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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN2017January20HealthcareRetrospective Study of CNS Tumors in Tertiary Care Hospital
English0104Rajul Iqbal DesaiEnglish Nidhi Shailesh SoniEnglish Iqbal Mohammad DesaiEnglish Kunjlata RajputEnglishBackground: Central Nervous System tumors are group of neoplasms having different prevalence in different sex and age groups and various parts of CNS. The aim of our study to show the prevalence of various brain tumors and their age and sex distribution.
Methodology: The present 1.5 years study from a single tertiary care center, Gujarat research and medical institute, the patient diagnosed with CNS tumors and registered between 2014 and 2015 in the pathology department were consecutively screened. The inclusion criteria were cases of CNS tumors of all age groups. The tumors of peripheral nervous system. With these criteria, a total of 107 cases of CNS tumors were studied, and their histological typing and grading was done.
Result: All the CNS tumors were divided into seven categories: Tumors of neuroepithelial tissue; tumors of the cranial and paraspinal nerves; tumors of the meninges; lymphomas and hematopoietic neoplasms; germ cell tumors; tumors of the sellar region; and metastatic tumors. most common lesions were Astrocytic Tumours followed by Meningeal Tumors. Male to Female ratio is 1.0 : 0.98.
Conclusion: Nowadays there is an increase in incidence of CNS tumors in developing countries because of advanced health care and diagnostic facilities. Astrocytic tumors are the most common followed by meningeal tumors. The study shows prevalent pattern and comparison with similar studies. This may help in locating prevailing etiological index of that region.
EnglishAstrocytoma, Central nervous system, MeningiomaINTRODUCTION
Brain tumors though not very common, result in significant morbidity because of their poor survival rate. A number of studies from Western countries have reported on the pattern, incidence and mortality of brain and central nervous system (CNS) tumors. Tumors of the central nervous system are a group of neoplasms having different prevalence in different sex and age groups and various parts of CNS. The tumors of central nervous system are reported to be less than 2% of all malignancy1. In developing countries like India, there is lack of resources which result in missing the diagnosis of new cases hence the exact tumor burden is underestimated. Hospital-based prevalence data, therefore, forms the basis for estimating the disease load. Nowadays health care and diagnostic facilities have advanced which leads to increase in incidence of CNS tumors in developing countries.
All the CNS tumors were divided into seven categories: Tumors of neuroepithelial tissue; tumors of the cranial and paraspinal nerves; tumors of the meninges; lymphomas and hematopoietic neoplasms; germ cell tumors; tumors of the sellar region; and metastatic tumors. The WHO classification offers a crude histological grading system, in which each CNS tumor is classified as Grades I-IV according to its degree of malignancy. This system can provide an estimate for the prognosis of a patient. In this study, age, sex and the histological tumor type and grade were systematically recorded.
The present 1.5 years study from a single tertiary care center, Gujarat research and medical institute, the patient diagnosed with CNS tumors and registered between 2014 and 2015 in the pathology department were consecutively screened. The H and E stained histopathological slides of biopsy received were evaluated. The cases were diagnosed and characterized where necessary using Immuno-histochemistry and categorized according to the WHO 2007 classification. The inclusion criteria were cases of CNS tumors of all age groups. The tumors of peripheral nervous system. With these criteria, a total of 107 cases of CNS tumors were studied, and their histological typing and grading was done.
RESULTS
Total 107 cases were found at Gujarat Research Medical Institute, GRMI, Rajasthan Hospital for the period of 1.5 years. In our study most common lesions were Astrocytic Tumours followed by Meningeal Tumors . Out of total 107 cases of CNS tumours, 25 cases were of Astrocytic Tumours and 21 cases were of Meningeal tumours. There was almost equal sex ratio as there were 54 males & 53 females out of 107 cases of CNS tumours. Male to Female ratio is 1.0 : 0.98
In our study, age distribution revealed that tumors were more common in age group 41 to 50 years (32 cases) followed by 31 to 40 years (22 cases). In our study it is observed that Astrocytic Tumours have almost equal distribution in both Males & Females, However in Meningeal tumours are more common in females. And in the others category the most common tumor was Pituitary adenoma (12 cases).
DISCUSSION
In our study, we noted that Astrocytic tumour was the commonest tumor (23.31%) which was contrary to Surawicz et al (1999)[5] in USA & Lee et al (2010)[6] in Korea noticed that most common tumor was meningioma (31.2%).
Aryal G. et al (2011)[9] in Nepal noticed that astrocytomas were most common tumors of CNS followed by meningiomas. According to Materljan E et al (2004)[8], neuroepithelial tumors were common CNS neoplasm. Sex distribution showed that meningioma affects females more than males, as it was noted by Surawicz et al.[5]
In our study, astrocytoma was seen in males & females equally. According to Surawicz et al (1999) gliomas affect about 40% more males than females.[5] Our study showed that male to female ratio was 1.0 : 0.98, but according to Balkishan B Yeole et al (2008) , brain – nervous system cancer were more common in male than female.[1] But according to Lee et al (2010) 6 CNS tumors occurred in females more often than in males (female to male, 1.43: 1).
According to WHO classification, majority of lesions belonged to Grade I in comparison to grade III or IV. But in cases of astrocytoma, grade III lesion was more common in comparison to Grade I lesion.
CONCLUSION
Nowadays there is an increase in incidence of CNS tumors in developing countries because of advanced health care and diagnostic facilities. Astrocytic tumors are the most common followed by meningeal tumors. The study shows prevalent pattern and comparison with similar studies. This may help in locating prevailing etiological index of that region.
Englishhttp://ijcrr.com/abstract.php?article_id=82http://ijcrr.com/article_html.php?did=821. Ram Kumar Gupta et al, JK-Practitioner 2012;17(4),42-46.
2. Balkrishan B Yeole et al, Trends in Brain Cancer Incidence in India, Asian Pacific Journal of cancers prevention, Vol 9,2008
3. Sarita N, Kanwardeep K et al, Histopathological spectrum of CNS tumors, IJSS 2015;3(6),130-134.
4. Jain A, Sharma MC, Suri V, Kale SS, Mahapatra AK, Tatke M, et al. Spectrum of pediatric brain tumors in India: A multi-institutional study. Neurol India 2011;59:208-11.
5. Surawicz TS, Davis F, et al. Brain tumor survival: results from the National Cancer Data Base. (Accepted for publication in Journal of Neuro-Oncology).
6. Hoffman S, Propp JM, McCarthy BJ. Temporal trends in incidence of primary brain tumors in the United States, 1985-1999. Neuro Oncol 2006;8:27-37.
7. Alexandru D, Bota DA, Linskey ME. Epidemiology of central nervous system metastases. Prog Neurol Surg 2012;25:13-29.
8. Materljan E, Materljan B, Sepcić J, Tuskan-Mohar L, Zamolo G, Erman-Baldini I. Epidemiology of central nervous system tumors in Labin area, Croatia, 1974-2001. Croat Med J 2004;45:206-12.
9. Aryal G. Histopathological pattern of central nervous system tumor: A three years reterospective study. Journal of Pathology of Nepal, 2011;1:22-5.
10. Rigau V, Zouaoui S, Mathieu-Daudé H, Darlix A, Maran A, Tré- tarre B, et al. French brain tumor database: 5-year histological results on 25 756 cases. Brain Pathology,2011;21:633-44.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN2017January20HealthcareAmlodipine - A Novel Offender of Gingival Overgrowth-A Case Report
English0508Shobana P.English Ramakrishnan T.English Nirmala J. I.English Vidya SekharEnglish Manisunder N.English Ebenezer M.EnglishAim: There are only few cases presented with Amlodipine-induced gingival enlargement so far. The main purpose of this case report is to discuss about Amlodipine-influenced gingival enlargement in a 56 years old female hypertensive patient and its periodontal management and maintenance. Case Report: In this case report, patient with a history of hypertension for past 2 years and presenting with Amlodipine-induced gingival enlargement and various approaches to manage it were discussed. Discussion: One of the common clinical features of gingival disease is gingival enlargement, otherwise termed as Gingival Overgrowth. Gingival enlargement occurs as a side effect following the administration of certain drugs. The most common drugs causing gingival enlargement are Anticonvulsants for eg Phenytoin, immuno-suppressants like Cyclosporine and calcium channel blockers (Nifedipine). Amlodipine - a third-generation calcium channel blocker is found to be associated with Gingival overgrowth even when prescribed in a very low dose of about 5mg. Conclusion: The results of this case report suggested that the combined non-surgical and surgical therapy resulted in complete healing of the gingival overgrowth with less post-operative complication.
EnglishDrug-Induced Gingival Overgrowth (DIGO), Calcium Channel Blockers (CCBs), Gingivectomy and AmlodipineINTRODUCTION
One of the common clinical features of gingival and periodontal disease is the increase in the size of the gingiva. Current terminologies used to describe this condition are Gingival enlargement and gingival overgrowth (GO). An overgrowth or increase in size of the gingiva is called as Gingival enlargement. 1 Various etiologic factors have been associated with this condition, of which the two most common causes are inflammation and medications used. Certain systemic drugs prescribed for non-dental treatment have an unwanted side effect on the gingiva. Kimball in 1939, was the first to describe about Drug-induced gingival enlargement with chronic usage of phenytoin- an anti-epileptic drug. More than 20 prescribed medications are associated with this condition.2 Drug influenced gingival enlargement is defined as an enlargement resulting in whole or in part from systemic drug use. 1
The other drugs associated with gingival overgrowth are broadly classified into 3 categories according to their therapeutic actions, i) anticonvulsants ii) immuno-suppressants and iii) calcium channel blockers (CCBs)3 . Among these drugs CCBs especially Nifedipine causes gingival overgrowth in about 10% of patients2. Amlodipine - a dihydropyridine derivative, induced enlargement of the gingiva is usually less common. Jorgensen in 1997 reported that the prevalence of gingival overgrowth in patients taking Amlodipine is about 3.3%4. It is indicated in the management of both hypertension and angina.
The mechanism behind the GO is not well documented. Both inflammatory and non-inflammatory mechanisms have been suggested. The non-inflammatory mechanism suggests a defective collagenase activity due to increased uptake of folic acid, a blockage in the synthesis of aldosterone in the adrenal cortex with a consequent feedback increase in adrenocorticotropic hormone (ACTH) levels and an upregulation of keratinocyte growth factor. The inflammatory theory suggests that inflammation develops as a result of a direct toxic effect of drug concentration in gingival crevicular fluid and with bacterial plaque. This inflammation leads to an up-regulation of several cytokine factors particularly the transforming growth factor beta 1 (TGF-β1)5 . In addition, Inflammatory Enlargements generally are complications secondary to any other type of enlargement, creating a combined gingival enlargement6. The management of this combined enlargement always require combined treatment.
CASE REPORT
A patient named Mrs. Vasanthi 56 years old female came to our hospital with a chief complaint of bleeding and swollen gums and mild gnawing pain occurs occasionally. On intraoral examination enlarged gingiva with generalized bleeding on probing with presence of local factors like plaque and calculus were observed (Fig 1). Patient’s medical history reveals that she is hypertensive and under medication (T. Amlong 5mg once daily) for past 4 years. Enlargement involves marginal gingiva as well as interdental papilla of mandibular anteriors, premolars and certain maxillary teeth regions. On the basis of history given by the patient and clinical features it was diagnosed as Amlodipine -induced gingival overgrowth compounded with plaque induced chronic periodontitis.
CASE MANAGEMENT
A complete blood investigation was taken to rule out other systemic diseases. Patient’s physician was consulted regarding the dental treatment procedure under Local anaesthesia and opinion was obtained, substituting the drug was not advised for this particular case. Patient was subjected to initial Phase I therapy (Fig 2) which included complete scaling and root planing (SRP) with adjunct prescription of antibiotics (Cap. Moxikind 500mg tds for 5 days, T. Flagyl 400mg bd for 5 days). Patient recalled a couple of week after SRP and was instructed to maintain good oral hygiene with the use of mouth rinses (Chlorhexidine). A drastic response was noticed after two week in the revisit. It resulted in Regression of the size of enlargement with some amount of fibrotic component left unresolved (Fig 3). A surgical therapy was planned to completely eliminate the remaining amount of gingival enlargement. Under local anaesthesia, bleeding points were marked; the remaining enlargement was excised by giving an external bevel incision along the marked points with NO.15 scalpel (Fig 4, 5). After the surgical gingivectomy procedure, saline + Betadine irrigation was done. Periodontal dressing was placed after achieving hemostasis. Post operative instructions and analgesics were given. Healing was uneventful without any post-operative complications. The patient was asked to report after few weeks and observed to remain asymptomatic. Oral hygiene instructions were given and patient is under maintenance phase with no signs of recurrence (Fig 6). The histopathological study report shows the presence of dense infiltration of chronic inflammatory cells and perivascular inflammatory infiltrate and connective tissue shows dense bundles of collagen fibres with fibroblasts. And the epithelium shows hyperplasia, acanthosis and intracellular edema (Fig 7).
DISCUSSION
The mechanism by which calcium antagonists induce gingival overgrowth is yet to be explained. Nifedipine induced gingival overgrowth was first reported in the year 1980s by Lederman et al., and Ramon et al., soon after Diltiazem, Verapramil and in cases with Amlodipine and Felodipine were also described. The severity of gingival overgrowth in patients taking these medications correlates well with poor plaque control and is always correspond with the degree of Plaque-induced inflammation7 . Seymour et al., stated that the pathogenesis of drug-induced gingival enlargement is a multifactorial model which involves an interaction of several factors, which expands on the interaction between drug and metabolite with the gingival fibroblasts. The predisposing factors are age, genetic predisposition, pharmacokinetic variables, drug-influenced alterations in gingival connective tissue homeostasis, histopathology, ultrastructural factors, inflammatory changes and drug-induced actions on growth factors8 . Gingival overgrowth influenced by Amlodipine usually begins at the interdental papilla, which occurs within 6 months of taking medications at a dose of 10mg/day. Few cases have reported at a dose of 5 mg of Amlodipine when used more than 6 months 8. The treatment option for such case should always start with Non-surgical therapy; the main aim of this approach is to reduce the inflammation thereby allowing it to resolve since few patients respond well along with substitution of the drug. In this present case scenario, the patient’s physician was not willing to substitute the drug. When gingival enlargement persisted even after eliminating the inflammatory components, then there is a need of periodontal surgery. It is the clinician’s decision to choose the technique whether scalpel gingivectomy, periodontal flap surgery, electrocautery or laser excision. Fardel and Lygre in 2015 stated that surgical treatment was more effective than non-surgical treatment in reducing the size of overgrowth.5 It was reported that more than 75% of patients using CCBs needed treatment for Gingival overgrowth and replacing the drug with non-CCB antihypertensive significantly reduces the Gingival Overgrowth5 .
CONCLUSION
In this present case the combined non-surgical and surgical therapy resulted in complete healing of the gingival overgrowth with less post-operative complication. Yet there is a need of post-therapy maintenance and long-term follow-up in order to evaluate the long-term recurrence of gingival overgrowth in patients who had not replaced Amlodipine with the alternative drug. Within the limitation of the present study it has been concluded that combined treatment would be more effective in managing combined enlargement cases.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=83http://ijcrr.com/article_html.php?did=831. American Academy of Periodontology, editor. Glossary of periodontal terms. American Academy of Periodontology; 2001.4th ed:21
2. Joshi S, Bansal S. A rare case report of amlodipine-induced gingival enlargement and review of its pathogenesis. Case reports in dentistry. 2013 Aug 6;2013.
3. Srivastava AK, Kundu D, Bandyopadhyay P, Pal AK. Management of amlodipine-induced gingival enlargement: Series of three cases. Journal of Indian Society of Periodontology. 2010 Oct 1;14(4):279.
4. Tejnani A, Gandevivala A, Bhanushali D, Gourkhede S. Combined treatment for a combined enlargement. Journal of Indian Society of Periodontology. 2014 Jul;18(4):516.
5. Fardal Ø, Lygre H. Management of periodontal disease in patients using calcium channel blockers–gingival overgrowth, prescribed medications, treatment responses and added treatment costs. Journal of clinical periodontology. 2015 Jul 1;42(7):640- 6.
6. Newman MG, Takei H, Klokkevold PR, Carranza FA. Carranza’s clinical periodontology. Elsevier health sciences; 2011 Feb 14:118.
7. Bharti V, Bansal C. Drug-induced gingival overgrowth: the nemesis of gingiva unravelled. Journal of Indian Society of Periodontology. 2013 Mar 1;17(2):182.
8. Tripathi AK, Mukherjee S, Saimbi CS, Kumar V. Low dose amlodipine-induced gingival enlargement: A clinical case series. Contemporary clinical dentistry. 2015 Jan;6(1):107.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN2017January20HealthcareA Comparative Evaluation of the Efficacy of Andrographis Paniculata, 2% Chlorhexidine and 5.25% Sodium Hypochlorite Against Enterococcus Faecalis- An Invitro Study
English0913Ravi Varman C.1English Thillainayagam S.2English Dinesh D.S.3English Jaisenthil A.4English Bharath N.B.5English Karthikeyan S.6EnglishAim: To evaluate and compare the antimicrobial efficacy of 0.5% phytochemical extracts of Andrographis Paniculata (AP), 2% Chlorhexidine (CHX) and 5.25% Sodium hypochlorite (NaOCl) as an endodontic irrigant against Enterococcus faecalis.
Methodology: Forty freshly extracted human single rooted mandibular premolars were selected, decoronated and standardized to 12mm root length. Cleaning and shaping was done using ProTaper® (Dentsply) up to size F3 and irrigated with 3% NaOCl. Contamination of the specimens was carried out for 21 days at 37ºC. The specimens were then divided into four groups (n=10) for irrigation with 0.5% AP, 2% CHX, 5.25% NaOCl and distilled water as control. Before and after irrigation, microbiological samples were collected using sterilized paper points, and efficacy was expressed as reduction in microbial load using Colony Forming Units. Statistical analysis was performed using One-way Anova/Kruskal-Wallis test with Tukey’s Post Hoc test.
Result: In the root canals, the 0.5% herbal extract of AP was found to be equally effective to 2% CHX and highly effective than 5.25% NaOCl against Enterococcus faecalis with a marked decrease in the number of CFU at the 48th hr. from 2.6 x10³ to 0.9 x10³. The values were statistically significant with pEnglishEnterococcus faecalis, Endodontic irrigant, Leaf extracts, Andrographis paniculata, Colony forming unitIntroduction:
Microorganisms and their toxic metabolic products are responsible for the development and persistence of apical periodontitis of endodontic origin. Enterococcus faecalis, facultative anaerobic gram-positive cocci is the most commonly isolated species in persistent root canal infections1.
Sodium hypochlorite, the most commonly used irrigant has some undesirable characteristics like tissue toxicity, allergic potential and disagreeable smell and taste. Chlorhexidine used as an irrigant is active against E.faecalis but has less tissue dissolving property2.
The constant increase in antibiotic resistant strains and side effects caused by synthetic drugs has prompted researchers to look for herbal alternatives. Various natural plant extracts has antimicrobial and therapeutic effects suggesting its potential to be used as endodontic irrigants. Pharmacological studies have acknowledged the value of medicinal plants as potential source of bioactive compounds3.
Andrographis Paniculataor kalmeghis available abundantly in India, Pakistan and Srilanka and also one of the most widely used plants in Ayurvedic formulations. A.paniculata was recommended in Charaka Samhita dating to 175 BC for treatment of jaundice along with other plants in multi plant preparations4. Andrographis has demonstrated significant activity in fighting common cold, flu and upper respiratory infections. The pharmacological studies suggest its anti-inflammatory, antipyretic, anti-viral, immunostimulatory, potential cancer therapeutic agent, anti-hyperglycaemic and antioxidant properties5-11. Researchers have found that the acetone and methanol extracts of leaves and stems of A.paniculata showed greater inhibitory effect (30.33±0.88mm) on the growth of Enterococcus feacalis4.Hence the purpose of this study was to evaluate the antimicrobial efficiency of the leaf extracts of A.paniculata against Enterococcus faecalis as an endodontic irrigant.
Materials and methods:
Phytochemical extract: Shade dried powder of leaves of A.paniculata were obtained (Aravindh herbals, Chennai). The coarse powder of the sample was extracted with 2.5 litres of 95% ethanol by maceration process until the extraction was completed. Then the extract was filtered and the solvent was removed by distillation under reduced pressure.
Specimen preparation:Forty extracted human, permanent straight single-rooted mandibular premolar teeth with no caries, apical fractures and resorption were selected and stored in saline. The teeth samples were decoronated using rotary diamond disc with a standardized length 12 mm below the CEJ. In order to standardize the samples, each canal was prepared up to size 30 with ProTaper rotary nickel-titanium instruments (Dentsply Tulsa Dental, Johnson City, TN) according to manufacturer's instructions. The root apices were coated with nail varnish to seal the apical foramen. The canals were irrigated with 10ml of 5.25% NaOCl and 10ml of 17% EDTA. The specimens to be tested were sterilized at 121°C for 15 minutes at 26 psi and stored in 100% humidity at 30°C until use.
Isolation of micro-organisms: Purestrain of Enterococcus faecalis from American Type Culture Collection (ATCC #29212) was used. Respectively cultures were grown overnight at 37°C in brain heart infusion (BHI) broth on a rotary shaker 150 rpm and microbial growth were checked by changes in turbidity at 24 hours.
Antimicrobial activity test:As a preliminary test, the minimum inhibitory concentration(MIC) of A.paniculata against E.faecalis was checked by well diffusion method. Test pathogens were spread on the test plates- Mueller Hinton Agar (MHA). Sterile well of 6mm diameter was made and 5, 10, 20 µl of the medicament was loaded in the well. The test plates were incubated for 24hr. the zone of inhibition (mm in diameter) were read and taken as activity against the test pathogen. Chlorhexidine was loaded as the positive control and the MIC of A.paniculata against E.faecalis was found to be 0.5%.
Contamination of the specimens: Contamination of specimens werecarried out for 21 days at 37°C with E.faecalis adjusted to a degree of turbidity 1 according to McFarland scale, which corresponds to a microbial load of 3 × 103 cells/ml. Under laminar flow, the samples were recontaminated every second day with fresh broth containing the microorganism.
Irrigation procedure: The specimens were irrigated with 25-G needle tip was placed to a depth of 1mm short of WL, respectively.
Group 1: Irrigation was done with 2% CHX
Group 2: Irrigation was done with 5.25% NaOCl
Group 3: Irrigation was done with extracts of A.Paniculata
Group 4: Irrigation was done with distilled water.
CFU procedure: After incubation, the tooth canal was drilled and the invaded bacteria was collected and placed in nutrient broth. Then 100µl of the broth was plated on the sterile nutrient agar medium and spread evenly with L-rod and incubated overnight. CFU was evaluated at 0thhr and 48thhr using digital counter.
Results:
In the root canals , the 0.5% herbal extract of AP was found to be equally effective to 2%CHX and highly effective than 5.25%NaOcl against Enterococcus faecalis with a marked decrease in the number of CFU at the 48thhr from 2.6x10³ to 0.9x10³. The mean values of No.of bacterial colonies before and after irrigation are listed in Table [1].
Table [1]: Mean values of No.of bacterial colonies before and after irrigation
CFU at 0th hour
CFU at 48th hour
Samples
No. of colonies
Samples
No. of colonies
GROUP I
2.3x103
GROUP I
0.142x103
GROUP II
2.4x103
GROUP II
1.88x103
GROUP III
2.9x103
GROUP III
0.177x103
GROUP IV
2.5x103
GROUP IV
2.5x103
Statistical analysiswas performed using One-way Anova/Kruskal-Wallis test with Tukey's post-hoc test.The values were statistically significant with pEnglishhttp://ijcrr.com/abstract.php?article_id=84http://ijcrr.com/article_html.php?did=84
Ghonmode WN, Balsaraf OD, Tambe VH, Saujanya KP, Patil AK, Kakde DD. Comparison of the antibacterial efficiency of neem leaf extracts, grape seed extracts and 3% sodium hypochlorite against E. feacalis–An in vitro study. Journal of international oral health: JIOH. 2013 Dec;5(6):61.
Dutta A, Kundabala M. Comparative anti-microbial efficacy of Azadirachta indica irrigant with standard endodontic irrigants: A preliminary study. Journal of conservative dentistry: JCD. 2014 Mar;17(2):133.
Vinothkumar TS, Rubin MI, Balaji L, Kandaswamy D. In vitro evaluation of five different herbal extracts as an antimicrobial endodontic irrigant using real time quantitative polymerase chain reaction. Journal of Conservative Dentistry. 2013 Mar 1;16(2):167.
R. Radha, M. Sermakkani ,V. Thangapandian. Evaluation of phytochemical and antimicrobial activity of Andrographis paniculatanees (Acanthaceae) aerial parts. Int. J. of Pharm. and Life Sci. (IJPLS). 2011 Feb;2( 2): 562-7
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Rajagopal S, Kumar RA, Deevi DS, Satyanarayana C, Rajagopalan R. Andrographolide, a potential cancer therapeutic agent isolated from Andrographis paniculata. Journal of Experimental therapeutics and Oncology. 2003 May 1;3(3):147-58.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN2017March4HealthcareThe Prevalence of Philadelphia Chromosome in BCR-ABL Positive Chronic Myelogenous Leukemia Cases in North Indian Population
English1419Fatima Bhopalwala Ali1English R.K. Verma2English Mustafa Ali3English Navneet Kumar4EnglishAim: The aim of my study was to identify the prevalence of Philadelphia chromosome in BCR-ABL positive CML cases in North Indian population. Philadelphia (Ph) chromosome is a specific cytogenetic marker, essentially required for the diagnosis, clinical management and follow up of patients of chronic myelogenous leukemia (CML), which is a myeloproliferative neoplasm of hematopoietic cell. It results from a reciprocal translocation, t (9; 22) (q34; q11.2) in the hematopoietic stem cells. The molecular consequence is the formation of the chimeric BCR ABL1 gene which plays a central role in the development of CML.
Methods: Bone marrow and peripheral blood sample from 66 CML cases were collected from Dept. of Clinical Hematology, KGMU. The samples culture and cytogenetic analysis was done in the Dept. of Anatomy, KGMU.
Results: Out of the total 66 cases, karyograms of 52 cases (78.8%) were obtained. 49 cases (94.2%) showed the presence of Philadelphia chromosome, while 5.8% cases showed normal karyogram. Most common age group showing the presence of Ph+ve CML was 41-50 years (28.6%) followed by patients in 51-60 years group. Majority of cases were males (59.2%). Compared with stage of CML 81.6% of Ph+ve cases were in chronic phase.
Conclusion: Majority of the CML cases were Philadelphia positive, with males more commonly involved. Ph+ve CML was seen commonly above 40 years of age with maximum patients presenting in chronic phase of CML. Our results are at par with research reports published around the world on the Philadelphia chromosome prevalence in CML.
EnglishChronic myelogenous leukemia, Philadelphia chromosome, BCR-ABLINTRODUCTION
The cytogenetic hallmark of CML is the Philadelphia (Ph) chromosome that results from a reciprocal translocation between chromosome 9 and 22,
i.e. t (9; 22) (q34; q11.2)1, occurring in the hematopoietic stem cells. The reciprocal translocation in this CML results in the fusion of breakpoint cluster region (BCR) gene on chr. 22q11 with the ABL1 (named after the abelson murine leukemia virus) gene located on chromosome 9q34. Thus, the molecular consequence of this translocation is the formation of the chimeric BCR-ABL gene, usually located on the Philadelphia chromosome1. BCR-ABL plays a central role in the development of CML. The BCR-ABL chimeric gene is transcribed into BCR-ABL1 mRNA, which in turn encodes a fusion protein p210BCR-ABL1. Rarely a breakpoint occurring in BCR gene may produce another fusion protein p230BCR-ABL1. The exact mechanism(s) by which these fusion genes promote the transition from benign to fully malignant state is still unclear. The attachment of BCR sequence to ABL results in three critical changes viz.
1) The ABL protein becomes constitutively active as a tyrosine kinase enzyme, subsequently activating downstream kinases that prevent apoptosis;
2) The DNA-protein-binding activity of ABL is attenuated;
3) The binding of ABL to cytoskeleton actin microfilaments is enhanced1, 2.
Imatinib mesylate (Glivec, formerly STI571) is a rationally developed, orally administered inhibitor of the BCR-ABL protein. Recent karyotype analyses show that 60%–70% of patients achieve complete disappearance of Ph-positive marrow cells and maintain exclusively Ph-negative bone marrow cells (a state designated as a complete cytogenetic response [CCyR]) 5 years after initiating imatinib treatment3 and overall survival is between 80-95%4. The gold standard for the detection of chromosomal aberrations is karyotyping5. Till date most of the work regarding the cytogenetics of CML and its significance in the diagnosis, prognosis, and treatment of the disease has been reported from countries other than India (Hehlmann et al., 2007; Fabarius et al., 2011)6,7, while such studies reported from our region are limited (Chavan et al., 2006; Anand et al., 2012).8,9 Thus, the present study was done to determine the prevalence of Philadelphia chromosome in BCR-ABL positive individuals where the BCR-ABL positivity was confirmed by Fluorescent-In-Situ-Hybridization (FISH) assay prior to enrollment.
MATERIAL AND METHODS
Selection criteria and Collection of samples-
The study was conducted after obtaining the approval from the Ethical Committee of the King George's Medical University U.P., Lucknow. Screening of the patients was done in the Department of Clinical Hematology, and samples were collected in the hematology laboratory of the same department and also in the Department of Pathology, King George Medical University U.P., Lucknow. The consent was taken from each participant after explaining the purpose of the study. The diagnosed cases of CML (diagnosis confirmed on the basis of clinical and hematological evaluation) irrespective of age and sex were included in the study. Lack of confirmed diagnosis and/or consent from the patient served as the exclusion criteria. The CML cases were BCR-ABL positive as detected by Fluorescent-In-Situ-Hybridization (FISH) assay prior to enrollment. Bone marrow aspirate and/or peripheral blood samples of the CML patients were collected. Detailed personal history, occupational history was taken and thorough clinical examination was done at time of sample collection.
Preparation of Karyogram
Harvesting of sample
Bone marrow aspirate and blood sample of the CML patients were collected in BD Vacutainer sodium heparin vial. The sample was taken in a test tube containing culture media (RPMI 1640) and incubated in CO? incubator in slanting position. After incubation, Colchicin solution was added and test tube was again incubated for one hour and then centrifuged at 1000 rpm for 10 minutes. Supernatant was discarded by pipetting of media leaving as little medium as possible over the cell button at bottom of test tube. Cell button was suspended in hypotonic solution (Potassium chloride + Sodium citrate). Slides were prepared by dropping method, and were treated with trypsin to obtain better banding. Adequately aged slides were stained with Giemsa stain. Karyotyping results were obtained by analyzing 20 metaphase fields for each case and in cases where abnormal karyotype were suspected, the observation was extended to a total of 30 fields. The karyotypes were reported as per International System for Human Cytogenetic Nomenclature (ISCN, 2013) guidelines.10
Statistical analysis
Data was analyzed using Statistical Package for Social Sciences (SPSS) version 15.0. Data has been represented as frequencies and percentages and mean and standard deviation. Chi-square test has been used for the purpose of analysis. The confidence level of the study was kept at 95%, hence a “p” value less than 0.05 indicated a significant association.
RESULTS
A total of 66 CML patients were enrolled out of which 52/66 (78.8%) karyograms were found satisfactory. Thus these 52 karyograms of BCR-ABL positive hematologically confirmed cases of Chronic Myelogenous Leukemia were analyzed. The CML cases in the present study comprised of adult patients with their ages ranging between 20- 69 years and the mean age was 49.77 years (table 1). Majority of patients were male (n=29; 59.2%). There were 20 (40.8%) females (table 1). Male to female ratio of study population was 1.36:1.
In our study all the patients had BCR-ABL analysis done at the time of diagnosis of CML and the BCR-ABL positivity was 100%, while on cytogenetic analysis done on these patients Philadelphia chromosome was seen in 49 out of 52 cases, and rest 3 cases showed a normal karyogram without any translocation i.e.; Ph negative BCR-ABL positive CML cases (5.8%). The Ph+ve BCR-ABL+ve CML cases were 94.2 % (figure 2). The association between the presence of Philadelphia chromosome in a patient and the clinical stage of CML is shown in the figure 2. The majority of Philadelphia positive (93.02%) and all the Philadelphia negative patients were in chronic phase of CML. Accelerated phase CML was seen in 5 Philadelphia positive cases and blast phase in 4 of Ph+ve cases only. However, association between Philadelphia status and stage of disease was not statistically significant (p=0.717).
DISCUSSION
Conventional cytogenetic analysis has been considered mandatory for all newly diagnosed cases of leukemias, because karyotyping plays a vital role in their diagnosis, classification and prognostification11. This holds true for chronic myelogenous leukemia as well. The frequency of CML has been increasing worldwide and so the disease burden on the diagnosis and treatment aspect as well is increasing. This has opened a wide area of potential research for the medical fraternity in the field of cytogenetics of chronic myelogenous leukemia.
Our study group consisted of 66 cases of CML who were hematologically confirmed, and their consent was obtained prior to enrollment. For all leukemia types, the age adjusted incidence is found to be higher in males, with a ratio of 1.9 vs. 1.1 (male vs. female) in case of chronic myelogenous leukemia 5. Similarly, the male patients included in the present study were 36 (54.5%) and females were 30 (45.5%) and thus CML was found to be more common in men, (Figure 3) with a male: female ratio of 1.2:1 among the total 66 cases of CML enrolled (Table 1). Our findings were in resonance with the study conducted by Chavan et al8 who found a male: female ratio 1.9:1 out of 175 haematologically confirmed CML cases. The CML cases in the present study comprised of adult patients with their ages ranging between 20- 69 years and the mean age was 49.77 years (Table 1). Our results regarding age of patients were same as seen by Boronova et al12 who analyzed 72 CML patients and found their age in the range of 19-74 years with median age of 46.4 years (Presov region, Slovakia). The hallmark of CML is Philadelphia chromosome, which causes formation of chimeric BCR-ABL oncogene at the molecular level. In our study all the patients had BCR-ABL\ analysis done at the time of diagnosis of CML and the BCR-ABL positivity was 100%, while on cytogenetic analysis done on these patients Philadelphia chromosome was seen in 49 out of 52 cases, and rest 3 cases showed a normal karyogram without any translocation i.e.; Ph negative BCR-ABL positive CML cases (5.8%). The Ph+ve BCR-ABL+ve CML cases were 94.2% (figure 2). Our findings were in agreement with another Indian study of Anand et al, 9 who found 96% cases to be Ph positive at the cytogenetic level. All of the Ph negative BCR-ABL positive patients were in CML chronic phase. Also, Boronova et al12has detected Philadelphia chromosome in 94.4% of CML cases in Presov region of Slovakia. This comparison signifies that presence of Philadelphia chr. in CML cases is uniform and comparable in different regions of the world.
It has been well documented in the past that few CML patients may not demonstrate Ph chromosome (Ph chromosome negative and BCR-ABL positive), yet have clinical course and morphological features just like typical CML4. We experienced the same in the present study where no difference in the presentation was seen between Philadelphia positive and negative CML subjects.
The prognosis for patients with Ph+ve CML than those without this translocation is a matter of debate and greatly relies on clinical researches especially those focusing on long term cytogenetic follow up of CML patients. Results of such studies will only re-emphasize on the clinical importance of identification of
Philadelphia chromosome during the treatment phase. The patients in our study, with Ph negative BCR-ABL positive CML belonged to the young age group and none was above 45 years of age. On the contrary, the frequency of Ph+ve CML cases was highest in age group 41-50 years (14/49 cases; 28.6%) followed by those in the age group 51-60 years (13/49 cases; 26.5%)(figure 1). Female patients with
Philadelphia chromosome positive CML were 20 (40.81%) and Ph+ve males were 29 (59.18%) (Table 1). Chavan et al 8 observed in the Indian population that the incidence of CML with Ph chromosome was predominant in the age group of 26-50 years (65.62%) and the frequency of Ph+ve CML was more preponderant in males (n=61, 63.548%) than females (n=35, 36.46%). However, Boronova et al12 detected Philadelphia chromosome in 27 men and 41 women (Russian population). This difference in observation may suggest that gender wise distribution of Philadelphia chromosome positive CML may vary in different population group around the world. One more explanation for this difference in observations may be the selection criteria employed in different studies are responsible for the characteristics of patients. However these Ph-ve CML cases were BCR-ABL positive as detected by Fluorescent in Situ Hybridization (FISH) assay prior to enrollment. Du et al13 in their study of 148 patients, found that 95.5% carried Ph chromosome. For rest 7 cases without Ph chromosome, 4 were identified as being BCR/ABL fusion gene positive. This observation is similar to ours and signifies the fact that molecular cytogenetic analysis must be done to directly visualize the rearrangement of BCR-ABL oncogene. We believe that advanced molecular studies provide deeper insights into the pathogenesis as well as reason for chromosome resistance in this type of CML and thus, are important for diagnosis and follow up of chronic myeloid leukemia cases. Moreover, molecular cytogenetic studies like FISH assay which directly visualize the rearrangement of the BCR-ABL gene are necessary to correctly define the Ph+ve or Ph-ve CML.
Meanwhile, conventional cytogenetic methods have their own advantages and remain the gold standard for detecting chromosomal aberrations.8-10 Taking into consideration the stage of CML of our study subjects, 81.6% cases of Ph+ve karyotype had chronic CML and all the patients in the accelerated and blastic phases showed the presence of Philadelphia chromosome(figure 2). All the 3 patients having normal karyogram or Philadelphia negative BCR-ABL positive CML belonged to chronic phase of Chronic myeloid leukemia. This was in resonance with the findings of Deininger et al14 who investigated 515 CML patients having clonal cytogenetic abnormalities in Philadelphia chromosome-negative cells, for their prognosis and most patients had chronic phase CML.
CONCLUSION
The Philadelphia positive BCR-ABL positive CML cases were 94.2% and the prevalence of Philadelphia positivity in CML was found to be comparable in different population groups of the world. Pertaining to disease stage, 81.6% cases of Ph+ve karyotype had chronic CML and all the patients in the accelerated and blastic phases showed the presence of Philadelphia chromosome. While, all the Philadelphia negative BCR-ABL positive CML belonged to chronic phase of CML. All the Ph negative CML cases were seen in young patients below 45 years of age. The frequency of Philadelphia positive CML cases was highest in age group 41-50 years, followed by those in 51-60 years age group and more prevalent in men with 59.18% male patients and 40.81% female patients which were different from previous studies done on other populations and/or having different selection criteria. Thus, Cytogenetic analysis done in cases of CML serve to confirm the diagnosis, sequential karyotyping helps to monitor the treatment efficacy and additional chromosomal abnormalities as and when detected, add important prognostic information. Thus, conventional cytogenetic analysis serves as a cost effective technique which can be done in every case of case of CML, and only those who are found Philadelphia negative should be subjected to molecular cytogenetic analysis to directly visualize the rearrangement of BCR-ABL oncogene.
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: None
Funding: None
Englishhttp://ijcrr.com/abstract.php?article_id=85http://ijcrr.com/article_html.php?did=851. Longo DL, Kasper DL, Jameson JL, Fauci AS, Hauser SL, Loscalzo J, editors. Harrison’s principles of internal medicine. 18th ed. New York: Mcgraw hill; 2012.
2. Cavalli F, Kaye SB, Hansen HH, Armitage JO, Piccart-Gebhart MJ, editors. Textbook of medical oncology. 4th edition. London: Informa Healthcare; 2009.
3. Perrotti D, Jamieson C, Goldman J, et al. Chronic myeloid leukemia: mechanisms of blastic transformation. J Clin Invest. 2010;120(7):2254–2264.
4. Vardiman JW, Melo JV, Baccarani M, Thiele J. Myeloproliferative Neoplasms. In: Swerdlow SH, Campo E, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman JW, editors. WHO classification of tumours of haematopoietic and lymphoid tissues. 4th edition. Lyon: IARC Press. 2008:32–37.
5. Pitchford CW, Hettinga AC, Reichard KK. Fluorescence in situ hybridization testing for −5/5q, −7/7q, +8, and del(20q) in primary myelodysplastic syndrome correlates with conventional cytogenetics in the setting of an adequate study. Am J Clin Pathol. 2010;133(2):260–4.
6. Hehlmann R, Hochhaus A, Baccarani M. Chronic myeloid leukaemia. Lancet. 2007;370:342–50.
7. Fabarius A, Leitner A, Hochhaus A, et al. Impact of additional cytogenetic aberrations at diagnosis on prognosis of CML: long-term observation of 1151 patients from the randomized CML Study IV. Blood. 2011;118(26): 6760-68.
8. Chavan D, Ahmad F, Iyer P, et al. Cytogenetic Investigation in Chronic Myeloid Leukemia: Study from an Indian Population. Asian Pacific J Cancer Prev. 2006;(7):423-426.
9. Anand MS, Verma N, Varma S, et al. Cytogenetic and molecular analysis in adult chronic myelogenous leukemia patients in North India. Indian J Med Res. 2012;135(1):42-48.
10. Shaffer LG, McGowan-Jordan J, Schmid M, editors. ISCN (2013): An International System for Human Cytogenetic Nomenclature. Basel: S. Karger, 2013.
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12. Boronova I, Bernasovsky I, Bernasovska J, et al. Detection of Philadelphia chromosome in patients with chronic myeloid leukemia from the Presov region in Slovakia(1995-2004). Bratisl Lek Listy. 2007;108(10-11):433-436.
13. Du QF, Liu XL, Song LL, et al. Clinical significance of cytogenetic analysis in chronic myeloid leukemia (with report of 155 cases). Di Yi Jun Yi Da Xue Xue Bao. 2002;22(10):905-7.
14. Deininger MW, Cortes J, Paquette R, et al. The prognosis for patients with chronic myeloid leukemia who have clonal cytogenetic abnormalities in philadelphia chromosome-negative cells. Cancer. 2007;110(7):1509-19.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN2017March4HealthcareMini-Clinical Evaluation Exercise in Dental Education in Kingdom of Saudi Arabia - A pilot study
English2024Samer Kasabah1English Kalpana Gokul2EnglishThe Mini-CEX (clinical evaluation exercise) is a workplace based assessment tool designed to assess the clinical skills, attitudes, and behaviors of students that are essential in providing high quality patient care.It involves direct observation of real patient encounters followed by one on one structured feedback sessions by observing faculty. Mini-CEX has already found wide acceptance in medical education but is largely untested in dental education
Aim:
1. This pilot study has been planned to implement Mini-CEX as an assessment tool
2. To analyze the perception of students and faculty about the use of Mini-CEX
3. To analyze the possible advantages and disadvantages of Mini-CEX as an assessment tool in dental education.
Method: Twelve undergraduate students of final year BDS, from Buraydah College of Pharmacy and Dentistry underwent one Mini-CEX encounter each. Four teaching faculties performed the roles of assessors who rated the performance of students by directly observing the students while they performed various clinical skills. Rating was done using the standardized Mini-CEX rating form. This was followed by systematic feedback session and at the end students’ and teachers’ perception of the Mini-CEX was sought through structured questionnaires.
Results: Both the students and assessors were more than satisfied and showed positive response to the new assessment method. Direct observation of students performing various clinical skills and immediate feedback on the areas where the student went wrong were appreciated the most.
Conclusion: This pilot study strongly supports the implementation of Mini-CEX as a very effective assessment method in the field of Dental Education.
EnglishAssessment method, Dental Education, Mini-CEXIntroduction
Assessing students in Dental education by certain number of marks in examination is less important because it will give information of the end result about a student’s performance with very little information on “how” the student got those scores. Hence, gathering evidence of clinical competence and professional behaviour by direct observation in real clinical environments becomes very significant way of assessment. In the Miller’s framework for assessing clinical competence, Mini-CEX (clinical evaluation exercise) falls in the highest level of the pyramid and collects information about student’s performance in their everyday practice (Fig.1)[1]
The assessments at the lower level of Miller’s Pyramid focus more on knowledge domain. “Does” level of Pyramid assess the students on a real patient encounter which are designed to assess the clinical skills, attitudes, and behaviors of students that are essential in providing high quality patient care. It involves direct observation of real patient encounters followed by one on one structured feedback sessions by observing faculty [1]
Originally Mini-CEX was designed by J. Norcini in 1995[2] in the USA for the evaluation of Internal Medicine residents’ clinical skills. The principal characteristics of Mini-CEX are direct observation of real patient encounters and immediate structured feedback to the learner after the encounter [2, 3]
A Mini-CEX is approximately a twenty minute encounter, during which a student performs focused history taking and physical examination of a patient in a real setting while the faculty or the assessor observes. After a discussion on the diagnosis and management plan for the patient, the faculty assesses the student using the Mini-CEX evaluation form and provides feedback [2, 3]
Some of the important drawbacks of traditional methods of assessments especially in the subject of Oral Medicine and Radiology are that, it only considers the final diagnosis if it’s right or wrong and not “how” the students have reached the diagnosis. There is rarely a direct observation of students performing various skills before arriving at final diagnosis. This impacts both the ‘validity’ and the ‘reliability’. Moreover, communication skills are rarely assessed, there is very little scope for direct feedback, and some important skills may not be tested at all.
Since the traditional long case discussions are time consuming, the number of cases and exposure to variety of cases become very limited [4]
Mini-CEX, in contrast, has the potential to be a more practically suited assessment tool in situations involving patient–doctor interactions and where communication skills and professionalism are important.
The search of data base revealed that Mini-CEX has not been implemented as an assessment tool in dental education in Kingdom Of Saudi Arabia. Hence, this pilot study was planned to implement Mini-CEX as assessment tool in KSA. The goal of this pilot study was to introduce Mini-CEX as an assessment tool for undergraduate students in the subject of Oral Medicine and Radiology and study the perception of both students and faculty towards this method of assessment.
Methods
This pilot study was carried out in the Buraydah College of Pharmacy and Dentistry, Al Qassim, KSA in 2016. Twelve undergraduate Students of final year BDS underwent Mini-CEX in the subject of Oral Medicine and Radiology.
Since it’s a novel methodof workplace based assessment. An orientation session on the details of Mini-CEX was given to both the students and the teaching faculties. In that session, detailed description was given regarding the method of assessment and criteria for scoring the Mini-CEX rating form and the do’s and dont’s of feedback sessions. A presentation was made to the entire faculty and handouts of Mini-CEX forms were distributed.
Totally there were 12 Mini-CEXencounters.12 cases of equal complexity were selected. After patient consent, the student starts the encounter by performing a focused case history, does appropriate physical examination and orders the relevant investigations and arrives at final diagnosis and then plans for appropriate treatment plan. During the entire encounter, theassessor directly observes the student and with the help of the checklist, rates the student’s performance under the six domains using the Mini-CEX rating form (Annexure2)
At the end a Global scoring was done to grade a student as clinically competent or incompetent. The scoring was done on 9 point scale with 3 categories as below satisfactory, satisfactory and above satisfactory.After the student–patient interaction was complete, a systematic feedback session of about 10 min took place. The assessor first explained to the student the things that were done well, followed by the things that could be done better. These suggestions were put in writing on the Mini-CEXrating form. The assessor then suggested a specific learning plan for the student to improve in the weak areas.
Finally student’s and assessor’s perception on the use of this novel Mini-CEX as an assessment tool was obtained with the help of a structured questionnaire. All 12 students and 4 faculty members participated voluntarily in giving the feedback.
Results
Twelve undergraduate students of final year BDSunderwent Mini-CEXin the subject of Oral Medicine and Radiology.After the completion of the encounter, Perceptionsof were obtained from both students and faculty members using structured questionnaire.
Implementation of Mini-CEX: Student selects an interesting case at the outpatient. After the Patient consent the student fixes the appointment for Mini-CEX with faculty. Student does the focused case history relevant to the chief complaint of the patient, does appropriate examinations and orders required investigations, arrives at diagnosis and discusses the appropriate treatment plan with the patient. The entire procedure should not exceed 15-20 minutes. While the student performs all the above mentioned procedures, the faculty is directly observes and scores the student based on structured criteria (Annexure 2). However, the faculty does not interfere the student. After the completion of the encounter, the faculty gives an effective feedback on where the student went right and where exactly he went wrong and also suggests an action plan to improve.
Perceptions of students on Mini-CEX:
After the orientation, all the students voluntarily agreed to undergo Mini-CEX as an assessment tool. All the twelve students felt that the entire Mini-CEXsession was well organized. Students felt that the skills chosen to be assessed during the Mini-CEX were very significant to become a successful clinician than just score good marks. The students particularly appreciatedthat their communication skills were assessed which they felt was never assessed by the traditional method of assessment. All the students felt that direct observation by the faculty was very significant due to which their preparation was better than the traditional method of assessment.
The immediate feedback on the weak areas and quick coaching and action plan to improve was appreciated the most by all the students. Students also felt that the immediate feedback enhanced experiential learning and increased their level of confidence.
Two students felt that time given was not sufficient to finish all the 6 competencies of Mini-CEX. One student felt it was more stressful experience than the traditional format since the faculty observed her performance.
All students felt that the constructive feedback helped reinforce the skills that they did well, and helped them identify weak areas. All the students agreed that the feedback motivated them to learn further. Overall, the students were found to perceive Mini-CEXpositively.
Perception of faculty towards Mini-CEX:
Four faculty members assessed Mini-CEX encounters. All the assessors felt that the orientation session was adequate to understand the working of Mini-CEX. All assessors agreed that planning the Mini-CEX process requires more time and thinking than traditional evaluation methods. However, all also felt that a major advantage of Mini-CEX over other newer methods of assessment like OSCE (Objective Structured Clinical Examination) is that no additional manpower, equipment, instruments, materials are required. Three assessors felt that more time was required to conduct a Mini-CEX encounter
All the assessors found that this method allows assessment of a student’s attitude and communication skills, which are very important in all professions andespecially in dentistry. They agreed that the Mini-CEX format allows for moreopportunities for improvement by providing immediatefocused feedback, which also acts as a motivating factorto students for further learning
Discussion
The objective of this pilot study was to introduce Mini-CEXas an assessment tool for students in the subject of OralMedicine and Radiology, and to study the perception of both students and faculty toward this novel method of assessment. Since there are many drawbacks with the traditional methods of assessments especially in the subject of Oral Medicine and Radiology, there is need for better assessment methods especially in the real patient scenario. Hence this pilot study was planned to implement this novel assessment method.
Among all the positive response, the assessment of communication skills and the immediate feedback on how it could be improved was appreciated the most by all the students. Only one student felt that it was stressful to have the assessor observing her performance. Two students also felt that the time was insufficient. Immediate feedback was also appreciated by all the students. They felt it was very significant to note their areas of weakness.
Overeem and Govaerts also reported higher satisfaction with narrative feedback, and they also suggested that narrative feedback can improve in trainingevaluation [5, 6]
The overall perception of students toward Mini-CEX was positive and they felt that this assessment method was agood experience would motivate them to improve in specific areas. Behere Ralso found similar perception when used on 12 undergraduate students of dentistry [7]
All assessors agreed that organizing and implementing the Mini-CEX required more planning and involvement than traditional assessment. Alves de Lima[8], Wilkinson[9]reported issues regarding the feasibility of using Mini-CEX.These studies suggests that assessment tool must be well integrated within the curriculum and additionally propose that workshops are a better way to implement an instrument than written instructions. All assessors felt that being an examiner for Mini-CEX was more timeconsuming than the traditional method of evaluation. All assessors agreed that their presence impacted the trainees’ performance. Weller [9] also found similar results.
Mini-CEX has been largely tested and used in the field of Medical education; however, very few studies reported the use of Mini-CEX in dental education. Studies by Behere R, Pande N and M. Iniesta are the only 3 reports till date to implement the use of Mini-CEX in dental education[7,10,11]. All the three studies recommend the use of Mini-CEX as an assessment tool in dental education.
Conclusions
Mini-CEX was introduced in dental education in KSA may be for the first time. Traditional assessment methods in the subject of Oral medicine and Radiology have certain significant drawbacks like its time consuming and that limits the exposure of variety of cases to learning students. Moreover, fear of dental treatment is widely recognized, it is important that dental students develop sound communicationand counseling skills to allay patient fears and anxiety. This makes it ideal for implementation of Mini-CEX as an assessment tool.
The data arising from this pilot study strongly supports the implementation of Mini-CEXto improve the learning experience for undergraduate dentalstudents. This pilot study certainly recommends the use of Mini-CEX as an assessment tool in the subject of Oral Medicine and radiology and it also shows that both the students and faculties appreciatedMini-CEX as an assessment tool. However, further studies are required to check the feasibility of using Mini-CEXfor other disciplinesand procedures in dentistry.
ANNEXURE-2 CRITERIA FOR SCORING THE STUDENT
HISTORY TAKING SKILLS
Listens effectively
Picks up on non-verbal clues
Explores the issues and concerns of the patient
INTRAORAL EXAMINATION SKILLS
Efficient, logical, appropriate for the problem
Uses appropriate technique
Explains to the patient what is happening/will happen
Shows respect for comfort of the patient
PROFESSIONALISM
Shows respect, compassion, empathy
Establishes trust
Attends to the needs of the patient
Behaves appropriately with other family members, if present
COUNSELLING/COMMUNICATION SKILLS
Explains rationale for tests
Obtains consent from the patient for investigations
Educates about the condition and its management
Involves patient in decisions about treatment/management
Deals with questions from the patient
CLINICAL JUDGMENT
Orders or performs appropriate investigations
Interprets evidence - differential diagnosis
Accurate diagnosis and treatment planning
Considers appropriate referral
ORGANIZATION/EFFICIENCY
Sets priorities
Makes decisions in a timely fashion
Moves the process along effectively and efficiently without making the patient feel rushed.
OVERALL CLINICAL COMPETENCE
Demonstrates judgment, synthesis, caring, effectiveness, efficiency
Englishhttp://ijcrr.com/abstract.php?article_id=86http://ijcrr.com/article_html.php?did=86
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Govaerts MJ, van der Vleuten CP, Schuwirth LW, Muijtjens AM. The use of observational diaries in intraining evaluation: Student perceptions. Adv Health SciEduc Theory Pract 2005;10:171-88.
Behere R. Introduction of Mini-CEX in undergraduate dental education in India. Educ Health 2014;27:262-8
Alves de Lima A, Barrero C, Baratta S, Castillo Costa Y, Bortman G, Carabajales J, et al. Validity, reliability, feasibility and satisfaction of the mini clinical evaluation exercise (mini-CEX) for cardiology residency training. Med Teach 2007; 29:785?90.
Wilkinson JR, Crossley JG, Wragg A, Mills P, Cowan G, Wade W. Implementing workplace based assessment across the medical specialties in the United Kingdom. Med Educ 2008; 42:364-73.
Pande Neelam , Raisoni Poonam , Deshpande Saee ;Perceptions of dental postgraduates about Mini-cex: A Pilot Study; JETHS- Volume 1 Issue -2 Sept - Dec 2014
M. Iniesta, J. Viñuela, F. Utrilla, L. Aracil, A. Bascones-Martínez (2012) Implementation Of Mini-cex In The Subject Of Periodontology, ICERI2012 Proceedings, pp. 4203-4210.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN2017January20HealthcareBilaterally-Complicated Horseshoe Kidney Associated to Situs Inversus with Levocardia: A Case Report
English2528Rabea Ahmed GadelkareemEnglishAim: To present a very rare case of bilaterally-complicated horseshoe kidney by nephrolithiasis in a patient with situs inversus with levocardia and skeletal anomalies.
Case: A 41-year-old female presented by right loin pain. Abdominal ultrasound showed bilateral kidney stones with
malrotation, right mild hydronephrosis and transposition of the abdominal organs. Chest X-ray showed the heart normal in the left side. Also, computed tomography revealed a horseshoe kidney with bilateral stones. After counseling the patient about the stones treatment options, she preferred extracorporeal shock-wave lithotripsy which was tried on the right side firstly, but it failed. So, percutaneous nephrolithotripsy was scheduled.
Discussion: Situsinversus is a spectrum of congenital anomalies. Situs Inversus total is is the commonest variety and was reported with renal congenital anomalies like horseshoe kidney, acquired renal diseases like renal cell carcinoma, and in living kidney donation. However, situs inversus with levocardia is a rare variety with a known association to the congenital heart defects. Its association to a complicated horseshoe kidney and scoliosis could not be found in the English literature before the current case. Moreover, absence of congenital heart defects is extremely rare.
Conclusion: Association of situs inversus with levocardia to skeletal anomalies and complicated horseshoe kidney is a unique situation. It indicates meticulous evaluation and management.
EnglishHorseshoe kidney, Levocardia, Nephrolithiasis, Situsinversus
Introduction
Situsinversus anomaly is the mirror image transposition of the thoracic and abdominal organs around the midline with multiple variants[1]. Situsinversus totalis includes dextrocardia representing the complete extreme variant of the spectrum[1, 2].This spectrum could be associated to renal anomalies like horseshoe kidney which is the commonest renal fusion anomaly with an isthmus connecting the lower poles. However, situsinversus with levocardia or isolated levocardia is an extremely rare variant [1, 3]. The heart is seen in its normal levo position in the chest, while the abdominal viscera are in the dextro position [1, 4, 5]. It is mostly associated to congenital heart defects [1]. Few cases without major heart anomalies lived long [6, 7]. So, the diagnosis of the combination of situsinversus anomalies to horseshoe kidney and management of its overt cases are challenging[8]. This article describes a rare case of horseshoe kidney complicated by bilateral stones in a patient with situsinversus with levocardia and skeletal anomalies.
Case report
A 41-year-old female patient presented by right loin pain of many months duration. She was single with no previous significant medical or urological history. On examination, she was tall, and generally looked healthy. Abdominal ultrasound revealed liver and spleen transposition, bilateral kidney stones, mildly dilated right kidney pelvicalyceal system and malrotation. Also, Kidney-Ureter-Bladder imaging films showed bilateral dense kidney stones with right lumbar scoliosis and right-sided small sacral bone defect (Figs. 1 and 3). Chest X-ray showed the heart in the normal left-sided position and so its apex direction (Fig. 2). Transverse cuts of the non-contrast computed tomography of the abdomen confirmed the diagnosis of situsinversus of the abdominal organs, horseshoe kidney with its isthmus and mildly dilated right pelvicalyceal system, tilted vertebrae of scoliosis, and nephrolithiasis (Fig. 4). Both kidney moieties were low in position and the right one was relatively higher and larger than the left (Figs. 3 and 4). In the right moiety, computed tomography described two stones; pelvic (16 mm x 14.6 mm) and upper calyx (3 mm x 2 mm). Also, there were two left stones; pelvic (11.4 mm x 9.7 mm)and lower calyceal (3 mm x 3 mm) stones (Fig. 3 and4). The average Hounsfield Unit values of the right and left kidney stones were 604 and 610, respectively. Examination revealed no upper respiratory tract disorders. Also, she was virgin and the gynecological evaluation was irrelevant. Cardiac evaluation by electrocardiogram and echocardiography revealed normal findings.
The patient was counseled for the anomalies and the possible lines for stones treatment which were extracorporeal shock wave lithotripsy and percutaneous nephrolithotripsy. She preferred shock wave lithotripsy to percutaneous nephrolithotripsy. Considering the anatomical challenges of situsinversus, scoliosis and the mild degree of hydronephrosis, I agreed to this preference as an initial option. Unfortunately, two sessions of shock wave lithotripsy failed to affect right side stone topography. So, percutaneous nephrolithotripsy was scheduled. However, the patient seemed to be unconvinced with this decision and she did not fit for the date of operation.
Discussion
Etiology of situsinversus anomalies was attributed to the biological expression of a certain protein that affects the heart looping during embryogenesis. Mostly, it has an autosomal recessive inheritance pattern [2]. Organ situsanomalies represent a spectrum and classified into situssolitus (the normal variant), situsinversus totalis (the commonest), situsinversus with levocardia, isolated dextrocardia and situs ambiguous [1].
Horseshoe kidney is a fusion anomaly with a reported incidence of 0.25% [9]. It is attributed to the abnormal migration of the posterior nephrogenic cells. However, mechanical forces may have a role in the anatomical orientations of the horseshoe kidney including the relatively low position and malrotation[10]. The typical anatomical findings were described and illustrated in the present case.
The urologist may meet situsinversus anomalies as an association to one of the following genitourinary disorder categories; congenital disorders only[10, 11], acquired disorders only [8], combination of congenital and acquired disorders[12] or without any disorders like in living kidney donation[13].
The present case belonged to the combined disorders category. Coincident combination of the multiple unrelated rare anomalies is very rare medical situation [10]. Therefore, further congenital or acquired disease combinations usually attribute to extremely rare situations. This could be applied to the current combination of situsinversus with levocardia, skeletal anomalies, and horseshoe kidney which was complicated by nephrolithiasis and hydronephrosis. Moreover, an extremely rare feature in this case of situsinversus with levocardia is the absence of the congenital heart defects which were reported up to 100% ofcases [1]. Similarly, Imamura et al. [3] and Jo et al. [5]reported single cases of this variant without congenital heart defects in adults. Only, few cases of situsinversus with levocardia were reported with urological disorders including adrenal adenoma [7] and micropenis[3]. However, similar presentations to the current case included cases of horseshoe kidney and the common variant situsinversus totalis combined to cilia defects syndromes like Kartagener syndrome [12], or combined to Klippel-Feil syndrome. These syndromes consist of the heart anomalies, skeletal anomalies including scoliosis and renal anomalies including the horseshoe kidneys[14].
Association of situsinversus to nephrolithiasis is a rare finding[15]. Moreover, association of horseshoe kidney/situsinversus combination to nephrolithiasis could be detected very rarely in publications [2]. Accordingly and again, addition of a common congenital or acquired disorder to a rare anomaly, solely or in combinations, will create a rare situation too. The evidence evolves from the literature, where nephrolithiasis is common with horseshoe kidney reaching up to 60% [9], but it is rarely reported in combinations of situsinversus and horseshoe kidney[2].
Anatomical and metabolic abnormalities of horseshoe kidney predispose to nephrolithiasis[9]. In such cases, shock wave lithotripsy is the preferred treatment method for small stones (≤15 mm), while percutaneous nephrolithotripsy is the standard line of treatment for larger stones or after failed shock wave lithotripsy. However, anatomical challenges are considered in decision-making[9, 11]. Accordingly, relatively hard stones with multiple rare anatomical anomalies may indicate the non-invasive lines of treatment. So, in the current case, shock wave lithotripsy was tried firstly, although it failed, mostly, due to stone impaction or localization issues. Then, shift to percutaneous lithotripsy was the logic following step. However, missing of the patient at the scheduled dates might make the situation incomplete.
To the best of my knowledge, the current case is the first one to be reported with this constellation of congenital anomalies and presented by urological symptoms; situsinversus with levocardia(without congenital heart defects), skeletal deformities and horseshoe kidney complicatedby nephrolithiasis and hydronephrosis.
Conclusion
Association of situsinversus with levocardia(without congenital heart defects) and skeletal anomalies to a bilaterally nephrolithiasis-complicated horseshoe kidney is very rare entity and novel urological situation. Meticulous evaluation is indicated to exclude the high possibilities of congenital heart defects co-existence and choose the best line for treatment of complications.
Acknowledgement
I acknowledge the immense help received from the scholars whose articles are cited and included in reference of this article. I’m grateful to authors / editors / publishers of all those articles and journals from where the literature for this article has been reviewed and discussed.
Ethical approval
Ethical committee of the Faculty of Medicine in Assiut University approved this case study. Informed consent was taken from the patient.
Funding: None
Conflict of interest: None
Englishhttp://ijcrr.com/abstract.php?article_id=87http://ijcrr.com/article_html.php?did=87
Fulcher, A.S., Turner, M.A., Abdominal manifestations of situs anomalies in adults. Radiographics, 2002 Nov-Dec. 22(6): p. 1439-1456.
Kaushik, R., Chandrakar, K., Ksheersagar, D., et al., Situs inversus totalis- A case report. J Cont Med A Dent 2015 Jan-Apr. 3(1): p. 97-99.
Imamura, T., Momoi, N., Go, H., et al., Rare case of isolated levocardia with polysplenia including normally structured lung without cardiac anomaly. Congenit Anom (Kyoto), 2011 Dec. 51(4): p. 187-190.
Abdullah, N.L., Quek, S.C., Seto, K.Y., Teo, L.L., Clinics in diagnostic imaging (160). Levocardia with abdominal situs inversus. Singapore Med J, 2015 Apr. 56(4): p. 198-201; quiz 202.
Jo, D.S., Jung, S.S., Joo, C.U., A case of unusual visceral heterotaxy syndrome with isolated levocardia. Korean Circ J, 2013 Oct. 43(10): p. 705-709.
Sugiura, M., Okada, R., Hiraoka, K., Isolated levocardia with polysplenia in an aged with special reference to minor cardiac abnormalities. Jap Heart J, 1968 Nov. 9(6): p. 603-608.
Toutounchi, S., Krajewska, E., Fiszer, P., et al., Laparoscopic adrenalectomy in a patient with situs inversus levocardia. Wideochir Inne Tech Maloinwazyjne, 2012 Aug. 7(3): p. 213-215.
Treiger, B.F., Khazan, R., Goldman, S.M., Marshall, F.F., Renal cell carcinoma with situs inversus totalis. Urology, 1993 May. 41(5): p. 455-457.
Ding, J., Huang, Y., Gu, S., et al., Flexible ureteroscopic management of horseshoe kidney renal calculi. Int Braz J Urol, 2015 Jul-Aug. 41(4): p. 683-9.
Chaturvedi, P., Thomas, K., Congenital renal anomaly in a patient with situs inversus. Postgrad Med J, 2003 Jun. 79(932): p. 355-359.
Cimen, H.I., Atik, Y.T., Adsan, O., Laparoscopic simple nephrectomy patient with situs inversus totalis and left renal hypoplasia: A case report. Can Urol Assoc J, 2015 Jul-Aug. 9(7-8): p. E521-523.
Sa?lam, E., Türk, A., Selimo?lu, A., et al., Renal cell carcinoma in a patient with Kartagener syndrome: First case report in English language. J Urol Surg, 2015. 1: p. 33-35.
Gonzalez-Heredia, R., Garcia-Roca, R., Benedetti, E., Hand-assisted robotic right donor nephrectomy in patient with total situs inversus: A case report. Int J Surg Case Rep, 2016. 23: p. 44-46.
Bejiqi, R., Retkoceri, R., Bejiqi, H., Zeka, N., Klippel - Feil Syndrome associated with congential heart disease presentaion of cases and a review of the curent literature. Open Access Maced J Med Sci, 2015 Mar. 3(1): p. 129-134.
Senayli, Y., , Kaya, Z., Senayli, A., Xzkan, F., Pyelolithiasis based on ureteropelvic junction obstruction with situs inversus totalis: Handling of a child. Intern J Urol, 2009 Jul. 6(1): p. 8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN2017January20HealthcareFormation of the Median Nerve by an Additional Lateral Root: Embryological Basis and its Clinical Implications
English2931Archana Srivastava1English Anita Rani2English Archana Rani3English Pradeep Kumar Sharma4EnglishAim: A complicated network of arrangement of brachial plexus lead to frequent variations in this region. Therefore, a careful dissection of cadavers was performed during routine dissection classes of first year MBBS students.
Case Report: During dissection of right arm of a 50 year old male cadaver the median nerve was found to be formed by the union of three roots instead of normally described two. An additional lateral root originated from the lateral cord of the brachial plexus. The medial root united with one lateral root in the axilla, lateral to the axillary artery to form the main trunk of the median nerve. The additional lateral root travelled independently in arm and pierced the coracobrachialis muscle without supplying it and then joined the main trunk of median nerve in the lower one-third of the arm. This type of variation in the median nerve is uncommon.
Discussion: Variations in median nerve are documented in the literature but the present case report is rare.
Conclusion: A detailed knowledge of normal and variant anatomy of median nerve should be kept in mind for correct diagnosis and appropriate treatment.
EnglishMedian nerve, Lateral root, Additional lateral root, Medial rootINTRODUCTION
The median nerve is formed in the axilla by fusion of two roots, the lateral and medial roots. Medial root of median nerve arises from the medial cord (C8,T1) of brachial plexus. The lateral cord (C5, C6, and C7) gives rise to lateral root of the median nerve. The two roots unite either anterior or lateral to the third part of the axillary artery.1 Median nerve then enters the arm lateral to the brachial artery. At the level of insertion of coracobrachialis muscle, it crosses the artery in front of it and then descends medial to it up to the cubital fossa. It enters the forearm between the two heads of pronator teres muscle. A high percentage of variations in the formation of median nerve have been reported. It includes the presence of additional roots, formation of the nerve in the arm and formation medial to axillary artery.2 The present case, reports an unusual formation of median nerve by three roots. The knowledge of these anatomical variations is of great importance to the surgeons in order to avoid injury to the median nerve during neck and axilla surgery.
CASE REPORT
During dissection of right arm of a 50- year old male cadaver, an additional third root of the median nerve was found. The main trunk of median nerve was formed by the union of the medial root and one lateral root in the axilla, lateral to the axillary artery. The additional root originated from the lateral cord, it travelled independently in arm and pierced the coracobrachialis muscle without supplying it and then joined the main trunk of median nerve in the distal one-third of the arm (Figure 1 & 2). The further course of median nerve in the arm was normal. The course and pattern of supply of the median nerve in the forearm and palm was normal. The musculocutaneous nerve showed no anatomical variation in the formation, course and supply. Vascular supply of the limb did not show any variation. No communication between the median and musculocutaneous nerves was observed. The formation, course and branching pattern of median nerve in the other limb was normal.
DISCUSSION
Formation of median nerve by two roots is seen in 48% to 88.5% of cases.2 Whereas formation by three or more roots has been well documented in the literature. These additional roots arise usually from the lateral cord of the brachial plexus.3-5 The reported incidence of this variation ranges from 14.2% to 20%.6,7 Rarely the additional root may arise from the medial cord or from the anterior division of the middle trunk of the brachial plexus.8,9 The median nerve may sometimes receive a communicating branch from the musculocutaneous nerve which is regarded by some authors as an additional lateral root.10 Sontakee et al. (2011) described a case where the median nerve was formed by three roots, two roots from the lateral cord and the third root from the medial cord. The first lateral root joined the medial root in the axilla and the second lateral root joined the medial root in the arm to form the median nerve.11 Pais et al. (2010) reported the formation of median nerve by three roots in their case study.12 The two lateral roots joined the medial root in the axilla to form the median nerve. A similar variation was reported by Satyanarayana et al. (2009).5
Das and Paul (2005) observed in their case that the median nerve was formed by two lateral and one medial roots. The upper lateral root crossed the third part of axillary artery anteriorly to unite with medial root to from the median nerve in the axilla. The median nerve thus formed was related medial to the axillary artery.13 A high incidence of variations in the site of union has also been documented.2,7
In our case, the median nerve was formed by union of two lateral roots and one medial root. The main trunk of the median nerve was formed in the axilla and the second lateral root joined the main median nerve trunk in the lower third of arm. This type of variation in the formation of median nerve is rare.
The variations in the formation of median nerve had been explained on the basis of embryological development. In human, the forelimb muscles develop from the mesenchyme of the para-axial mesoderm during fifth week of embryonic life. The upper limb buds lies at the level of lower five cervical and upper thoracic vertebrae. The axon of the spinal nerves then enters the mesenchyme of the limb buds and grows within it making an intimate contact with differentiating mesoderm. This directional growth of nerve fibres is controlled by cell surface receptors such as neural cell adhesion molecule (N-CAM) and L1 and transcriptional factors like cadherins.14,15
As the signalling of the developing axon is regulated by expression of these factors in a highly coordinated site specific fashion, any alteration in signalling between mesenchymal cells and neuronal growth cones can lead to significant variations.16
Knowledge about the variations in the formation of median nerve has clinical importance as these roots may be injured during surgery or trauma giving rise to unusual clinical symptoms. During brachial plexus block given by the anaesthetists, these variations may be responsible for failed or incomplete nerve block.
CONCLUSION
Embryological basis of different variations should be kept in mind to arrive at correct diagnosis. The knowledge of such anomalies are very important for the surgeons performing procedures in the axilla as well as for anatomists for academic purpose.
ACKNOWLEDGEMENTS
I express my gratitude to the staff of the Department of Anatomy for assistance in providing infrastructure facilities and necessary help. 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.
Source of Funding: Nil
Conflict of interest: All authors have none to declare.
ABBREVIATIONS USED: MN-Median Nerve, LR1- Lateral root, LR2- Additional lateral root, MR- Medial root, AA- Axillary artery, AV- Axillary vein, MCN- Musculocutaneous nerve, UN- Ulnar nerve, RN-Radial nerve, CB- Coracobrachialis, BB- Biceps brachii
Englishhttp://ijcrr.com/abstract.php?article_id=88http://ijcrr.com/article_html.php?did=88
Standring S. Gray’s Anatomy 39th ed. Churchill Livingstone. Elsevier, New York, 2005.
Pandey SK and Shukla VE. Anatomical variations of the cords of brachial plexus and the median nerve. Clin Anat 2006; 20: 150-156.
Saeed M and Rufai AA. Median and musculocutaneous nerves: variant formation and distribution. ClinAnat 2003; 16 (5): 453-457.
Sargon MF, Uslu SS, Celik HH, Aksit DA. Variation of the median nerve at the level of brachial plexus. Bull Assoc Anat 1995;79 (246): 25-6.
Satyanarayana N, Vishwakarma N, Kumar GP, Guha R, Dutta AK, Sunitha P. Rare variations in the formation of median nerve-embryological basis and clinical application. Nepal Med Coll J 2009; 11 (4):287-290.
Budhiraja V, Rastogi R and Asthana AK. Anatomical variations of median nerve formation: embryological and clinical correlation. J MorpholSci 2011; 28 (4): 283-286.
Channabasangouda Patil S, Shinde V, Jevor PS and Nidoni M. A study of anatomical variations of median nerve in human cadavers. Int J Biomed Research 2013; 4 (12):682-690.
Paranjape V, Swamy PV, Mudey A. Variant median and absent musculocutaneous nerve. J Life Sci 2012; 4 (2): 141-144.
Uzun A, Bilgi S. Some variations in the formation of the brachial plexus in infants. Tr J Med Sci 1999; 29: 573-577.
Natsis K, Paraskevas G, Tzika M. Five roots pattern of median nerve formation. Acta Medica 2016; 59 (1):26-28.
Sontakee BR, Tarnekar AM, Waghmare JE and Ingole IV. An unusual case of asymmetrical formation and distribution of median nerve. Int J Anat Variations 2011; 4: 57-60.
Pais D, Casal D, Santos A, O’Neill JG. A variation in the origin of median nerve associated with an unusual origin of the deep brachial artery. J of Morph Sci 2010; 27 (1): 35-38.
Das S and Paul S. Anomalous branching pattern of lateral cord of brachial plexus. Int J Morphol Sci 2005; 23 (4): 289-292.
Brown MC, Hopkins WG, Keynes RJ. Essentials of neural development. Cambridge. Cambridge University Press, 1991; p. 46-66.
Larsen WJ. Human embryology. 2nd ed. Edinberg. Churchill Livingstone. 1997; p. 311-339.
Samnes DH, Reh TA, Harris WA. Development of nervous system. New York: Academic Press, 2000; p. 189-197.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN2017January20HealthcareRidge Augmentation Meet for Esthetics: An Interdisciplinary Approach
English3236Irudayanirmala J.English Ramakrishnan T.English Shobana P.English Vidya SekharEnglish Edilbert raja I.English Karthikeyan A.EnglishAim: Dentoalveolar defects occur due to maxillofacial trauma, accidents, traumatic tooth extraction, advanced periodontal diseases, which results in loss of alveolar ridge and attached mucosa. These defects when occur in anterior region needs hard and soft tissue augmentation. Though many techniques exist for effective soft and hard tissue augmentation, approach is mainly based on the extent of the defect and specific procedures for prosthetic rehabilitation. Bone graft along with GBR is valuable treatment option for ridge augmentation followed by Fixed partial denture.
Case Report: This article presents case report of hard tissue augmentation in seibert`s class 3 alveolar ridge defect followed by Fixed partial denture with Gingival colored porcelain in missing Right maxillary lateral incisor region.
Discussion: Increase in the density of the defected area can be achieved by bone grafting with GBR. Thus it paves the way for replacement of the lost tooth along with function and esthetics.
Conclusion: The clinical and radiographic findings of this case suggests that bone grafting procedures combined with resorbable collagen membrane followed by esthetic metal ceramic fixed partial denture can be an acceptable alternative to removable partial denture, implant therapy.
EnglishDentoalveolar defects, Guided bone regeneration, Bioresorbable Demineralized bone matrix, Ridge augmentation, Fixed prosthesisINTRODUCTION
Alveolar ridge augmentation designed to correct deformed alveolar ridge by enlarging or increasing, as in size, extent or quantity.1 Alveolar process is often affected after tooth loss by a continuous resorptive process in dentoalveolar defects. principal site of resorption is Labial aspect of the alveolar crest in which First reduces in width and later in height. These local alveolar ridge defects creates aesthetic and functional problems that includes loss of papillae, formation of open inter dental spaces, loss of buccal contour, unaesthetic gingival texture, phonetic problem, and food impaction respectively.2
Based on the location of the deformity, Seibert 1983 classified ridge defect as class1,class II, class III.2
Class 1 - Bucco lingual loss of tissue with normal apico coronal ridge height.
Class II – Apico coronal loss of tissue with normal buccolingual ridge width..
Class III - Combination of both buccolingual and apico coronal loss ( both width and height)
Advanced alveolar bone loss in above defects prevents replacement in an optimal prosthetic position. So ridge augmentation play a major role in replacement of teeth. It require bone regeneration outside of the existing bony walls that includes GBR techniques involving bone grafting material and membrane.3
GBR is technique that has same principle as GTR, but is not associated with teeth. Primary objective of GBR is to regenerate a single tissue i.e bone compared to GTR which regenerate multiple tissues (bone,cementum,PDL)4
Sterile bio resorbable Demineralized bone allograft has been used alone in ridge augmentation which is osteoconductive as well as osteoinductive in nature. GBR stabilize the bone graft below the membrane, minimize the risk of collapse and soft tissue in growth over osteogenic cells intended for bone regeneration.5
This is the case report of Hard tissue augmentation with bone graft along with collagen membrane to enhance bone regeneration in seibert`s class 3 alveolar ridge defect in missing Right maxillary lateral incisor region. Later right maxillary lateral incisor was replaced with ceramic fixed partial denture with gingival-colored porcelain using central incisor and canine as abutments.
CASE REPORT:
A 24 years old Female named Ramani was referred to the Department of periodontics, Adhi parasakthi dental college and hospital, for ridge augmentation, prior to fixed partial denture replacement by the Department of prosthodontics.
Implant was not planned because of inadequate width and height. Also patient needs immediate replacement. Medical history was Non-contributory. The dental history revealed, loss of Right maxillary lateral incisor due to trauma 1 year back. Evaluation of the edentulous space (through clinical and Radiographic examination) revealed siebert`s class 3 ridge defect (Combination of both buccolingual and apico coronal loss ( both width and height) [Fig.1,2] In order to create an emergence profile and soft tissue contour around the fixed partial denture, the ridge defect was planned to be corrected using Guided bone regeneration technique using bone graft with a resorbable collagen( Heali-guide) membrane.
SURGICAL CONSIDERATIONS:
RECIPIENT SITE:
Patient was asked to rinse with 10 ml of 0.2% chlorhexidine for one minute before surgery. Local anesthesia was given and crestal incision was placed on the edentulous area of Right maxillary lateral incisor region, continuing with the intra sulcular incision at the adjoining teeth.
Full thickness mucoperiosteal flap elevated that showed deformity in the labial aspect. A surgical bur was used to decorticate the bone for binding of bone graft over the defect area and also providing vascular supply.[Fig.3]
Allograft ( sterile bio resorbable Demineralized bone matrix- Xeno graft) was placed over the deformity[Fig.4] and covered with resorbable collagen membrane (HealiGuide).[Fig.5] Flap was closed by Horizontal mattress suture using 3-0 silk[Fig.6] and periodontal dressing was placed. Post operative instructions were given. Patient was advised Amoxicillin (500mg), three times daily for 5 days, and Ibuprofen (400mg) thrice daily or 3 days along with 10ml of chlorhexidine (0.2%) mouthwash twice daily for 14 days. The patient was recalled after 1 week for suture removal. Healing was satisfactory with no post surgical complications.
Patient was recalled after 1 month and clinical examination of the treated ridge defect showed significant improvement in ridge width.[Fig.7] Post operative models after 1 month showed improvement in ridge contour.[Fig.8]
RESTORATIVE PROCEDURE:
Teeth preparation done on maxillary central incisor and canine region.[Fig.9] Contouring of gingiva was done to get emergence profile[Fig.10] Since maxillary right central incisor pulp horn was so high, Intentional RCT was done on this tooth.[Fig.11].Immediately temporary crown placed.[Fig.12]. After 2 days post operatively, healing of gingiva took place with contoured margins. [Fig.13] In this case, young female patient had high esthetic expectations, Gingival-colored porcelain was used to metal-based ceramic crowns to compensate soft tissues on the maxilla .So metal ceramic crown with Gingival colored porcelain was constructed between maxillary right central incisor and canine region.[Fig.14,15] Then the prosthesis was checked for any occlusal discrepancies. The patient was instructed oral hygiene instructions including dental floss and interproximal brushes designed for fixed partial denture. The esthetic outcome of the procedure satisfied both clinician and patient.
DISCUSSION:
Large vertical and horizontal bone defects in missing teeth are not successfully treated by conventional fixed or removable prosthesis alone. Bone grafts with GBR showed successful bone regeneration in the ridge defects.
Bone regeneration occur at the periphery of the defect, by the formation of woven bone with new blood vasculature. New vascular supply comes from surgically created perforations in the cortical bone. Then woven bone is replaced by mature lamellar bone.4
Collagen membrane used for GBR has the ability to promote platelet aggregation, be chemotactic for fibroblast, enhance wound stability required for proper healing, and mechanical support to the tissue during bone formation.[5,6] Non –degradable membranes has been used for ridge defects with good results, however need of second surgery for its removal, and infection on exposure overcome by rersorbable membrane.
Recently, Non-expanded dense PTFE (Polytetrafluoroethylene) membrane provided sufficient regenerated ridge due to its no need for primary closure, easy to achieve over filling.7 Bone replacement grafts have an ability to stimulate progenitor cells .Progenitor cells undergo differentiation to osteoblasts and form bone under the membrane.5
There are various treatment options for the patients who have severe maxillary dento alveolar defects. Although removable partial dentures are indicated in soft and hard tissue lost in order to acquire lip support. They are not the first choice of patients who have high esthetic and functional expectations.
Conventional tooth supported FPD may be an ideal treatment option where implants are contra indicated or patients refuse the implant therapy due to its surgery, and long time to complete the treatment. However, Natural abutment teeth with sufficient bone support are required for these kinds of prosthesis. Moreover it reduces treatment time and cost.8
CONCLUSION:
Prior to treat Dentoalveolar defects, Careful diagnosis and surgical – prosthetic treatment planning with joint consultation should be performed. In order to obtain better results, ridge augmentation with bone grafting along with GBR is more predictable and metal ceramic fixed partial denture with Gingival-colored porcelain enhanced the esthetic outcome. Correction of a localized ridge defect with hard tissue augmentation is a valuable method for FPD in which improved mucogingival esthetics as well as phonetics.
ACKNOWLEDGEMENT:
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=101http://ijcrr.com/article_html.php?did=101
American Academy of Periodontology. Glossary of periodontal Terms (2001).
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524192EnglishN1111November11Research
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