They have not achieved weight requirements as per age. The weight-for-age indicator does not differentiate height and body mass in children above 10 years.
Weight-for-age reference data are not available beyond age 10 because this indicator does not distinguish between height and body mass in an ageing period where many children are experiencing the pubertal growth spurt and may appear as having excess weight (by weight-for-age) when in fact they are just tall.
HAZ=Height-for-age z score; WAZ=Weight-for-age z score; Weight-for-height z score; SD=Standard deviation
Predictors like illiteracy of parents, the joint family were significantly associated with undernutrition characteristics like stunting, underweight, and wasting. Parents' non-healthcare occupation was significantly associated with stunting. All predictors associated with undernutrition measures were represented in Table 4.
Discussion
Children in the age group between 5 and 15 years were considered as school age. This age is a very crucial period for physical growth, mental development, and social changes. The present study provides insights for the planning and development of educational programs based on socio-demographic correlates of undernutrition in rural school children.
The current study revealed a nutrition lag in terms of height and weight compared to the reference standards laid down by the WHO. In developing countries, including India, most children fail to grow in length and weight as per the age-specific pattern; there was a vast difference in the prevalence of low weight for age and height for age between the regions. Our study findings show that the prevalence of stunting, underweight, and wasting among rural school children was 25.4%, 11.5%, and 17.7%, respectively. Our study showed a low prevalence of underweight and wasting compared to the studies conducted in the Uttar Pradesh (2010) and Telangana (2016) states of India. It might be due to; improvements in the government nutritional schemes for school children in recent years. Even though there was a reduction in under-nutrition status in our study compared to the previous studies in India, there was still a need to address and educate the importance of nutrition and health among parents and children. The prevalence of under-nutrition status was low in India compared to other developing countries like Ethiopia, and Egypt.2,3,8,9
The study results show that there was no statistically significant difference in stunting, underweight, and wasting among male and female rural children. However, the proportion of under-nutrition status was high among female children. Our findings are contrary to the findings of other studies conducted in India, where the prevalence of under-nutrition was significantly high among girl children.10–12 Our study also supports these findings because the sample size is less compared to other studies in our study.
Predictors like illiteracy of parents, joint family, and non-healthcare occupation of the parents were significantly associated with malnutrition characteristics among school-going children in our study. These predictors are reported in various studies conducted in school-going children of India and other countries.3,9–11 Nutrition educational programs targeting children and parents will bring down the burden of under-nutrition in specific to rural school-going children.13,14 Finally, the study shows that maternal education, maternal working status, and family type are core determinants of child nutrition and health.15 Strategies focused on improving female literacy, women empowerment, and restricted family size will positively affect child nutrition and health.
Strengths and limitations
The study provides insights into the development of nutritional schemes or programs for school-going children in rural settings of the Anantapur district. The study was conducted in government schools located in rural areas of the Anantapur district. So, these findings may not apply to private schools and schools located in urban settings of the district.
Conclusion
The study concludes that the prevalence of stunting, underweight, and wasting was existing among rural school-going children. Even government provides nutritional schemes to overcome malnutrition disorders in school children, there was still a gap to prevent nutritional disorders. Targeted educational programs on the importance of child nutrition and malnutrition complications towards mothers are required to improve nutritional status among school-going children.
Acknowledgement
All authors would like to thank school management, children, and parents who spend their time providing valuable data to complete the study successfully.
Conflict of interest: Nil
Ethical clearance number: RIPER/IRB/PP/2019/009
Source of funding: Nil
Author’s contribution
This work was carried out in collaboration among all authors. Author GN designed the study, performed the statistical analysis, wrote the protocol, and wrote the first draft of the manuscript. Author RT, PC, KVV, MDM, UK, and MR helps in hypothesis framing, literature review, design, data collection, data entry, and managed the analyses of the study. All authors read and approved the final manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=4239http://ijcrr.com/article_html.php?did=4239
1. Srivastava A, Mahmood SE, Srivastava PM, Shrotriya VP, Kumar B. Nutritional status of school-age children - A scenario of urban slums in India. Arch Public Health. 2012 Dec;70(1):8.
2. Aurino E, Schott W, Behrman JR, Penny M. Nutritional Status from 1 to 15 Years and Adolescent Learning for Boys and Girls in Ethiopia, India, Peru, and Vietnam. Popul Res Policy Rev. 2019 Dec;38(6):899–931.
3. Ayalew M, Bayley A, Bekele A, Handebo S. Nutritional Status and Educational Performance of School-Aged Children in Lalibela Town Primary Schools, Northern Ethiopia. Int J Pediatr. 2020;20(1):1-9.
4. Kamran Shaikh M, Kamble N, Bhawani D, Bele S, Sita RR. Assessment of nutritional status among school children of Karimnagar, Telangana, India. Int J Res Med Sci. 2016;4(1):4611–7.
5. Kanjilal B, Mazumdar P, Mukherjee M, Rahman MH. Nutritional status of children in India: household socio-economic condition as the contextual determinant. Int J Equity Health. 2010;9(1):19.
6. Murarkar S, Gothankar J, Doke P, Pore P, Lalwani S, Dhumale G, et al. Prevalence and determinants of undernutrition among under-five children residing in urban slums and rural area, Maharashtra, India: a community-based cross-sectional study. BMC Public Health. 2020 Dec;20(1):1559.
7. Srivastava A, Mahmood SE, Srivastava PM, Shrotriya VP, Kumar B. Nutritional status of school-age children - A scenario of urban slums in India. Arch Public Health. 2012 Dec;70(1):8.
8. Abdel Wahed WY, Hassan SK, Eldessouki R. Malnutrition and Its Associated Factors among Rural School Children in Fayoum Governorate, Egypt. J Environ Public Health. 2017;2017(1):1–9.
9. Girma A, Woldie H, Mekonnen FA, Gonete KA, Sisay M. Undernutrition and associated factors among urban children aged 24–59 months in Northwest Ethiopia: a community based cross-sectional study. BMC Pediatr. 2019 Dec;19(1):214.
10. Patel PP, Patel PA, Chiplonkar SA, Khadilkar AV, Patel AD. Effect of mid-day meal on nutritional status of adolescents: a cross-sectional study from Gujarat. Indian J Child Health. 2016 Sep 25;03(03):203–7.
11. Sharma M, Watode B, Srivastava A. Nutritional Status of Primary School Children through Anthropometric Assessment in Rural Areas of Moradabad. Ann Int Med Dent Res [Internet]. 2017;4(2):1-10
12. Rema N. Prevalence of nutritional and lifestyle disorders among school-going children in urban and rural areas of Coimbatore in Tamil Nadu, India. Indian J Sci Technol. 2011 Feb 20;4(2):131–40.
13. Mwaniki EW, Makokha AN. Nutrition status and associated factors among children in public primary schools in Dagoretti, Nairobi, Kenya. Afr Health Sci. 2013 Mar;13(1):39–46.
14. Agia H, Abe K, Andrianome VN, Randriamampionona E, Razafinombana AR, Murai T, et al. Risk factors for malnutrition among school-aged children: a cross-sectional study in rural Madagascar. BMC Public Health. 2019 Dec;19(1):773.
15. Rahaman SN, Das S, Dash SK, Giri B, Ali KM. Nutritional Status of Primary School Children in Different Parts of India: A Review. IJCRR. 2019;11(07):01–4.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Nutritional and Nutraceutical Properties of Upland Edible Aroids and Selection of Superior Germplasm from Borail Hills Range, India
English121128Medhi PramodEnglish Choudhury Shally SultanaEnglish Sarma AniruddhaEnglish Sarma Pranab PratimEnglish Harish GDEnglish
Introduction: Borail Hills Range of Assam State of India has an enormous variety of tuber crops including aroids are important for the ethnic people for their regular dietary supplements. During scarcity of major cereal rice, the tubers play a major role in the regular diet of the ethnic groups like Dimasas, Zeme Nagas, Hmars, Hrangkhols, Biates, Kukis, Sakacheps, Vaipheis and Pnars. Aim: Quantification of the nutritional (viz. Carbohydrate, Protein, Total Fat, Crude fibre and Calorific value); nutraceutical (viz. Total mineral content, phenol content, antioxidant activity, flavonoid and the ascorbic acid); anti-nutritional (oxalates/ammonium oxalates) properties and also microelement (viz. Ca, Fe and Zn) of upland edible aroids. Methodology: Collection of the edible aroid tubers from the study area was followed by preparation of passport data and obtained Indigenous Collection numbers from Indian Council of Agricultural Research-National Bureau of Plant Genetic Resource (ICAR-NBPGR), New Delhi. Tuber samples were dried and ground to moisture-free powder for phytochemical analysis for nutritional, anti-nutritional, neutraceutical and micronutrient quantification were done. Result: A total of 27 numbers of cultivar and wild edible aroids belongs to 11 species and variability within them was analyzed phytochemically. Phytochemical analyses were broadly categorized and tabulated into nutritional property estimation, nutraceutical and anti-nutritional property estimation and microelement quantification. Conclusion: After phytochemical analysis, five nutritionally and nutraceutical superior Colocasia esculenta variants were selected (IC-0631527, 0631529, 0631536, 0631544 and 0631546) emphasizing higher calorific value and also lower anti-nutritional properties. All the selected superior germplasm were multiplied for field trial leading to agro technique development for upland cultivation.
EnglishAroids, Nutritional, Anti-nutritional, Nutraceutical analysis, Superior germplasm, Borail Hills Range, India
Introduction
Edible aroids consist of Colocasia (taro, eddoe, dasheen), Xanthosoma (tannia, new cocoyam), Alocasia (giant taro) and Amorphophallus (elephant foot yam). In addition to the tubers, the leaves and leaf petiole are used as vegetables. Colocasia and Xanthosoma occupy an important role in the diet of many tropical countries.1
The nutritional composition of roots and tubers varies from place to place depending on the agro-climate, the crop variety and other factors.2 Again, the dietary habits of the population in different regions of the world have been determined mainly by the availability of foods locally and also local practices.3 Also, taro tubers play an important role in the livelihood of millions of relatively poor people in less developed countries and are an excellent source of carbohydrates.4 Moreover, edible aroid corms and leaves are traditionally used to cure many ailments.5
A perusal of literature reveals that tender Taro leaves eaten cooked as vegetables contain higher protein and also a good source of carotene; minerals like potassium, calcium, phosphorous, iron and vitamins like riboflavin, thiamine, niacin, vitamin A, vitamin-C and also dietary fibre.6,7 Nutritionally, taro corms contain 63-85% water, 1.3-3.0% protein, 0.2-0.4% fat, 6.0% carbohydrates and appreciable quantities of Vitamins-C (15.34-61.72 mg/100 g). There was considerable variability in the mineral composition of taro and they appeared to be good sources of potassium, calcium, iron, copper and manganese.8
Production of certain free radicals in the human body may be enhancing the chances of diseases like cancer, rheumatoid arthritis, and atherosclerosis as well as ageing-related problems.3
Organisms are well protected against free radical damage by the enzymes like superoxide dismutase and catalase. Compounds like ascorbic acid, and tocopherols can prevent oxidative stress.9 However the natural antioxidant such as vitamin C, E, carotenoids, phenolic compounds, etc. that are present in herbs and spices are responsible for inhibiting the deleterious consequences of oxidative stress exerted by the reactive oxygen species (ROS).10 It has also been reported that the antioxidant activity of plant materials are well correlated with the content of their phenolic compounds.11,12
Many works have been done on different aspects of aroids worldwide. But, research work on the chemical and nutritional content of North East Indian wild edible tubers, rhizomes, corms, roots and stems is scanty and sporadic.13,14
Borail Hills Range of Assam State of North East India coordinates in between 24º 58/ N to 25° 50/ N latitudes and 92° 50/ E to 92° 52/ E longitudes. The ethnic groups of the area are- Dimasas, Zeme Nagas, Hmars, Hrangkhols, Biates, Kukis, Sakacheps, Vaipheis and Pnars. Aroids have a good sign for them from nutritional aspects. During the late winter months (i.e. by late January), when Jhum rice stock begins to exhaust, they mix rice with the tubers for an additional nutritional supplement. Again, additional income generation by selling their agro-products in the nearby makeshift markets is also another output for the economic wellbeing of those ethnic groups.15a,15b The present work was undertaken to estimate the nutritional, anti-nutritional and nutraceutical properties of upland edible aroids for the selection of nutritionally superior germplasms from Borail Hills Range of Assam State of North East India.
2. Materials and methods
2.1. Collection and sample preparation
Individual sampling was done selectively for collecting the aroid germplasm samples during September 2016 and February 2017. Passport information data on each accession was recorded at the time of collection, following the standard procedure of the Indian Council of Agricultural Research-National Bureau of Plant Genetic Resource (ICAR-NBPGR).16 Subsequently, all the collected aroid germplasms were submitted to ICAR-NBPGR Regional Station, Shillong, India for further conservation and multiplication and later Indigenous Collection (IC) numbers of each of the accessions were obtained from National Authority (NBPGR).
Collected upland edible aroid corms or cormels were cleaned, sliced and air-dried properly. Then the samples were dried in a hot air oven at 60°C till a constant weight was obtained. Then the dried materials were ground to powder form and stored at 4° C for further analysis.
2.2. Methods of analysis
All the phytochemical analyses were done on a moisture-free basis. Laboratory analysis of upland edible aroid samples was carried out to estimate the nutritional (viz. Carbohydrate, Protein, Total Fat, Total Crude fibre contents and Calorific value), nutraceutical (viz. Total mineral content, total phenolic content, antioxidant activity, ascorbic acid and the flavonoid content), antinutritional properties (viz. oxalates/ammonium oxalates) and also quantification of microelement (viz. Ca, Fe and Zn).
2.2.1. Nutritional analysis
Total carbohydrate estimation was done by following the standard procedure of the Anthrone method.17Total protein estimation was done by following Lowry’s method.18Total fat content determination was done by using the Soxhlet apparatus. The crude fibre in the samples was determined and extracted fibre was expressed as a percentage of the original defatted sample and calculated.19 Calorific values were estimated by using a Bomb colourimeter (Optics Tech Make).
2.2.2. Nutraceutical analysis
The amounts of ascorbic acid present in the samples were calculated by using 2, 6- dichloro phenol indophenol dye.20For quantitative estimation of flavanoid, spectroscopic analysis was done21 for the present study. The total phenol content was determined by Folin-Ciocalteau’s method.22The antioxidant activities of the sample extracts along with standard were assessed based on the radical scavenging effect of the stable DPPH method.23
2.2.3. Anti-nutritional analysis
The standard permissible limit of the oxalate contents in edible aroids is 71mg/100g and beyond this limit is not recommended for human consumption. Estimation of anti-nutritional properties (oxalates/ ammonium oxalates) was done by titration method.24
2.2.4. Micronutrients analysis
Quantification of microelement viz. Ca, Fe and Zn were done by Atomic Absorption Spectrophotometer (AAS) [Model: AAS-700, Perkin Elmer]. Standard methodology as advocated by Jackson 25 and Brooks26 was utilized for the digestion and analytical procedures for quantification of total metal concentration in dried sample powders.
2.2.5. Statistical Analysis
The data generated were subjected to statistical analysis. All the assays except the micronutrients were recorded in triplicates and the average values were expressed as Standard Deviation (mean ±SD).
3. Results
A total of 27 numbers of cultivar and wild edible aroids belongs to 11 species and variability within them from the agro-climatic zone of the Borail Hills Range of Assam State of North East India were analyzed phytochemically. The present phytochemical studies on the edible upland aroids have been broadly subdivided into the following and the findings are presented in Table-1, 2 and 3 respectively -
Nutritional property estimation (viz. Carbohydrate, Protein, Total Fat, Total Crude fibre contents and Calorific value) (Table-1).
Nutraceutical and Anti-nutritional property estimation (viz. Total mineral content, total phenolic content, antioxidant activity, flavonoid and the ascorbic acid content) (Table-2).
Microelement quantification (viz. Ca, Fe and Zn) (Table-3).
4. Discussion
Phyto-chemical content variability of the aroid tubers is related to species origin, geography, planting season, the season of harvest and agronomic factors like the soil quality.6 Thus, the nutritional composition of roots and tubers varies from place to place depending on the climate, the soil, the crop variety and other factors.27
From the present study total percentage (%) of carbohydrate, total protein, total fat and crude fibre were recorded to be ranging from 22.56±0.24 (IC-0631541) to 64.93±0.01 (IC-0631536), 2.30±0.05 (IC-0631530) to 4.65±0.01 (IC-0631538), 0.48±0.01(IC-0631523) to 4.78± 0.04 (IC-0631531) and 1.35 ±0.32 (IC-0631528) to 29.95±0.23 (IC-0631523) respectively. Calorific values was ranging from 237.14±04 (IC-0631541) to 365.10±0.21(IC-0631527) kcal/100g.
The antioxidant in food items reduces oxidative damage to the consumer as many plant products have been validated as the source of natural antioxidants. Enzymes like Superoxide dismutase and catalase or compounds such as ascorbic acid, phenolic compounds, tocopherols, β-carotene, lycopene and glutathione, etc.28 act as an antioxidant agent. Total phenolics and other natural products like vitamin C and carotenoids have been shown to possess various biological properties related to antioxidant activity.29, 30, 31 Present work revealed the ranges of antioxidant activity (IC50= µg/ml) from 183.01±0.05 (IC-0631549) to 96.94±0.05 (IC- 0631523).
Again, the value ranges of ascorbic acid (mg/100g), flavonoid (µGqe/mg), total phenol content (µgGAE/mg), total minerals content (%) were recorded from 10.81 ±0.23 (IC-0631528) to 38.56±0.04 (IC-0631546), 3.45±0.32 (IC-0631523) to 9.21±0.12 (IC-0631522), 14.02±0.26 (IC-0631533) to 34.20±0.02 (IC-0631523) and 1.02±0.37 (IC-0631525) to 15.3± 0.15 (IC-0631547) respectively.
Anti-nutritional properties (mg/100g) range was from 55.15±0.44 (IC-0631550) to 104.02±0.59 (IC-0631539).
The main nutrient supplied by taro tubers is dietary energy provided by carbohydrates. However, low protein and fat contents in taro tuber limit in preparation of protein and fat-rich foods. The outcome of the present work on the nutritional, nutraceutical and anti-nutritional property studies of the edible upland aroids may be significant for nutritional applications and diet formulations.
5. Conclusion:
Out of 27 numbers of cultivar and wild edible aroids analyzed phytochemically, a total of 5 Colocasia esculenta variants, which are nutritionally and nutraceuticals superior (i.e. IC-0631527, 0631529, 0631536, 0631544 and 0631546) were selected emphasizing mainly the calorific value and also lower anti-nutritional properties of the tubers or cormels studied. All the selected superior taro germplasm were multiplied for field trial leading to agro technique development for upland cultivation.
Thus, the development of upland taro agro-technique or package of practice for enhanced tuber crop productivity has been taken up as follow up action. Thus, enhanced productivity will be helpful to set up new agro-based (i.e. aroid) cottage industries. So, as a future scope, germplasm conservation and multiplication for the future breeding programme, also production and marketing of the commercial starch from tubers which are used in adhesives, dextrins, food, sweeteners, ethyl alcohol production, soaps and detergents, laundry, cosmetic, pharmaceuticals and biodegradable plastics, etc. will be helpful for the opening of new vistas for agro-based cottage industries for the economic wellbeing of the ethnic people of North East India.
5. Acknowledgements
The authors express their heartfelt thanks to the ethnic people of Borail Hills Range of India for sharing their knowledge on edible aroids. The authors are also thankful to the Natural Resource Data Management System, Department of Science and Technology, Government of India for awarding the research project. The authors are also thankful to the Indian Council of Agricultural Research-National Bureau of Plant Genetic Resource(ICAR-NBPGR), New Delhi for providing Indigenous Collection (IC) numbers of the collected aroid samples.
Conflict of interest: The author(s) declare(s) that they have no competing interests.
Source Funding: Natural Resource Data Management System, Department of Science and Technology, Government of India, New Delhi for funding (April 2016 to December 2018) in the form of the research project.
Authors’ contributions
Pramod Medhi carried out the taro germplasm collection, taxonomic identification, sample preparation and phytochemical analysis works. Shally Sultana Choudhury, Aniruddha Sarma and Pranab Pratim Sarma also carried out phytochemical analysis works. Harish GD assisted in getting Indigenous Collection (IC) numbers from the national authority.
Englishhttp://ijcrr.com/abstract.php?article_id=4240http://ijcrr.com/article_html.php?did=4240
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411322EnglishN2021November20Healthcare
Application of Lepidium sativum Seed Mucilage as a Disintegrant in Pharmaceuticals Formulations: Exploring the Myth vs. the Reality
English129132Mahapatra Abikesh Prasada KumarEnglish Gupta NirajEnglish Panigrahy SubodhkantEnglish Paul BasudevEnglish Ekambaram Vijay KumarEnglish
Introduction: The uses of Lepidium sativum seed mucilage (LSSM) as a disintegrant in various pharmaceutical formulations were already discussed. Researchers claimed that the different functional properties of the seed mucilage of Lepidium sativum enable it to use as a natural disintegrant. Furthermore, scientific research on the disintegrant activity of the LSSM has revealed that it could be effectively used as an alternative to synthetic disintegrants. However, certain factors restrict its use as a disintegrant on the large scale. Aim: In the current scientific discussion, we technically analyzed the prospective obstacles that limit the use of Lepidium sativum seed mucilage as a natural disintegrant in pharmaceuticals. Discussion: In the present discussion, the real case scenario of the functional use of LSSM as a disintegrant on the large scale in different pharmaceutical formulations was summarized. Diligence effort was given to evaluate the different factors associated with the isolation process as well as the intrinsic functional properties that restrict its use as a disintegrant. Conclusion: In conclusion, we opined that Lepidium sativum seed mucilage (LSSM) can be used as a disintegrant. However, before its use in the pharmaceutical industry on a commercial scale, a lot of research and development must be done.
EnglishLepidium sativum, Seed mucilage, Disintegrant, Pharmaceutical formulations, Pharmaceutical excipient, Intrinsic functional properties
Introduction
Lepidium sativum is a readily available medicinal herb. The Lepidium sativum seeds, roots, and leaves have medicinal properties. However, the plant is well recognized for its seeds.1 Several researchers are investigating the use of Lepidium sativum-derived products as a disintegrant, binder, control release polymer, gelling agent, oxidizing, and as viscosity-enhancing agent due to their extensive functional properties.2,3 Based on its popularity many researchers explored the use of Lepidium sativum seed mucilage in different pharmaceutical dosage forms.2,4 There is an increasing interest in using seed mucilage from Lepidium sativum in pharmaceutical formulations, which plays distinct roles in tablet and liquid dosage forms.4 Lepidium sativum mucilage has become more popular as a disintegrant. Though several studies have been focused on the development of a cost-effective isolation and extraction process of mucilage from Lepidium sativum seeds; however, there is very little information available on how to efficiently extract the mucilage from seeds.
The extraction and isolation of Lepidium sativum seed mucilage by using cost-effective and easily accessible solvents is critical for its commercial viability. The factor which contributes most is the yield of extraction process. Due to low yield, the cost of extracted mucilage may shoots up. In an attempt to get maximum yield Karazhiyan et al.5 and Kilor et al.6 proposed several extraction processes. In a recent advancement, Mahapatra et al.7 reported a modified method produced a yield of approximate 20% which was relatively higher compared to other reported yields. Mucilage is present around the seeds and an effective solvent, and a simple economic, and user friendly method needed to extract the mucilage from the seeds efficiently. Even if an effective method was utilized, a higher amount of input seeds was needed to get the desired amount of mucilage. Therefore, due to this reason, the observed yield was always found less. Hence, this shall not function as a cost-effective approach and is a tedious task for the manufacturer to produce on a large scale.
Maintaining an alkaline condition during extraction of mucilage from seeds of Lepidium sativum could increase yield by hydrolyzing insoluble constituents into soluble which increases the extraction yield. The effect of alkaline condition on the yield of mucilage from seeds of Lepidium sativum was discussed by Karazhiyan et al.5 and Mahapatra et al.7. Karazhiyan et al.5 extracted mucilage from cress seed (Lepidium sativum) by optimizing pH (alkaline pH), temperature, and water: seed ratio by using response surface methodology. Mahapatra et al. in their research work improved the yield of the seed mucilage of Lepidium sativumby optimizing pH (alkaline pH) and water: seed ratio by using a quality by design (full factorial design) approach. The pH modification proposed by both authors was not justified by solid scientific evidence like why pH was adjusted to alkaline (pH 10). As the extracted mucilage will be used in the finished product as a disintegrant the alkaline pH would affect the pH of the finished product which might affect the finished dosage form stability. Thus, getting a higher percentage yield by maintaining an alkali condition (pH 10) and utilizing the obtained disintegrant in the finished product in the lab scale may be possible. However, reproducing the result on a commercial scale for stability is quite difficult.
Settling (or swelling) volume is considered an essential functional related characteristic of disintegrants.8 This test has been used for several decades. The greater the swelling volume, the greater the capacity of that material to accommodate adsorbed water molecules.9,10 The swelling index of seed mucilage of Lepidium sativum by Mahapatra et al.7 and Archana et al. 10 was found to be 10.3 % and 11 % respectively. Based solely on the swelling volume, the most used synthetic disintegrants used in the pharmaceutical formulations having a swelling index in between 10-30 ml and are follows the order: SSG > CCS > XPVP SSG.11 Among the 3 disintegrants SSG yields faster disintegration times than CCS and XPVP. However, the reported swelling index of the extracted seed mucilage of Lepidium sativum is very much less as compared to the other synthetic disintegrants (SSG / CCS/ XPVP) used in pharmaceuticals. This contributes to a lower disintegrant activity of seed mucilage of Lepidium sativum as compared to the other synthetic disintegrant. The particle size of the disintegrant also contributes rate and extent of swelling. A group of a researcher by Rudnic et al.12 investigated the role of particle size on the rate and extent of swelling and demonstrated higher particle size endorses disintegrant activity. Studies have shown that the particle size is mainly controlled by the extraction process and there is a need of higher control in the extraction process to control the particle size of mucilage.12 Controlling the particle size by extraction process without using any milling step is a tedious process on a larger scale and thus limit its use as a substitute for other marketed synthetic disintegrants.
The determination of ash values, as well as contaminants such as heavy metals and aflatoxins, always represents qualitative standards for naturally extracted materials and these tests determine the authenticity and purity of the material. The determination of ash values (total ash, acid insoluble ash, and water-soluble ash), heavy metals (Cd/Pb/As/Hg) and aflatoxins from a natural source like Lepidium sativum seed mucilage is critical and may need a sophisticated instrument which again may not be economic. Moreover, limited information available in the literature database for these contaminates and showed that the values were very high.13 Due to high chance of contaminants there is a higher probability of lower purity level which signifies that the extracted mucilage is not pure and may not be good for use as an excipient or adjuvant in pharmaceutical formulations for human consumption. Many authors reported the extraction and characterization of Lepidium sativum seed mucilage. It is reported that a large number of organic solvents belonging to classes 1, 2, and 3 such as ethanol, acetone, and chloroform are used for the extraction process. However, residual solvents removal as per Q3C (R6) was not confirmed by any of the authors which restricts the use for human consumption in regulated markets such as the United State America, Canada, Europe, and Australia where the requirement of residual solvent is highly stringent and considered as an organic impurity which needs to be taken into consideration for human consumption. Moreover, the extracted mucilage was from a natural source. Thus, consideration of pesticides or microbiological levels is highly essential. However, this aspect was ignored by the researchers, and consideration of any pesticides or microbiological levels should have been studied as it might represent a major drawback for its use. It was reported that the appearance of the extracted mucilage was brownish red or pale brown in color.13 If it is used as a disintegrant in pharmaceutical formulations, it may cause unacceptable appearance for the final formulation and it will be more critical for uncoated tablets. Moreover, getting a longer shelf life will be always a challenging task owing to its natural source.
Many scientific studies have been published on the extraction of seed mucilages of Lepidium sativum by using cost-effective methods however have poor yields. Researchers also evaluated various physico-chemical properties and demonstrated their potential use as disintegrants in pharmaceutical formulations. It was claimed that the seed mucilages of Lepidium sativum can be established as a potential new excipient that can suffice the requirement of novel disintegrants for pharmaceuticals. However, we emphasized that reality is different. The use of seed mucilages of Lepidium sativum as a disintegrant in pharmaceuticals is a very much challenging task owing to its low disintegrating efficacy, not being cost-effective, poor control over its particle size and other quality standards such as compromised purity, pesticide content and microbial load (figure 1). Any dosage form in pharmaceuticals must pass through several quality control tests. The same applies to excipients also. Due to the stringent regulatory requirements, it seems an even tougher assignment.
Conclusion
In this summary, we discussed the potential hurdles that enable the use of seed mucilages of Lepidium sativum on a commercial scale as a disintegrant in pharmaceuticals. We also acclaimed that it can be used on small scale i.e. laboratory scale. It could be used in pharmaceuticals, however, for a viable use a lot of work and research needs to be done before it can be used in the pharmaceutical industry on a commercial scale.
Acknowledgements
The authors express their sincere thanks to the management of OPJS University, Churu, Rajasthan, INDIA for providing the necessary support. 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 and journals from where the literature for this article has been reviewed and discussed.
Conflict of interest
The authors have no conflict of interest to declare
Source of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical approval
Ethical approval is not required for this study
Author’s contributions
We declare that this work was done by the authors named in this article: APKM conceived, drafted and designed the manuscript. SKP and BP collected and analyzed the data. . SBP supervised the work and assisted in the data analysis. VKE contributed to the final revision of the manuscript. All authors have read and approved the final manuscript.
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