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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Antioxidant, Cytotoxic, Antidiabetic and Phytochemical Investigation of Root Extracts of Tecoma stans (Bignoniaceae) English0109Atif ShahzadEnglish Samina AfzalEnglish Imran AhmadEnglishEnglishSecondary metabolites, Antioxidant activity, MTT assay, Tecoma stans, Antidiabetic, Brine shrimp lethality assay Introduction Plants are an essential part of the earth. Since ancient time, human beings have been using plants as medicine. These medicinal properties of plants are due to the presence of biologically active constituents. It has been scientifically reported that these constituents obtained from plant extracts have various biological activities. The main purpose of these constituents in plants is to protect them from various harms but studies indicate that many of them can also be used against various disorders and diseases in humans. The most important of these biologically active constituents are secondary metabolites for example flavonoids, glycosides, steroids alkaloids, terpenes, and tannins. These secondary metabolites can be extracted by using different solvents and used in the preparation of useful drugs. The importance of chemical as well as pharmacological evaluation of plant-derived bioactive compounds used to treat many human illnesses has been increasingly recognized in the past few decades, but still, there are numerous useful medicinal plants and herbs waiting to be explored and evaluated for their effective medicinal application.1,2,3,4 Tecoma stans is distributed worldwide mostly grown in tropical and subtropical countries. It belongs to the family Bignoniaceae and is commonly known as the yellow bell. Phytochemical studies on the plant have shown the presence of secondary and primary plant metabolites such as alkaloids, phenolics, sugars, sterols and triterpenoids. Almost every part of the plant is of therapeutic value for example flowers showed antidiabetic, anticancer, anti-inflammatory activity and antioxidant activity.5,6,7,8 Survey indicates that very few reports are available on its roots part so there was a need to explore the root regarding its phytochemical and pharmacological analysis. Therefore, the present work aimed to study the qualitative photochemical screening and quantitative analysis of total phenolic, flavonoid and alkaloid contents of methanol and dichloromethane extracts of Tecoma stans roots as it is indicated that alkaloids, flavonoids and other polyphenols of Tecoma stans are main compounds thought to be responsible for positive results of many therapeutic activities. Plant extracts were also evaluated for antioxidant activity, alpha-amylase, alpha glycosidase inhibitory. Roots were also investigated for their cytotoxic potential using lethality assay as well as MTT assay against two important cancer cell lines (PC3 and HeLa).  Material and Methods  Plant Material The whole Tecoma stans plant was collected. The plant was identified by plant taxonomist Dr. Zafrulla Ullah Zafar (Associate Professor), institute of pure and applied biology, Bahauddin Zakariya University, Multan, Pakistan and a voucher specimen holding no. Kew – 318412 was deposited in the same institute. Plant Extract Preparation. The collected roots of the Tecoma stans were first freed from soil and then shade dried. The dried roots were grounded to coarse powder and subjected to simple maceration process. The weighed amount of coarse powder in an extraction bottle was soaked with known volume of dichloromethane (DCM) for 24 hrs. with intermittent shaking. Then the filtration was performed after 24 hrs. of addition of solvent (DCM). This process was repeated in triplicates using the same solvent. Then extraction of the marc was completed by using methanol in the same way. Both extracts were concentrated in a rotary evaporator at 35C to obtain crude extracts. Dichloromethane and methanol extracts were labeled as TSD and TSM respectively.  Qualitative estimation of Phytochemical Constituents A preliminary phytochemical examination for extracts was completed as described by.9 Quantitative estimation of phytochemical constituents Total Phenolic contents Folin–Ciocalteu colorimetric method with slight modification was adopted for the purpose of quantification of total phenol content in the methanolic and dichloromethane root extracts of Tecoma stans. Accurately weighed 10 mg of gallic acid was dissolved in 10ml methanol to make the concentration of the solution 1 mg/ml and from this different concentrations of gallic acid (10-200 µg/ml) were prepared. Aliquots of 0.5 ml of plant extracts (10mg/10ml in methanol) and each of the standard gallic acid solution were taken in tubes and mixed with Folin–Ciocalteu reagent five ml (1:10 in deionized H2O). After few minutes, 4 ml of a saturated solution of sodium carbonate (7.8% w/v) was added in each solution given in tubes and covered with silver foils and subjected to incubation for sixty minutes (at room temp.) with shaking. Now the absorbance of each solution is measured at 765 nm wavelength. Blank was also used which was methanol only. All the samples were analyzed in triplicates. Gallic acid (GA) was used as a reference. Results obtained were expressed as gallic acid equivalent (GAE) per gram of the sample. The calibration curve was plotted from pure phenolic standard which was gallic acid to quantify phenolic contents in both extracts.10 Total Flavonoid Contents AlCl3 colorimetric assay with modification was adopted to quantify the methanol and dichloromethane root plant extracts of Tecoma stans regarding flavonoids. A standard was also used which was rutin and the results were expressed as Rutin equivalent (RUE) per gram of the sample.  Dissolved 10 mg of rutin in 10ml methanol and from this varying concentration (10-120mg) solutions were prepared. Now 0.18 ml 5% w/v of sodium nitrite solution and 2 ml of distilled water were added in each solution of rutin. Similarly 0.8 ml of extracts (10mg/10ml) mixed with 0.18 ml 5% w/v of sodium nitrite solution  and 2 ml of distilled water.  After 10 minutes, 2ml 10% AlCl3 w/v solution was also added in both extracts as well as in standard rutin solutions. All solution were allowed to stay for 10 minutes and then 1 ml 4%  sodium hydroxide was added to each mixture and made volume up to 5 ml using distilled H2O and mixtures were allowed to stay for 15 minutes. The absorbance of each mixture and blank was determined at a wavelength of 510nm. With the help of the standard curve of standard, the amount of flavonoid was calculated as mg rutin equivalent per gram of extract. All readings were performed in triplicates.10 Total Alkaloid contents Total alkaloid contents in both extracts of Tecoma stans were calculated by spectrophotometrically.11 Atropine solution was used as the reference standard and its solution was prepared by dissolving 10mg of atropine in 10ml distilled water. The plant extracts with concentration1 mg/ml were dissolved in hydrochloric acid which was 2 normal and then filtered. 1.5 ml of filtered sol. was shifted to a separating funnel. In this separating funnel, 6 ml of phosphate buffer of neutral pH and 4 ml of bromocresol green solutions were added and followed by vigorous shaking using 4ml chloroform for extraction purposes. The extracted solution was further diluted with chloroform up to 10ml and absorbance of this diluted solution was measured at 470 nm wavelength. The calculations were performed in triplicates. Atropine calibration curve plotted by preparing varying dilutions of (50, 75, 100, 125, 150, 175, 200, 225 and 250 µg/ml) atropine solution and performed same procedure as mentioned above. Absorbance of each dilution noted at 470nm against blank solution (devoid of atropine). Antioxidant activity DPPH Assay The antioxidant potential of dichloromethane, as well as methanol root extracts of Tecoma stans, was measured by using the DPPH assay.10 1mg/ml solution of DPPH was prepared in methanol. 10 mg extract was carefully dissolved in10 ml methanol to prepare 1mg/ml solution. From this stock solution 60, 50, 40, 30, 20 and 10 μg/ml dilution prepared. In each of these dilutions, 75 µl 1, 1- diphenyl-2-picrylhydrzl solution was added. All test tubes were placed in the dark for 35 minutes and then the absorption was noted at 517 nm. IC50 was also determined from % DPPH radical scavenging activity. Ascorbic acid was used as a reference. The stock solution of reference was prepared with the procedure same for each plant extract. The whole experiment was performed in triplicates. % inhibition of the 1, 1- diphenyl-2-picrylhydrzl free radical was measured by the formula given below: AB is the absorption of a blank sample containing DPPH.  Whereas, AS is the absorption of DPPH solution having tested plant extract solution/ Standard. ABTS Assay ABTS assay is based on ABTS+? radical cation decolorization when it is reduced to 2, 2 – azino -bis (3-ethylbenzthiazolin 6 sulphonic acid). Radical cation was produced by reacting 1:1 volumes of seven mM  ABTS solution in H2O with 2.25 mM K2O8S2 and staying this mixture in dark at 30°C for 15 hours because the time was needed to get unchanging absorbance at 734 nm wavelength. After this, the solution was diluted using methanol until an absorbance value 0.69 ± .05 at 734 nm was achieved.  Ascorbic acid was taken as the reference standard. All stock solution and their dilutions were prepared as provided in DPPH assay. 2 ml of prepared solution of radial cation was reacted with 200μl of each of dilution of plant extracts and ascorbic acid. Vortexed the solutions and after 30 minutes absorbance was measured at 734 nm. The amount of sample required to decrease the absorbance of ABTS by 50% (IC50) was also calculated. All calculations were repetitive at least three times. The following formula was employed to calculate the percent radical scavenging activity.12 Where AB is the absorbance of ABTS radical and AS is the absorbance of ABTS+.plus plant extracts / standard. Cytotoxic activity The brine shrimp lethality test The artificial seawater was placed in a chamber consisting of small plastic container having partition for light for attracting attract the hatched shrimp and dark areas (having shrimp eggs). Two days were given for the shrimp to hatch and mature as larva. A stock solution of both methanolic and dichloromethane root extracts (30mg/3ml) were prepared. From this stock solution 10, 100, 1000 µg/ml dilution were prepared. Each dilution was prepared in three replicates. A control was also prepared having 6ml only sea water. Both plant extracts with different dilution were added to different test tube and evaporating solvents, 6 ml of artificial seawater added to every tube with moderate shaking. Now 10 shrimps were added into each tube. Therefore, there were total of 30 shrimps in each dilution. After adding 6ml artificial seawater to each test tube, they were exposed to the light (lamp). After 24 hours, the no. of living (surviving) and dead shrimps were counted. The percentage mortality (%Mortality) was calculated by formula given below. Lethality concentration (LC50) was also calculated, whereas LC50 value of greater than 1000 µg/ml is non-toxic (inactive) while LC50 value less than 1000 µg/ml is toxic (active).13,14 Cytotoxicity against HeLa and 3T3 cell lines The anticancer activity of both plant extracts was calculated in 96-well microplates using MTT assay. In this study, two human cancer cell line namely prostate cancer cell line (PC3 cell line) and cervical cancer cell line (HeLa cell lines) were used to validate the plant cytotoxic potential. Both cell line were first cultured in Dulbecco's Modified Eagle's Medium having 100 µg/ml streptomycin, 100U/ml of penicillin and ten percent of fetal bovine serum and kept in 6.5% CO2 incubator at 37 oC . A culture of the cells having a concentration of 1 x 106 cells/ml was prepared and placed into 96 well plates. Now cells were incubated (6.5% CO2 incubator) with various concentrations (10-30 ug/ml in 0.5% DMSO) of both plant extracts and standard drug Doxorubicin for 48hrs at 37 0C. After 48 hours, sample solutions were washed using phosphate-buffered saline having 7.4 pH. Into each well, 200µl 0.5% MTT  phosphate buffer saline solution was added and subjected to incubation (6.5% CO2 incubator) again for more 4 hrs. Now absorbance at wavelength 570nm was noted. Similarly, the absorbance of wells without samples was also measured at 570nm as blanks. All calculations were performed in triplicates. The% cell inhibition was calculated by using formula given below.15 Antidiabetic Activity α Amylase Inhibition Activity 250 μL of both extracts of Tecoma stans  having dilutions 150, 250, 500 and 1000 mg/mL was added in tubes,  mixed  with  0.020 molar  250 μL of sodium phosphate buffer  having pH 6.9 which was already containing 0.50 mg/ ml of  enzyme solution (α-amylase). This solution was preincubated at 25 C for 15 min followed by mixing of  250 μL of  starch solution (1%) in 0.020 molar buffer 6.9  pH (sodium phosphate)  at timed intervals and incubated again  at 30 C for 15 minutes. The reaction was ended by adding 500 μL of  DNS (dinitrosalicylic acid reagent). The tubes were ungergone for  incubation for 6 minutes and subjected to cooling  to room temperature. Solution (The reaction mixture)  in the tube was diluted with 8 mL of distilled H2O. After dilution, absorption of this mixture was determined at 540 nm using spectrophotometer. Control was prepared by the same method but here the extracts was repalced with distilled water. All reactions were performed in triplicates.  The inhibitory activity of α-amylase was calculated as percentage inhibition using formula giving below.16                                           Whereas, Aconl is absorbance of control and Aext is the absorbane shown by the extract. IC50 (50% inhibition of enzyme activity) were also calculated. Glucosidase Inhibition Activity The substrate solution for assay consisting of  p-nitrophenyl glucopyranoside abbriviated as pNPG was prepared in 20mM phosphate buffer having 6.90 pH. 100????L of alpha glucosidase (1.0U/mL) was preincubated using 50????L of the varing dilutions of  both methanolic and dichloromethan root extracts (150,250,500 and 1000ug/ml).  Then 50????L of substrate solution in the form of p-nitrophenyl glucopyranoside 3.0mM  mixed in 20mM phosphate buffer with 6.90 pH was added to initiate the reaction. This reaction mixture was then  incubated at 37C for 25 min. After this, reaction was stopped by mixing 2mL  0.1Molar sodium carbonate solution (Na2CO3). The enzyme inhibitory potential was calculated  by quantifying the yellow colored para nitro phenol released from substrate at 405nm.17All the reactions were performed in triplicates. Percentage inhibition is calculated as                    Whereas A conl is absorbance of control and A ext is the absorbane shown by the extract. IC50 (50% inhibition of enzyme activity)  were also calculated. Statistical analysis To calculate the IC50, a logistic linear regression model was fit to the data using Microsoft Excel 2010. The obtained values were expressed as ‘Mean ± SD’. A value of pEnglishhttp://ijcrr.com/abstract.php?article_id=4538http://ijcrr.com/article_html.php?did=4538
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5HealthcareRisk Predictors for Lymphoma Development in Sjogren Syndrome - A Systematic Review English1014Monica KEnglishIntroduction: Sjogren syndrome is a systemic autoimmune disease characterized by lymphocytic infiltrates of salivary and tears glands, leading to oral and ocular dryness and by autoantibody secretion. The association between primary Sjogren syndrome and lymphoma, mostly non-Hodgkin ?s lymphoma or lymphoproliferative disease, has been documented for the past 40 years. The aim of our systematic review was to evaluate the available evidence regarding the identification of serological and hematological predictors for lymphoma in Sjogren syndrome patients. Materials and Methods: Articles were searched and selected through PubMed. Hand search from the relevant journals was also performed. Articles were reviewed and analyzed. The articles were reviewed based on serological and hematological risk predictors such as Anti-Ro antibodies, Anti-La,C3 levels, C4 levels, Cryoglobulins, Lymphopenia, anemia, antinuclear antibodies (ANA), and Rheumatoid Factor positivity. Results: Review of these articles showed significant associations of prognostic factors with the development of lymphoma. Within the limitations, Identification of a high-risk phenotype for lymphoma development at the time of Sjogren Syndrome diagnosis has been a major diagnostic challenge over years. Conclusion: All these factors act as a guide to identify patients with high risk at the time of diagnosis leading to an increase in disease-free survival rate. EnglishSjogren syndrome, Lymphoma, Risk Predictors, Autoantibody, Antinuclear antibodies, Rheumatoid Factorhttp://ijcrr.com/abstract.php?article_id=4539http://ijcrr.com/article_html.php?did=4539
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Impact of Co-Morbidities on Mortality of Patients with Covid-19 Infection     English1519Saima JatoiEnglish Muhammad Adnan BawanyEnglish Sunil Dat MaheshwariEnglish Muhammad Akbar MemonEnglish Zia Masarrat FarooquiEnglish Hasham Masood QureshiEnglish Introduction: The spread of the coronavirus has been so swift and intense since October of 2020. The first case of this viral infection was reported and diagnosed in December of 2019 and since then this disease has taken no time in turning into a worldwide pandemic. Aim: To assess the inter-relationship of comorbidities and mortality in patients infected with coronavirus disease. Methodology: The method of this study included taking into consideration all individuals infected with the viral disease in a specific time period. This study focuses on achieving results against two outcomes: Mortality as a result of any cause within 30-days after the initial COVID-19 virus detection and severity index data (composite) containing hospitalization and mortality details. The logistic regressions model and Cox proportional hazards regression model were used to adapt the study being conducted to the socio-economic situation. The conclusions drawn from the study were also divided into age groups. A sum total of 200 individuals infected with COVID-19 were taken into consideration for this study. Half of these patients were assessed and were shown to have at least one other disease (comorbidity). These patients were followed up and the median time period for this follow-up assessment was 20 days. Study design: A Cross-sectional study. Place and Duration: Isra University Hospital from 1st Feburary 2021 to 31st July 2021. Results: The results of this study showed that the participants of this study that one or more secondary illnesses (primary illness, in this case, being the coronavirus infection) had a higher chance of death via coronavirus as compared to individuals only infected by the viral infection. The study also brought to attention that as each number of comorbidities grew (for example, if a patient infected with COVID-19 was also assessed positive for hypertension and heart diseases, so did the chance for mortality; 2.14 times per comorbidity. The adverse impact of one or more comorbidities on people over the age of 50 is much more drastic (higher risk of death) as compared to people under than the said age group. Conclusion: This study has found that the presence of comorbidities in the considered individuals such as Asthma, chronic obstructive pulmonary disease, chronic kidney disease, chronic liver disease, hypertension, ischemic heart disease, rheumatoid arthritis, diabetes mellitus and HIV were associated with severity in the coronavirus disease as well as a high risk of mortality. EnglishCoronavirus, Mortality, Morbidity, Comorbidities, Chronic kidney disease, Chronic liver disease Introduction The first case of this viral infection was reported and diagnosed in December of 2019 and since then this disease has taken no time in turning into a worldwide pandemic, affecting each and every aspect of our lives right before our eyes, in a matter of days. The spread of the coronavirus has been so swift and intense that since October of 2020, in the United States of America, this disease has jumped the ladder of the leading causes of mortality and has landed itself the third place, especially for adults of 45 years of age or older.1 By the first quarter of 2021, over 150 million (accounting for about 2% of the total world population) cases of COVID-19 were reported, 3 million of which passed away.2 This sudden increase is only predicted to grow further in the coming years, and also in other countries.3 The first case of this virus diagnosed in Pakistan was in the city of Multan on February 26, 2020. As one of the most important cities in Pakistan, Multan reported a large number of affected population as well as a high rate of mortality. Existing research literature on coronavirus disease highlights that the risk factors for acute outcomes of the viral infection mainly include old age. Age is one of the biggest and most prominent risk factors when it comes to predicting mortality or assessing disease for severity in individual cases. Some of the other risk factors, in addition to old age,male gender, hypertension, cardiovascular disease (CVD), diabetes mellitus, cancer, kidney disease and dementia  also documented.4-10 This research aims to study the direct proportionality of mortality and disease severity of COVID-19 patients with the presence of symptomatic secondary diseases. Methodology In this cross-sectional study, individuals showing a positive nasopharyngeal PCR test result was considered and assessed from1st February 2021 to31st July 2021. Individuals that were not residents of the city under study were excluded from the database. Individuals selected by simple random sampling method. The testing done at all provincial health labs, commercials testing centers as well as all hospital labs using the polymerase chain reaction (PCR) technique. This study has been undertaken keeping in mind ethical sensitivities as its research area envelops a large grouping of the general population. It has made sure to receive, before even taking its preliminary steps, ethical proprietary consent from the Research Ethics Office of university. The primary outcome was the death rate that should take place within 30 days after the affected has been labeled positive for the presence of coronavirus in the bloodstream. The data including demographic data, comorbidities, COVID-19 PCR and other laboratory results were gathered on a semi structured proforma designed for the study after taking the written informed consent from the patient or the attendant, the data for mortality was received from the attendant on phone call when the patient was not on follow up. Descriptive analysis was done by calculation of proportions, studying mean values of standard deviation curves (SD) and establishing medians by calculating interquartile value ranges for the variables (IQRs). To compare the datasets of each group, the alive group and the dead group Student-t-test, Chi-Square test, Wilcoxon rank-sum test, Fisher’s exact test and Kruskal-Wallis test was done. The first step of the research procedure was to take into inspection the follow-up period for each infected individual from the time of their positive diagnosis of SARS-COV-2 until the death of or if alive then a period of 30 days is to be considered. As most positive cases were hospitalized even before the diagnosis for COVID-19 was given when the first wave of COVID-19 hit, logistic regression was used as the primary methodology to estimate the impact of the composite severity outcome. While employing the two methodologies, namely the Cox model or the model for logistic regression, there was a need to control various variables such as socio-economic variables, demographic variables, LTC contacts and multiple or singular comorbidities. In order to measure, calculate and analyze values against comorbidities, separate modes of analyses were conducted against three comorbidity-related variants, like the Presence of any comorbidity, number of comorbidities and the types of comorbidity. This method was used in order to avoid any kind of collinearity in the results. In order to study secondary illness impact on different age strata, two regression models (multivariable Cox model and logistic model) were employed to study the associations between these secondary illnesses and the two outcomes in five age groups. People below the age of 50, People falling within the bracket of 50-59, People falling within the bracket of 60-69, People falling within the bracket of 70-79 and People above the age of 80. Results A total of 200 individuals were identified as appropriate for this study group with a positive SARS-COV-2 polymerase chain reaction (PCR) test, out of which 25 were taken out because they were from other cities. In the nutshell, the study was based on a total of 175 (87.5%) individuals as these were in the follow up. The mean age was 42.7±12 with majority of patients were in 60-69 years of age group. 110(62.8%) were males and rest were females. 130 (74.28%) have co morbidities from which a large number have atleast 2 co morbidities. Unadjusted results of the study held show that other increased the number of comorbidities will have note-worthy associations with individual’s deaths. Each individual have multiple co morbidities.  The mortality risk is higher in individuals with co morbidities (11.5%) as compared to non comorbid patients (8.8%). (See Table 1) Out of all these diseases, asthma, chronic obstructive pulmonary disease and chronic kidney disease stand at the top of the formation for being the three illnesses causing the highest risk for mortality. (see Table 2) For the purpose of studying the effects of comorbidities on mortality in the context of various divisions of age group, the authors made use of the multivariable Cox hazard regression proportional models. One is compelled to notice that the number of comorbidities greatly elevate death risks in higher age strata. As age increases, the high-risk influence of the comorbidities increases. If we compare the individuals without comorbidities within the same age stratum, then the ones having five or more than five comorbidities had a death risk multiplied by:395.4 times for people in the age group of 60-79 years, 35.8 times for people falling within the bracket of 50-59 and 12.3 times for people falling less than 50 years.  On top of that, individuals more than 50 years of age show an increased mortality risk as well as an increased risk for comorbidities such as asthma, chronic obstructive pulmonary disease, hypertension, diabetes mellitus, rheumatoid arthritis, Ischemic heart disease, chronic liver disease and chronic kidney disease. The higher number of comorbidities shows a relationshio with higher number of mortality.  (see Table 3) Discussion For the purpose of identifying how much co morbidities adversely impact mortality rate of disease among SARS-COV-2 patients, the authors of this study, initiated such study. Quite a large sum of comorbidities was considered as potential instigators of adverse impact on the coronavirus disease for the sake of this experiment. Out of all the diseases considered, it was found that asthma, COPD, Chronic kidney disease and chronic liver disease were strong predictors of increased mortality risk. It was also found that as the number of secondary illnesses increased in individuals, so did the chances of mortality of COVID-19. Another result post-examination was that as the age increased, this comorbidity and mortality association increased. It was also indicated by the study that if the comorbidity condition was controlled, then age was the strongest factor in influencing risk value for mortality in patients. The results of this study show HIV to be a non-influencing condition, which is strange and can be because like another study (Harrison’s) our study group consisted of a very small percentile of HIV patients (as small as 0.2%).10 This statement has a high probability of being true because in another study conducted on South Africa, as the number (percentage) of HIV patients grew (as high as 20%), the impact of HIV as comorbidity positively influencing mortality also increased.11 Another considerable finding of this study work was that in adults older than 50 years of age, the secondary illnesses, did have any considerable effect on the risk of death of the patients.12 Rather the impact was large and dangerous in individuals older than 50 years instead of those that had not crossed this mid-life line. The conclusive arguments drawn from this study’s findings are opposite to those drawn from the research done by Harrison.13 The authors found that HIV, rheumatoid arthritis, cardiovascular disease and diabetes mellitus posed an elevated risk in individuals below 50 years of age.14, 15 The intention behind conducting this study is to bring to light how important it is for vaccination associations to consider not only age but also the number and type of comorbidities that individuals are afflicted by while labeling groups as high-priority groups for swift vaccination ( target groups).This is probably the first research conducted to date in the city that is focused on a mortality risk of disease but this study, like all other studies, was carried out with its own set of limitations and had to face many challenges. One of these limitations is that this report only labels comorbidities as factors being only directly relevant to the death risk, not being causal in any way. The establishment of a causal relationship is well beyond the scope of this study. Conclusion: All in all, it can be concluded that diseases such as asthma, chronic obstructive pulmonary disease (COPD), chronic kidney disease, hypertension, diabetes mellitus, cardiovascular disease, HIV chronic liver disease and rheumatoid arthritis are dependable predictors of death risk in COVID-19. It was found and proved by this ongoing argument that the presence of comorbidities in any number, shape or form greatly impacted the risk of mortality in older individuals; older than 50 years of age. Hence, we can state that when the vaccination authorities make their decisions for effective and efficient vaccination protocol they must include ‘multiple comorbidities’ as an important parenthesis of individuals for priority-based vaccination. FUNDING SOURCE None. CONFLICT OF INTEREST None. PERMISSION Permission was taken from the ethical review committee of the institute. Englishhttp://ijcrr.com/abstract.php?article_id=4540http://ijcrr.com/article_html.php?did=4540 1. Woolf SH, Chapman DA, Lee JH: COVID-19 as the Leading Cause of Death in the United States. JAMA 2021, 325(2):123– 124. https://doi.org/10.1001/jama.2020.24865 PMID: 33331845 2.WHO coronavirus (COVID-19) dashboard [https://www.who. int/emergencies/diseases/novel-coronavirus-2019?gclid=Cj0K CQjwvr6EBhDOARIsAPpqUPHrNlvBEDEKh3MpkmrBsCZzGzHhZtPbpHqdqPKBD74mlsG9SFWOKT0aAtvdEALw_ wcB] 3. Kontis V, Bennett JE, Rashid T, Parks RM, Pearson-Stuttard J, Guillot M, et al: Magnitude, demographics and dynamics of the effect of the first wave of the COVID-19 pandemic on all-cause mortality in 21 industrialized countries. Nature Medicine 2020, 26(12):1919–1928. https://doi.org/10.1038/s41591-020-1112-0 PMID: 33057181 4. Noor FM, Islam MM: Prevalence and Associated Risk Factors of Mortality Among COVID-19 Patients: A Meta-Analysis. J Community Health 2020, 45(6):1270–1282. https://doi.org/10.1007/ s10900-020-00920-x PMID: 32918645 5. Ssentongo P, Ssentongo AE, Heilbrunn ES, Ba DM, Chinchilli VM: Association of cardiovascular disease and 10 other pre-existing comorbidities with COVID-19 mortality: A systematic review and meta-analysis. PLoS One 2020, 15(8):e0238215. https://doi.org/10.1371/journal.pone.0238215 PMID:32845926 6. Guan WJ, Liang WH, Zhao Y, Liang HR, Chen ZS, Li YM, et al: Comorbidity and its impact on 1590 patients with COVID-19 in China: a nationwide analysis. Eur Respir J 2020, 55 https://doi. org/10.1183/13993003.00547-2020 PMID: 32217650 7. Biswas M, Rahaman S, Biswas TK, Haque Z, Ibrahim B: Association of Sex, Age, and Comorbidities with Mortality in COVID-19 Patients: A Systematic Review and Meta-Analysis. Intervirology 2020:1–12. 8. Atkins JL, Masoli JAH, Delgado J, Pilling LC, Kuo CL, Kuchel GA, et al: Preexisting Comorbidities Predicting COVID-19 and Mortality in the UK Biobank Community Cohort. J GerontolA Biol Sci Med Sci 2020, 75(11):2224–2230. https://doi. org/10.1093/gerona/glaa183 PMID: 32687551 9. Zhou Y, Yang Q, Chi J, Dong B, Lv W, Shen L, et al: Comorbidities and the risk of severe or fatal outcomes associated with coronavirus disease 2019: A systematic review and meta-analysis. Int J Infect Dis 2020, 99:47–56. https://doi.org/10.1016/j. ijid.2020.07.029 PMID: 32721533 10. Harrison SL, Fazio-Eynullayeva E, Lane DA, Underhill P, Lip GYH: Comorbidities associated with mortality in 31,461 adults with COVID-19 in the United States: A federated electronic medical record analysis. PLoS Med 2020, 17(9):e1003321. https://doi.org/10.1371/journal.pmed.1003321 PMID: 32911500 11. Boulle A, Davies M-A, Hussey H, Ismail M, Morden E, Vundle Z, et al: Risk factors for COVID-19 death in a population cohort study from the Western Cape Province, South Africa. Clinical Infectious Diseases 2020. 12. Chen H, Kwong JC, Copes R, Villeneuve PJ, Goldberg MS, Ally SL, et al: Cohort Profile: The ONtario Population Health and Environment Cohort (ONPHEC). Int. J. Epidemiol. 2016, 46(2):405–405j. 13. Mondor L, Cohen D, Khan AI, Wodchis WP: Income inequalities in multimorbidity prevalence in Ontario, Canada: a decomposition analysis of linked survey and health administrative data. Int J Equity Health 2018, 17(1):90. https://doi.org/10.1186/ s12939-018-0800-6 PMID: 29941034 14. Davies HT, Crombie IK, Tavakoli M: When can odds ratios mislead? BMJ 1998, 316(7136):989–991. https://doi.org/10.1136/ bmj.316.7136.989 PMID: 9550961 15. Pelley L: 60% higher risk of death from coronavirus variants, Ontario analysis finds: sources. In: CBC. Toronto: CBC News; 2021: https://www.cbc.ca/news/canada/toronto/covid-variantsdeath-analysisontario-1.5964296
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Attitude of Pregnant Women for Covid-19 Vaccination English2025Rahila ImtiazEnglish Zubaida MasoodEnglish Erum JahanEnglish Sagheera Anjum MunaverEnglish Rubina IzharEnglish Syed Hassan Ahmed RizviEnglish Syed Hussain Ahmed RizviEnglish Objective: Coronavirus disease 19 (COVID-19) Vaccination is critical approach in restricting the COVID-19 epidemic in order to curb infections and diminish severity of illness particularly among most vulnerable group such as pregnant women. Therefore, this study was intended to assess the attitude of women in pregnancy toward COVID-19 vaccination. Methodology: This was a cross-sectional observational study conducted in the outpatient Department of Gynecology and Obstetrics of Abbasi Shaheed Hospital, Karachi by using a non-probability convenient sampling technique. The duration of the study was about 6 months from October 2021 to March 2022. A total of 325 pregnant women having pregnancy of after 14 weeks and before 34 weeks, who were physically and mentally fit with no past history of acute or chronic systemic disorder were included in the study. For quantitative variables mean and standard deviation was recorded and for qualitative variables frequency and percentages were reported. Results: The study results showed that the mean age of the participants was 28.92 ± 5.18 years, mean parity was 2.61±1.80, and mean gravidity was 3.66±1.86. When asked about their intention to receive the COVID-19 vaccine, 167(51.4%) participants indicated fear of pregnancy complication while 158(48.6%) had no fear. 170(52.3%) participants showed fear of complication related to baby. About 65(20.0%) were concerned about safety of vaccine. Most of the participants 290(89.2%) agreed that isolation methods and social distancing are not enough. 235(72.3%) believed that COVID-19 vaccine can protect from the infection only 90(27.7%) participants did not believe on the effectiveness of vaccine. Conclusion: This study concluded that despite the low educational level of pregnant women, most of the participants showed positive attitude and willing to be vaccinated. However, majority pregnant women had fear of detrimental effects for the fetus and mother which were two major concerns among pregnant women when considering COVID-19 vaccination. EnglishCoronavirus disease 2019, Pregnant women, COVID-19 vaccines, Vaccine acceptance INTRODUCTION Coronavirus disease 2019 (COVID-19), the extremely communicable viral disease that is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has had a terrible influence on the globe’s demographics leading to above 3.8 million demises internationally, evolving as the most substantial universal health catastrophe as the period of the influenza epidemic of 1918.1  According to WHO (World Health Organization), it is predicted that more than 2 million deaths were documented in a year or so. Therefore, it is vital to protect individual from getting this contagion. Most effective means for protecting from infection are the implementation of Standard operating procedures (SOPs) for instance use of face masks, social distancing and maintenance of individual cleanliness, but to keep such actions for prolong duration basically is unmanageable.2 Internationally, COVID-19 has executed huge encumbrances of morbidity and mortality amongst the general populace.3 In Pakistan, it is predicted that 560,000 cases were diagnosed wherein 12,218 deaths were reported.4 In spite of the implementation of SOPs, it is imperative to be vaccinated for COVID-19 in order to restrict the spread of contagion in Pakistani population.5 Vaccination is a critical approach in restricting the spread of COVID-19 epidemic and reducing the disease severity. As in other viral endemic infections in an earlier years, vaccination has definitely developed a substantial influence to human and animal wellbeing, particularly in emerging nations.6 Vaccination would be more effective on recognition of vaccination barriers in the population, particularly in more susceptible groups such as pregnant women. Commendations from the Society for Maternal-Fetal Medicine and American College of Obstetricians and Gynecologists (ACOG) have retained that pregnant and lactating women should be vaccinated based on their risk, so vaccines based on mRNA are believed to pose less harm to the fetus because of degradation of mRNA in the circulation.7,8 According to the statistics, pregnant women are at greater risk to develop severe COVID-19 infection.9 According to a report from the Centers for Disease Control and Prevention (CDC),  it is stated that pregnant women were three folds more expected to be hospitalized in critical condition or need intubation as compared to non-pregnant women, and death occurs from COVID-19 exceeds more probably one and half times.10 Vaccination’s acceptance based on society’s awareness of disease risk, attitudes and acquaintance about vaccine, and is essential for vaccination programs to attain high vaccination reportage rates, predominantly for newly evolving infectious diseases.11 Even before the existing COVID-19 endemic, the WHO recognized vaccine hesitancy that is characterized by the deferral in accepting vaccines or rejection of them that are one of the top ten dangers to world health.12 In general population of China, it is estimated that acceptance of the COVID-19 vaccine was 90%,13 in the United States it is reported 70%,14 and in France, it is predicted 75% .15 This is contrary to a former research piloted in the United States in year of 2020 wherein not more than half of pregnant women indicated they were expected to get the COVID-19 vaccination.16 Similarly, one more research stated that pregnant participants had a 44.3% acceptance rate of vaccine which was lower as compared to non-pregnant women (76.2%).17 In order to augment the vaccine acceptance, counseling exhibits a key role in alleviating uncertainties and supports women deal with health concerns associated with pregnancy. Providers should aware about concerns and current knowledge of their patient for appropriate counseling.18 A lot of researches explored the influence of social media on vaccine acceptance that directed different advices of this impact, as media stands may hasten the infodemic in public health emergencies to an extent that hampers healthy decisions from being made.19-21 Social media platforms can also be used to lessen the possibility of misrepresentation by presenting high-quality evidences from reliable and appealing means to pregnant and lactating women.22 COVID-19 infection is ever-so rising in incidence and severity along with the rising rate of occurrence of COVID-19 infection in pregnant women. Formerly, pregnant women stay un-vaccinated owing to misperception and lack of acquaintance provided by public health experts concerning COVID-19 vaccination. Therefore, the present study was planned to evaluate and attain insight into the attitude of pregnant females regarding their choice of preference of COVID-19 vaccination. METHODOLOGY This was a cross-sectional observational study conducted in the outpatient Department of Gynecology and Obstetrics of Abbasi Shaheed Hospital, Karachi by using non-probability convenient sampling technique. The duration of the study was about 6 months. This study was ethically approved by the concerned ethical committee. A total of 325 pregnant women having pregnancy of after 14 weeks and before 34 weeks, who were physically and mentally fit with no past history of acute or chronic systemic disorder were included in the study whereas pregnant women below 18 or above 35 years of age, intrauterine pregnancies having stillbirth, intrauterine growth retardation, miscarriage and medical complications, having contraindication to COVID-19 vaccine, refusing to participate in the study, pregnancy of before 14weeks and after 34 weeks were excluded from the study. Demographics details included age, weight, gravidity, parity, gestational week, estimated date of delivery, residence, socio-economic status, past obstetrics history complication, risk factor in current pregnancy were documented. After demographics details, pregnant women were asked about their acceptance for COVID-19 vaccination, In case of refusal of vaccination, the reasons and causes behind refusal were recorded. Data analysis was performed by using SPSS version 23.0. For quantitative variables mean and standard deviation was documented and for qualitative variables frequency and percentages were reported. RESULTS A total of 325 pregnant women were participated in this study. The mean age of the participants was 28.92 ± 5.18 years. The mean parity was 2.61±1.80. The mean gravidity was 3.66±1.86. The mean of estimated date of delivery was 27.45±3.58 weeks. The mean weight of participants was 73.48±11.46 kg. Women 42(12.9%) residing in rural areas and 283(87.1%) belonging to urban areas were ready to take the vaccine. About 81(24.9%) who never visited school were accepted the vaccination during pregnancy, 74(22.8%) women with matric level 74(22.8%) women who studied primary level, 39(12.0%) middle pass accepted the vaccination. Concerning profession, 209(64.3%) housewives and 51(15.7%) maid were aware about vaccination. Past pregnancies had complications such as 62(19.1%) participants had anemia, Pregnancy-induced hypertension 21(6.5%), Diabetes Mellitus 6(1.8%), Postpartum hemorrhage 17(5.2%), Preterm Birth 3(0.9%), Abortion 3(0.9%), 21(6.5%) had 1 Cesarean section, 30(9.2%) had 2 Cesarean section, 24(7.4%) had 3 Cesarean section. High-risk pregnancies such as anemia was reported in 133(40.9%) participants, gestational diabetes was reported in 6(1.8%) participants, Pregnancy-induced hypertension was reported in 6(1.8%) participants whereas most of the participants 177(54.5%) had no risk factor in pregnancy, as shown in Table I. When asked about their intention to receive the COVID-19 vaccine, 167(51.4%) participants indicated fear of pregnancy complications while 158(48.6%) had no fear. 170(52.3%) participants showed fear of complications related to fetus. About 65(20.0%) were concerned about the safety of the vaccine. Almost 57(17.5%) Participants did not accept vaccination due to their husbands refusal. Up to 35(10.8%) felt that social Distancing and implementation of Isolation means are enough to prevent the infection; however, most of the participants 290(89.2%) agreed that isolation methods and social distancing are not enough. In contrast to, 235(72.3%) believed that the COVID-19 vaccine can protect from infection only 90(27.7%) participants did not believe on the effectiveness of the vaccine, as shown in Table II.  DISCUSSION Vaccination programs can be implemented effectively only with high level of acceptance and coverage. Evaluating COVID-19 risk awareness is critical to attaining this, as considering the appropriateness of COVID-19 vaccination and reliance on the health system and media sources, mainly those used to acquire about the COVID-19 disease.23 One of the studies focused that the women living in rural areas have low rate of vaccine acceptance.24 This is troublesome as nearly 70% of the Indian people belong to rural areas.25 Therefore, delivery of proper evidence-based information is essential for awareness of the rural people. The present study was inconsistent with the above reported researches and showed that most of the participants 283(87.1%) were resident of urban areas had good information about COVID-19 vaccination. The educational level of pregnant women is an important predictor for their vaccination acceptance and their situation on professionals’ suggestions;26 On the contrary, one study by Mohan et al., in 2021 conducted in Qatar reported that vaccine acceptance is not dependent on level of education27 whereas Chinese research investigated pregnant women found that low education level was related with higher COVID-19 vaccine acceptance.28 As far as the present study is concerned, mostly participants had low education level but they were willing to accept COVID-19 vaccine. It was suggested in another research that most concerned priority related to vaccine is the protection of fetuses from the harmful effects of COVID-19 vaccines.26 An international research by Skjefte et al., in 2021 revealed that the main cause for COVID-19 vaccine hesitancy in pregnant women was the possibly detrimental adverse effects of vaccines for unborn babies.29 These findings were endorsed by the present study and revealed that majority of the participants 170(52.3%) had fear of complication associated with the fetus. Similarly, another most significant priority is the protection of pregnant women from the harmful effects of COVID-19 vaccines;26 these results were corroborated with the researchers  conducted in China and Turkey amongst pregnant women where safety of vaccine was a robust element of vaccine reluctance.28,30 These findings were consistent with the present study as most of the pregnant women showed vaccination hesitancy due to fear of pregnancy complication.  Interestingly, the role of partner is a critical element in acceptance of vaccines. Likewise, in one research, male partners have a positive attitude towards the COVID-19 vaccine acceptance among pregnant women.26 Furthermore, another study by Meharry et al., conducted in 2013 reported the negative role of husbands among pregnant women vaccine acceptance owing to inadequate acquaintance or lower vaccine application.31 In the present study, the role of husbands was positive 268(82.5%) in acceptance of COVID-19 vaccine among pregnant women due to awareness of consequences of COVID-19 infection. In spite of national programs to encourage vaccination against COVID-19, the rate of acceptance of vaccination for COVID-19 among Thai pregnant women was about 60%.32 This research was similar to the Vietnamese pregnant cohort in which 60% acceptance rate was observed.33 These findings were contradictory to other Asian countries with moderate socio-economic status wherein a higher acceptance rate was reported in Chinese (77%), Indian (82%), and Filipino (65%) pregnant women.28,29 The major cause for the low acceptance rates in Thai couples was the doubtful observation regarding the safety of vaccines, just because of detrimental effects related to vaccines transmitted to the fetus and mother as well. Moreover, an additional factor for vaccine refusal was the uncertainty of vaccine effectiveness. That research indicated that < 50% of the couples reported that they were assured about the effectiveness of COVID-19 vaccination. These results showed consistency with the effects of former researchers,28,33,16 advocated that the people anxiety of novel COVID-19 vaccines was an important hurdle to effective vaccination. Our results showed that most of the participants had fear of complications associated with fetus and mother and 90(27.7%) believed that COVID-19 vaccination is not effective to protect from infection. Similarly, one research assessed pregnant women who believed that the vaccine is potentially harmful for the babies eventually showed reluctance to vaccination.34 According to the CDC, the efficacy and safety of COVID-19 vaccination for pregnant women has been authentically proved.35 In addition to, ACOG reported no indication of complications related to mother or fetus from immunizing pregnant women with COVID-19 vaccines.36 Similarly, the WHO suggested that the Pfizer-BioNTech COVID-19 vaccine is an appropriate vaccine in pregnant women wherein the advantages of vaccination bypass the risks. Therefore, to make a decision, evidence about the risks of COVID-19 in pregnancy, the probable benefits of vaccination, and the prevailing boundaries of safety indication should be delivered.37 As far as the present study is concerned, majority of participants were reluctant for vaccination owing to harmful effects on mother as well as on baby. They also worried about the safety and efficacy of COVID-19 vaccination for pregnant women. Persistent public health campaigns, like educational television programs and awareness programs relevant to the safety of the COVID-19 vaccine in pregnant women, are mandatory to increase responsiveness. Further research are needed on safety and efficacy of the COVID-19 vaccine in pregnant women should be planned to overwhelming these difficulties and decline vaccine hesitancy. CONCLUSION This study concluded that despite the low level of education of pregnant women, most of the participants showed a positive attitudes and willingness to be vaccinated. However, the majority of pregnant women had fear of detrimental effects for the fetus and mother which were two major concerns among pregnant women when considering COVID-19 vaccination. Therefore, the representatives should promote, explore, and advertise significant information on vaccine effectiveness and safety among pregnant women because safety of the COVID-19 vaccine during pregnancy is a fundamental reason that leads to vaccine hesitancy. Conflict of interest: NIL Source of Funding: NIL Englishhttp://ijcrr.com/abstract.php?article_id=4541http://ijcrr.com/article_html.php?did=4541
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare An Evaluation on the use of Photon-Induced Photoacoustic Streaming in Root Canal Treatment English2629Khalifa A. AminaEnglish Hwisa A. SaraEnglish Introduction: The main purpose of endodontic treatment is to retain the involved teeth in the oral cavity for as long as possible by the prevention and elimination of infection in the root canal system. Irrigation of the root canal after instrumentation is a fundamental component of endodontic treatment success. It is mainly aimed to achieve debridement, smear layer removal, and disinfection of the entire root canal system. Recently, Photon Induced Photoacoustic Streaming (PIPS), which is an activation technique based on the using of Er:YAG (2.940nm) laser equipped with PIPS tip at sub-ablative energy levels, has been used to achieve this goal. Objective: Evaluate the ability of PIPS technique in removing smear layer and remnants. Material and Method: Review and summarize studies evaluated the effect of PIPS in root canal treatment. Results: Several in-vitro studies has been evaluated the evidence to support the benefit of PIPS technique over the traditional and other laser agitation techniques as an efficient method regarding removal of smear layer, remnants disinfection of root canal system and its benefits in other procedures. Conclusion: Photon-induced photoacoustic streaming in in-vitro studies seems to show better smear layer removal at coronal and middle thirds of root canal but not at the apical third, it has no superior effects compared with the other activation technique of endodontic solution. EnglishEndodontics, Erbium: YAG, Lasers, PIPS, Smear layer Introduction Removal of tissue remnant and smear layer produced by root canal preparation, in addition to the disinfection of the root canal system, represents a key role of successful endodontic treatment. 1 Traditionally, this goal is achieved by a sequence of procedures aimed at the treatment of the infected root canal and its three-dimensional tubular network, starting with a good, effective diagnosis and evaluation of the case, followed by traditional mechanical root canal enlargement by means of rotary instruments, removal of infected pulp tissue, smear layer (SL), disinfecting of the root canal by chemical disinfection agents and filling with biocompatible materials. 2, 3 Since the invention of the laser and the first research on using CO2 in endodontics by Weichman and Johnson in 1971,4 a considerable number of studies and experiments have been conducted to evaluate and investigate the benefit of lasers as an adjunct to root canal treatment.5, 6 The clinical use of lasers in root canal treatment was introduced by the development of the new delivery systems of lasers including thin and flexible fibers and endodontic tips in the late 1990s.7 This adjunctive application is primarily aimed to eradicate bacteria and their toxins and remove the pulpal tissue remnant and SL from the root canal.8 Photon-induced photoacoustic streaming, specific Laser-activated irrigation (LAI) technique, is based on the radial firing stripped tip with a laser of sublative evaporated at very low energies of 20 mJ at 15 Hz for an average power of 0.3 W at 50 μs impulses of the Er: YAG 2940nm.9 The impulses create an interaction of water molecules with peak powers of 400 W.10 This creates an expansion and successive shock waves lead to the formation of very powerful streaming of the fluid located inside the root canal, with no rising of temperature.11 The authors also stated that the energy conversion efficacy is larger when a conical fiber tip is used, with higher pulse energy and lower pulse duration.12 The newly designed radical quartz tip of 400µm diameter and 12mm long PIPS tip, stripped 3mm at its distal end, is not required to be placed inside the canal system itself but rather in the pulp chamber only. This reduces the need for using larger files and rotary instruments to create larger canal shapes to open the system Divito et al. 2012.13 The objective of this study was to evaluate the ability of the PIPS (Photon-Induced Photoacoustic Streaming) technique in removing smear layers and remnants from root canals. Materials and method Methods and Study Design; A literature search was conducted for the electronic database for the articles that addressed the effectiveness of use of PIPS technique in root canal treatment. The search keywords were; Endodontics, Er: YAG laser, Photon-induced photoacoustic streaming (PIPS), and the combination of PIPS with the other keywords. Primarily, titles and abstracts resulting from the electronic searches were screened. Thereafter, full-text articles were examined and selected according to the inclusion criteria. The reference lists of potentially included articles were also searched. Results and discussion Several studies were evaluated to define the benefit of using Photon-induced photoacoustic streaming (PIPS) in root canal treatment were these studies compared this technique to the traditional methods (Table 1). The PIPS technique was introduced by Olivi et al.13 as a revolutionary technology that eliminates the need of over enlarging the root canal size as the tip is not introduced into the canals according to the treatment protocol. Later in 2011 and 2012, Divito et al.14,15 conducted two in-vitro studies considering an apical root canal enlargement of ISO 20/0.06. They have studied the effect of different repetition rates of 10Hz and 15Hz. Their results showed that using of PIPs technique with these parameters to activate 17% EDTA for 20s and 40s has significantly removed SL. Furthermore, SEM magnification at 20,000X exposed higher opened dentinal tubules. One of the most significant findings of their work is the measurement of the temperature rise during irradiation. Thermocouples were utilized to conduct the temperature measurements which were found to be 1.2?C and 1.5?Cfor irradiation times of 20s and 40s, respectively. Even though they used an irrigant of 17% EDTA in the experiments, they compared their finding against conventional needle irrigation with saline. This is an obvious omission, and consequently, their results are questionable. The same great results were also achieved by using a combination of NaOCl and 17% EDTA as compared to using SNI technique.16 That is, the volume increase of canals treated with PIPS was found to be 2.6 times greater than that treated with SNI. The activation of 17% EDTA with PIPS, as compared to other activating techniques, showed 0% remaining Ca(HO)2 in canals of PIPS group, with significant superior effectiveness to SI (pEnglishhttp://ijcrr.com/abstract.php?article_id=4542http://ijcrr.com/article_html.php?did=4542
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Milling Fractions of Rice and Their Impact on Final Product Quality: A Review     English3642Farah ShamimEnglish Mohsin Ali RazaEnglish Misbah RiazEnglish Syed Sultan AliEnglish Samina SarfrazEnglish Saima TehseenEnglish Rice is rich in genomic variety with huge number of assortments developed everywhere. It is man’s most leading food sources. It supports two-third of the world’s occupants and is established in the social legacy of many associations. Above 90% of production and intake of rice on the planet happen in Asia and 87% is used worldwide. The volume of the worldwide rice trade has enhanced just about six overlap from 1960s to date. Around 80% rice are yielded by limited-scope ranchers and are consumed locally. Development of Rice needs to raise 40% by 2030 to meet the normal utilization need of individuals, which must be faced with reduce land and prohibitive water alongside the environmental change circumstances. Manipulation is the course to alter the grain into a structure adept for human utilization, hence, it must be achieved with outrageous consideration to stay away from breakage of the piece and extend the recovery extent. The present paper explains rice handling practices, its results and their importance with unique spotlight on dietary benefit and cooking quality. EnglishMilling, Rice, Quality, Cooking, Nutrition, By-products Introduction Rice (Oryza sativa L.) cultivating functions as the great kind of revenue for almost one billion people and offers the staple nourishment for 65% of world&#39;s masses, which is assessed to engender from 07-09 billion by 2050 and to get a handle on 10 billion preceding 2100 beating mass development testing advantageous 116 million tons of processed rice1. There are three center layers in rice seed, for example husk, grain and endosperm. Husk layer benefits in shielding the rice pieces from the bugs and growths assault. It is separated during operational process; the rice so acquired is called earthy colored rice which contains the grain layer and endosperm. The grain layer is composed of the pericarp, testa, aluerone layer and undeveloped organism (microorganism).2 Processing is a basic unit activity in handling of rice. The yield and nature of white rice got by paddy handling create the pay of rice producers. They are directly unforeseen of yield and paddy quality. The dirt, assortment, climatic conditions, applied invention underway and paddy management are the primary factors that impacts yield quality. For getting better produce, organization of suggested season of planting and reap with post-gather paddy the board is necessary. 3 According to genuine feeling as referred above, rice is the handled structure, which is prepared for cooking and paddy is the crude result from the field that require handling. Individuals can&#39;t eat paddy all things considered, expects to be appropriately handled. This essential interaction is the fundamental reason for the improvement of the paddy industry. In that way, the handling and processing of paddy is the most established and biggest agro-handling industry in our country. Whole creation (90 %) of paddy is manipulated into rice consistently by paddy handling units of fluctuating sizes and limits spread the nation over. Extra 10% of the paddy conveyed is warehoused as seed for next seasons gather. Exactness/and productivity of processing activity alongside grains conduct generally fix the market worth of grain. The minor effects of process are husk, microorganism, grain layers, and broken rice. It is a wonder of wear which includes eliminating material from strong surface either by mechanical activity or by combinations of different activities like rolling. Rice can be produced by two techniques for example scraped area processing and rubbing processing. 4 Economically, processing is a cycle comprising of different stages where paddy or unpleasant rice go through dehusking process first and afterward the external earthy colored grain layer is taken out during brightening technique. In the last, sticking wheat is totally removed from grain surface and this process is called cleaning. The different "stages of processing," alludes to the amount of grain and clean eliminated from earthy colored rice during processing. Techniques incorporate decides that how much grains are evacuated, the leftover excess endosperm, the compound arrangement of processed rice and wheat, and the actual characteristics of the processed rice.5 DOM, TRYand HRY: Level of processing is straightforwardly connected with the processing nature of the rice test. Quality of processing is commonly assessed as the all-out rice yield (Attempt) and head rice yield (HRY). Attempt is rates of absolute processed rice in light of the unpleasant rice weight. HRY can be characterized as the proportion of weight of processed rice bits found in rate to the heaviness of unpleasant rice or paddy in rate. As a rule, over?milling or processing for a more drawn-out term brings about low Attempt and HRY, with practically no further improvement in the whiteness or level of processing. Interestingly, under-milling or more limited span processing could bring about high Attempt and HRY, and produce a more obscure appearance and high lipid content in the processed rice. 6 The two over-milling and under-milling are bothersome since they produce unfortunate item that doesn&#39;t mirror the possible quality in business processing. Rice yield and processing quality together decide the financial worth of rice from the field to the plant and on the lookout. Each rice assortment displays different processing yield and level of processing rate at all cleaning time stretches as examined by assorted specialists. While expanding in degree of processing in cleaning time there is decline in processing yield and expansion in DOM. Processing yield and level of cleaning relies upon the sort of polisher and cleaning conditions. It&#39;s undeniably true that the volume of wheat fluctuates as indicated by assortment, states of climate and rural practices in the district, essential of processing degree changes with rice grains. 7 Processing shocks in any stage influence rice quality in later stages. Maker income relies upon the offer of paddy (natural) rice and mill operator income relies upon the offer of processed rice and side-effects to homegrown and worldwide business sectors. 8 In certain nations, level of processing is certifiably not a significant record of rice quality, while certain locales like Iranians like to consume rice with high whiteness.9 Rice parts which are 3/4 or more long when contrasted with length of unique bits acquired after complete processing is named as head rice. Head rice is 2 to multiple times costlier than of broken rice. Consequently, need of rice processing industry is to boost the amount of head rice with favored degree of part whiteness. HRY for short grain was viewed as more noteworthy in contrast with that of the long grain in light of the fact that during processing short grain assortments experienced less breakage than the long grain assortments. During processing, higher breakage is caused because of low surface hardness which thusly prompts inferior quality and recuperation. The earthy-colored rice is scoured between the outer layer of a grating cone and a sifter fitted with a bunch of elastic brakes. In the frictional sort machine, earthy colored rice pieces are scoured against one another under the gun to get the ideal whiteness. The course of grain expulsion in business processing is through extreme tension and erosion in a solitary or different disregard activity an exceptionally brief timeframe. 10 Youthful, pasty, fissured, excessively wet, and too dry grains typically are more defenseless to breakage in processing stage.11,12 It has additionally been cited by numerous researchers that bring down the level of processing, more noteworthy is the yield of head rice. Typically, the cost of broken processed rice is simply 30 to half of the cost of head processed rice. 13,14 Great quality rice has HRY of somewhere around 70%. Processing quality extraordinarily impacted by temperature incorporate whiteness, youthful portions, piece aspects, fissuring, protein content, amylose content and amylopectin chain length. 15, 16, 17 Effect of Moisture content on DOM: Changeability of processing yield increments and its sum is decreased when the rice is reaped with lower dampness content. Too soon or past the point of no return reaping of rice prompts emerge the more youthful or broken pieces, in this manner bringing about more broken processed rice. 18 There is an ideal reap time for each rice cultivar to acquire the most noteworthy all out processing yield with the least processed rice breakage. Most extreme head rice recuperation for Basmati 370 and IR 6 cultivars are accomplished at 34 Days Subsequent to Blooming (DAF) and for Basmati 198 cultivar at 40 DAF. Level of broken rice and head rice yield are essentially impacted by dampness content prior to processing. 19 Rice assortments with higher length are more defenseless to breaking and breakage during processing. 20, 21 Legitimate collect season of rice in type of the paddy dampness level at reaping time. General scope of reasonable gather dampness content went from 19 to 22% and 22 to 24% for a really long time and medium grain cultivars, separately.22 Gathering the rice a couple of days before development no affects the piece fissuring, however delays in collect time brought about huge rice parts fissuring (up to 24% of complete earthy colored rice), contingent upon the paddy cultivar. 23, 24 Fissuring can happen in the field before collecting, handling and capacity. Impact of dampness content in paddy at gather and capacity is critical on yield and nature of white rice, particularly in characterizing the particular proposals when reap the executives with yield and nature of white rice in various rice assortments. For the most part, the gather is directed when the normal dampness content in grain is underneath 18%. The ideal time for reap is the point at which the dampness content in grain is somewhere in the range of 18 and 20 %. Ideal gather dampness content for long-grain cultivars by and large is gone from 18 to 22 % and 19 to 20 % for medium-grain cultivars. Reap under 20 % dampness content of grain builds the level of grain breakage of all assortments with short and medium grain. 25, 26 Nutritional Value of Milling By-products: Processing process get changes compound synthesis, for example, the convergence of sugars, amino acids, nutrients, minerals and fats alongside changes in natural exercises like amylase or peptidase exercises. Rice is generally made out of carbs 80%, with little protein 6-7%, minerals, fats, and so forth. The proteins present in rice are especially nutritious, wealthy in fundamental amino corrosive lysine and hypoallergenic for use in food varieties. Yet, supplements in the rice portions are not consistently appropriated. Certain supplements like fats, nutrients, proteins and minerals are found in great fixation in microbe and external layers of endosperm for example wheat piece of portions. 27 Rice seeds have component of protein, starch, oil, salt and fiber in them which are generally the requirements of human body. Besides, rice additionally contains an adequate number of nutrients B, E and G. Nutrients are essential components of food sources. Sadly, the greater part of these nutrients are lost with the husk when processed, the sinewy front of the rice seed. Natively husked rice holds a portion of these nutrients. In any case, clean eliminates every one of the nutrients from rice. 28 Misfortune in processing is regularly because of the abuse of hardware and so forth which frequently prompts high breakage of grain. The DOM affects the grouping of supplements. The specialists viewed that as 84.2% of part proteins are moved in external endosperm and after processing further the grouping of proteins decline. 61% of the greater part of the minerals are available in wheat part of the pieces while the center of endosperm portion primarily comprises of starch (84.6%) in the bits. During processing tasks, these supplements are eliminated in this manner lessening the nutritive worth of starch. 29, 30 Misfortunes on cleaning are 29% of the protein, 79% of the fat. The distinction in the protein content between the two rice which is around 2g/100g may not at first right have all the earmarks of being huge, but rather a computation shows that it could be vital. Examination of mineral piece of husked and cleaned rice showed that the mineral substance diminished in the cleaned rice. 31 Earthy colored rice has high dietary fiber (a delicate purgative, forestalls gastro-digestive infections and really great for diabetes victims); plentiful in B nutrients and minerals (forestalls beriberi); and high in fat (energy source). Likewise, it has been accounted for that earthy colored rice contains high phytic corrosive (cell reinforcement, against malignant growth); it diminishes serum cholesterol (forestalls cardio-vascular infections); and it is viewed as a low glycemic record food (low starch, high complex carbs which diminishes hazard to diabetes). The upgrade of rice supply is one more benefit of earthy colored rice comparative with cleaned or white rice. 32 Water take-up and length development proportions are for the most part affected by DOM. Rice is said to ideally cooked when it arrives at an end point for example at the point when the rice bits have retained water to the maxima or the white center of rice bits has been gelatinized during cooking process. Supplements are packed chiefly in the microorganism and wheat layers of the rice grain. Supplements are eliminated with wheat and endosperm. White rice is ordinarily consumed worldwide however with developing wellbeing cognizance earthy colored rice or to some extent processed rice has begun acquiring significance. 33 As a general rule, rice grain contains various supplements, including fiber, minerals and nutrients, as well as wellbeing advancing bioactive phytochemicals like phenolics, flavonoids, a-oryzanol, tocopherols, ferulic corrosive, phytic corrosive and tocotrienols. 34, 35 Rice lipids, usually meant as oil (&#39;rice wheat oil&#39;) because of its fluid person at room temperature, are portrayed by a high healthy benefit. The high extent of unsaturated fats, representing up to 80 %, causes the fluid consistency of the oil. Protein is the second generally plentiful constituent of rice. The rate of misfortune in fat substance at progressive processing stretch contrasted altogether in various rice cultivars. 36 The decrease in fat substance with expansion in processing time could be connected to the expulsion of grain layer from the rice cultivars where the majority of the fat is concentrated. 37 Rice protein is of exceptionally top-notch contrasted with other food crops. Rice is healthfully better than numerous different food varieties that are wealthy in carbs. It is packed in the undeveloped organism, aleurone and subaleurone layers of endosperm than the inward endosperm.38 The grain establishes a greater amount of the external layers including aleurone layer, while the clean part contains generally a greater amount of subaleurone layers. Notwithstanding, the grain delivered in the plant would constantly be a composite combination of external and some portion of the endosperm layers. The dispersion of protein across the layers appeared to be impacted by high or low protein rice assortment. The progressive grating processing of chosen rice assortments showed that the clean portion (5-11% DOM) was the protein-rich part. Processing portions are delegated grain (0-6%), subaleurone-clean (6-12%) and subaleurone (12-20%) layers.39 The level of protein with processing length portrayed negative relationship, which showed higher protein content could be held by bringing down the time span of processing. The processing time as long as 60 seconds brought about the higher deficiency of 31 % protein content. 40 The protein part of the grain, in spite of the fact that to outrageous varietal and natural changing capacity, midpoints around 7 % in treated rice and 8 % in earthy colored rice. The amino corrosive equilibrium of rice protein is incredibly better. Lysine substances, for instance, midpoints around 3.8 to 4.0% of the protein.41 The amino corrosive profile of rice shows that it is high in glutamic and aspartic corrosive, while lysine is the restricting amino corrosive. Because of its significant degree of unsaturation, rice grain oil is known to have blood cholesterol bringing down impacts. The major unsaturated fats in rice oil are oleic corrosive (a monounsaturated corrosive) and linoleic corrosive (a fundamental polyunsaturated unsaturated fat). 42 The sugar content of rice cultivars at each progressive phase of processing are found to increment. It tends to be estimated either as an entire or as a measure of amylose content. The expansion in sugar satisfied with expanding the level of processing in rice portions. 43, 44 Carb are available chiefly as starch in rice parts that is gathered in the endosperm and the processing of rice up to different stages builds the starch content because of the expulsion of the grain and microbe from the rice kernels.45 The higher amylose content in processed rice takes up more water after cooking subsequently prompting expanding length of rice pieces. The higher prolongation proportion after each processing stretch might be related to the comparing decline in protein content as higher protein content pre-assumes higher gelatinization temperature and will in general upset the cooking of rice.46 The rice bits stretch the long way or expansiveness insightful subsequent to cooking in this manner giving better or coarse appearance to it. The extension proportion of the exploratory rice cultivars was found to increment at each progressive phase of processing span. The increment in extension proportion after each, processing term could be credited to increment in carb or amylose content and diminishing in fat substance. An intriguing converse relationship was seen between the amylose content of the rice and the wheat fat substance. detailed a comparable pattern in wheat fat substance with three rice assortments shifting in amylose content. 47 Most of analysts have taken a gander at unrefined fiber, which is a proportion of cellulose and lignin while dietary fiber is the genuine proportion of healthful advantages. Dietary fiber includes polysaccharides, oligosaccharides, lignin and related plant substances These are named dissolvable and insoluble, in light of their water dissolvability. The complete dietary fiber content of grating factory grain went from 24.0 to 50.1%, which is a lot higher than the grinding plant wheat that ran somewhere in the range of 19.9 and 40.3% at various DOM. The higher fiber content in rough factory grain can be ascribed to the moderately lesser endosperm breakage and thusly lower pollution with starch. The dietary fiber content of wheat from the two sorts of processing showed a diminishing pattern with the expansion in DOM. 48 Studies have shown that the external layers (wheat) of the rice grain have the most noteworthy centralization of debris content and it diminishes towards the focal point of the grain. Rice grain is the most plentiful wellspring of oryzanols those are related with numerous physiological capacities and medical advantages. 49 The oryzanol content went somewhere in the range of 1.3 and 1.8% in the removed oil from modern factory wheat. Among the assortments, the pigmented assortment had least oryzanol content in concurrence with a related study.50 Rice grain contains the most noteworthy measure of lysine (fundamental for protein amalgamation) which is by and large inadequate among every one of the cereal wheats and principally has hypoallergenic protein parts with a few gainful dietary properties. Similarly, somewhat processed rice with long grains is liked by Americans, while scented Basmati or Jasmine rice is enjoyed by Asians. Very much processed white rice is liked by individuals of the Indian subcontinent. As how much wheat fluctuates as indicated by assortment, states of climate and rural practices in the area, necessity of processing degree shifts with various rice grains. 51, 52 Lately, pigmented rice arrangements stand apart inferable from their high cheerful of polyphenols, minerals, supplements and different natural activities. The wheat layer contains polyphenols and anthocyanin, and has malignant growth anticipation specialist properties. The internal piece of red and white rice is indistinct and white. The zinc and iron substance of red/gritty shaded rice is 2-3 times higher than that of white rice.53 Histological investigations proved that the greater part of the oil in rice is available as particular globules in the aleurone layer. The fat substance diminished with expansion in DOM in both erosion and rough processing because of the expanded flood of starch from endosperm at higher DOM. With a huge expansion in DOM from 0.3 to 9.0%, fat substance in rice part decreased to the degree of 84% by rubbing processing. 54,55 Effect of Milling recovery on cooking quality of rice: It is undeniably challenging to normalize an approach for cooking rice as well as its degree of processing. There are varieties in the individual decisions from one locale to another like Japanese and Chinese favor tacky rice however Italians consume rice having high amylopectin content, for example, Baldo and Arborio rice. Asian favor nontacky rice having medium Amylose like Basmati. These assortments are short grained which supplies starch during cooking making it a smooth and rich. The protein content of grating factory wheat went from 15.8 to 20.9%, which was higher (4-35%) contrasted with grinding plant grain that ran somewhere in the range of 13.6 and 18.5%. The distinction could emerge because of the processing standard engaged with the factories. 56 The main characteristics of rice grains, for example, grain thickness plays a significant part in deciding the cooking and surface ascribes related with rice grains, generally more thickness rice grains will have higher processing degree, lesser amylose content and higher cooking length. 57 In grinding processing, the wheat protein content diminished with expansion in DOM, as it for the most part eliminates the outside grain layers and less of the subaleurone layer. Further, the destroyed protein part could be connected with the abundance of endosperm breakage during the process. The little broken shifted from 1.8% to 3.6% at 5% DOM and 8.6 to 13.8% at 10% DOM prompting moderate weakening of grain part with starch. Among the assortments, the less in wheat protein content is somewhere in the range of 5 and 10% DOM.58 Discussion: Processed rice quality is resolved principally by deciding its Level of Processing (DOM). It very well may be characterized either by estimating the excess measure of grain on the surface of manipulated rice pieces. It shows that short grains can stream all the more effectively in a processing chamber following rubbing kind of processing when contrasted with long grains. It has been seen that bring down the level of processing, more prominent is the yield of head rice. In a review, Koshikari assortments of rice were exposed to low DOM (2-5%) and it was seen that it not just better the HRY of the entire bits yet additionally diminishes the utilization of energy expected in the general interaction. This likewise showed more maintenance of food supplements like lipids and dietary strands in low-processed rice. to further develop the cooking quality, it is essential to pick a reasonable level of processing, for every cultivar which can help in diminishing misfortunes during cooking.59 The piece size gets diminished during processing and gelatinization temperature at DOM (20%) diminished cooking time for various assortments of rice. The warm properties of rice are viewed as reliant of the assortment and the states of handling which thusly additionally influence its cooking quality. Shoppers lean toward rice with uniform shape and clear endosperm. Factors influencing head rice yield and pallor in indica rice.60 HRY, characterized as the proportion of head rice to unpleasant rice, is a significant boundary utilized in processing industry. Market worth of head rice is higher than broken rice grains. Low pastiness which is related with more clear rice alongside HRY decides the cost of rice in practically all business sectors. The normal HRY of 39 assortments created by the Worldwide Rice Exploration Establishment (IRRI) was around 51.27% and 43.79% in DS and WS, individually. Notwithstanding, HRY has stayed at around 60% throughout recent years in US. Hence, HRY is one of the first concerns for rice rearing. During rice processing, harmed, pale and broken rice bits are typically isolated from head rice and the resultant processed rice is reviewed. This large number of variables are accepted to influence rice end-use usefulness. 61 Processed rice is evaluated in view of a few measures, one of which is the level of broken portions in the aggregate sum of processed rice. Notwithstanding, to give purchasers great rice, processed rice typically contains something like 10% of seed, paddy parts, or unfamiliar materials either independently or joined with under 4% broken portions. Processed rice with a lower level of broken rice parts ordinarily has a more noteworthy monetary worth. This is presumably on the grounds that most of rice, as head rice, is straightforwardly utilized by purchasers while broken rice is typically utilized in handling different items. 62 Conclusion: Serious issue in the rice handling industry in Pakistan is that just with regards to half of the whole paddy creation is handled by present-day plants and the excess by wasteful conventional hullers prompting extensive post-gather misfortune or handling misfortune. In this manner, there is a sensible extension for enlarging the development of the rice handling industry and lessening post-gather misfortunes with reasonable mediations and modernization. Likewise, the fundamental target of current rice processing is to eliminate the frame, grain and microbe with least breakage of endosperms Acknowledgment: Corresponding author is thankful to all authors for contribution in manuscript formatting, proof reading and reference writing. Further 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: This review paper was prepared for the Punjab Agriculture Research Board funded research project. Conflict of Interest: There is no conflict of interest Authors’ Contribution: The authors confirm scorporate responsibility for the following: study conception and design, data collection, analysis and interpretation of results, and manuscript preparation. Englishhttp://ijcrr.com/abstract.php?article_id=4543http://ijcrr.com/article_html.php?did=4543
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Respiratory Morbidities and Neurodevelopmental Outcome in Preterm Infants of Mother Exposed to Antenatal Corticosteroids       English4351Mosammad Alpana JahanEnglish Rabeya SultanaEnglish Tarun Kumar RoyEnglish Sanjoy Kumer DeyEnglish M. A. MannanEnglish Mohammad Kamrul Hassan ShabujEnglish Ismat JahanEnglish Sadeka Choudhury MoniEnglish Mohammod ShahidullahEnglish Introduction: Each year, about 15 million babies are born preterm, and 1 million babies die due to complications of preterm birth. Antenatal corticosteroid is one of the most effective evidence-based interventions that can reduce mortality and morbidity in preterm newborns. Objective: The purpose of this study was to evaluate the effect of antenatal corticosteroids on respiratory morbidities and neurodevelopmental outcomes among preterm neonates. Methodology: This prospective cohort study included admitted premature infant’s ≤ 34 weeks. Infant’s baseline demographics and maternal history of complete ACS exposure or no exposure were evaluated. The development of respiratory morbidities with support was compared between two groups during the neonatal period. After discharge from the NICU, neonates were followed up to assess neurodevelopment at 3rd and 6th months of age using Bayley Scales of Infant Development (BSID-III). Analysis was done to see the relationship with ACS exposure. Results: A total of 82 neonates were enrolled. Among them, 44 neonates in the ACS exposed group and 38 in the ACS unexposed group were assessed for the development of respiratory morbidity. Only 9(20.5%) in the ACS exposed group and 28 (73.7%) in the ACS unexposed group developed respiratory morbidities. Respiratory support with duration was also needed more in the ACS unexposed group. Neurodevelopmental assessment at 3 months was significantly lower in all three domains between the ACS exposed and unexposed groups: cognition (81.67±7.58 vs. 73.50±10.16: p-English Introduction Under-5 mortality rates are declining in many countries worldwide.But the decreasing trend in newborn mortality has been considerably slower. Currently, prematurity is the leading cause of death among children under five around the world, also a leading cause of disability and ill health later in life. According to the World Health Organization (WHO), about 15 million babies are born preterm each year and about 1 million babies die each year due to complications of preterm birth.1 Bangladesh is one of the top ten countries with the highest number of preterm births in 2010 (424,144 preterm births), around 2.8% of the global preterm burden and 14.1% nationwide.2 Data from the 2017-18 BDHS shows that under-5 mortality in the five years preceding the survey is 45 per 1,000 live births. The infant mortality rate is 38 per 1,000 live births and during infancy, the neonatal mortality rate is 30 per 1,000 live births. Deaths in the neonatal period account for 67 percent of all under-5 deaths.3 Preterm babies may have numerous respiratory complications. The most common respiratory disorders are respiratory distress syndrome, pneumonia and transient tachypnea of the newborn.4 Approximately one-third of preterm survivors also suffer from severe long-term neurological disabilities, such as cerebral palsy or mental retardation.5 Furthermore, preterm infants carry an increased risk of a range of neurodevelopmental impairments and disabilities including behavioral problems, school learning difficulties, and lower growth attainment.6 Early recognition of a delay in neurodevelopment implies that early intervention would have beneficial effects on their development. Antenatal corticosteroid administration has been identified as one of the most important antenatal therapies available to reduce respiratory distress and improve neurological morbidity and mortality in the preterm.ACOG in 2017, 7 and WHO 1 recommended for mothers with gestational age between 24 0/7 weeks and 34 0/7 weeks, 6 mg of Dexamethasone intramuscular (IM) at 12 hours interval for a total of four doses, or 12 mg of Betamethasone intramuscular (IM) at 24 hours interval for a total of two doses, the last dose should be given at least 24 h prior to delivery. This has since then been confirmed in numerous studies. According to the systematic review of 21 studies treatment with ACS is associated with an overall reduction in neonatal death, RDS, IVH, NEC, respiratory support, Intensive care admission and systemic infection in the first 48 hours of life.8 The first randomized control trial of antenatal betamethasone by Liggins and Howie showed reduced mortality rates and respiratory distress syndrome (RDS) in premature infants.9 This antenatal therapy should be considered not only because of the pulmonary maturation but also for its protective role in the premature infant’s brain. Western studies have found antenatal steroid therapy is very effective in preventing neonatal morbidity, but there is little evidence that ACS affects long-term neurodevelopmental and behavioral outcome in 28- to 32-week survivors.10 The use of antenatal corticosteroids has become standard care in cases of imminent or anticipated preterm delivery. In high-income countries, they used antenatal steroid in nearly 90% of cases where indicated, but in low-income countries coverage rates are estimated at 5% in Africa and 9 – 73% in SE Asia 11,12. WHO-recommended antenatal corticosteroids for improving preterm birth outcomes are currently included in Bangladesh’s clinical standards of preterm care at the hospital level. Although the majority of research shows that antenatal corticosteroids protect against respiratory morbidity and mortality, there are scarcity of data in our country that explore the impact of antenatal corticosteroids on respiratory morbidity and neurodevelopmental outcomes. Materials and methods This prospective cohort study was conducted in the Department of Neonatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from July 2018 to June 2019. After taking informed written consent and IRB clearance a total of 82 admitted premature infants with gestational age ≤ 34 weeks whose mother got a complete course of ACS or premature infants whose mother didn’t took any course of ACS were the study population. Hospitalized inborn and outborn babies were included consecutively. Newborn whose mother received an incomplete dose of antenatal corticosteroids or with congenital anomalies, syndromic manifestations or chromosomal malformations and suspected inborn errors of metabolism were excluded from the study. Death within 24 hours of admission in NICU in both ACS exposed and ACS unexposed group were also excluded. Infants’ baseline demographics including gestational age (GA), birth weight (BW), small for gestational age (SGA), gender and perinatal characteristics including place of delivery, mode of delivery, Apgar score at 5 minutes, maternal characteristics including parity, hypertension, diabetes mellitus, presence of risk factors of preterm delivery were collected from history sheet. Birth weight was recorded from labor room or neonatal referral sheet in case of outborn infants. If the neonate was admitted within 6 hours of birth, his/her admission weight was taken as birth weight. Admission weight was taken by a digital weighing scale (SALTER, Model-914). Gestational age was assessed by LMP, sonographic findings and modified new Ballard scoring. In the place of study obstetrician practices inj. Dexamethasone 12.5mg IM 12 hours apart two doses. So in this study, this schedule was taken as a complete dose of ACS. After admission in NICU, neonates were followed up for the development of any respiratory morbidity, if developed relevant investigations and treatment was given according to institutional protocol. Respiratory morbidities were the occurrence of neonatal respiratory disorders: respiratory distress syndrome, pneumonia, TTN or delayed adaptation. Duration with types of support were also analyzed in relation with ACS exposure. After discharge from neonatal unit babies were followed up for neurodevelopmental evaluation at 3 and 6 months of age by appropriately trained clinical psychologists, who were blinded to the child’s neonatal information. Children who attended at least one follow-up study visit were included in the study for analysis. To evaluate development, Bayley Scales of Infant Development (BSID-III), was administered in a calm environment. In the Bayley-III, cognitive development, expressive and receptive language, and fine and gross motor development all were evaluated. Development was classified “normal” if the score is above 85 and “at risk/delayed” if the Bayley III score was below 85 on any of the language, cognitive, or motor scales. Composite scores were analyzed in this study. Methods of data processing and statistical analyses: All quantitative data were expressed as the mean ± standard deviation. Demographic, perinatal variables, clinical outcome were compared between two groups (ACS exposed and ACS unexposed) using Chi-Squared test for categorical variables and an Independent-t test were applied to calculate the significance in differences of quantitative variables between two groups. Univariate analysis was performed to determine the independent effects of antenatal corticosteroids on neurodevelopmental outcomes. The statistical analyses were performed with the use of SPSS version 20.p-value of equal or less than 0.05 was considered statistically significant. Results During the study period, 130 eligible preterm infants ≤ 34 weeks gestation were admitted in the Neonatal Intensive Care Unit, BSMMU. A total of 82 neonates were enrolled. Flow chart of participants in the study is given in Fig-1. Demographic and baseline characteristics of studied infants were presented in table-1. The ACS exposed and ACS unexposed group had similar baseline characteristics, mean gestational age of ACS exposed and ACS unexposed infants were 32.59±1.58 weeks and 31.95±1.59 weeks, mean birth weight were 1665.57±398.53g and 1510.13±377.92g, respectively. Gender distribution reflects female predominance in both groups (52.3% vs. 47.7% and 52.6% vs 47.4%). It was observed that inborn received more ACS than outborn. Nearly two-third of studied infants was inborn. Neonates who were exposed to ACS were more likely to be small for gestational age. The comparison of maternal data in ACS exposed and ACS unexposed group was presented in Table 2. Cesarean section was the mode of delivery for more than half of the enrolled premature infants. Among the enrolled premature newborns singletons are more in ACS exposed group than ACS unexposed group (97.7% vs. 78.9%, p- 0.007). Maternal hypertension was present 24(54.5%) in ACS exposed infants as compared to 19(50.0%) in ACS unexposed group, however the difference was not statistically significant (p=0.681). In the distributions of the main reason women were considered at risk of preterm birth between the mothers who received corticosteroids and those who did not receive them, more women who received antenatal corticosteroids had premature rupture of membranes (47.7%). Among 82 enrolled neonates, 37 neonates developed respiratory morbidities (Table-3). Of them 9 neonates were exposed to ACS and 28 were unexposed (p-Englishhttp://ijcrr.com/abstract.php?article_id=4544http://ijcrr.com/article_html.php?did=4544 1. Blencowe H, Cousens S, Oestergaard MZ, Chou D, Moller AB, Narwal R. National, regional, and worldwide estimates of pre-term birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. The lancet. 2012 Jun 9; 379(9832):2162-72. 2. Definitions W. South East Asia Regional Neonatal-Perinatal Database. World Health Organization (South-East Asia Region) Available from-http://www. Newbornwhocc. Org/pdf/database. Pdf. Accessed-February. 2016 Feb;25. 3. NIPORT I. Bangladesh demographic and health survey 2017- 18: key indicators. Dhaka, Bangladesh, and Rockville, Maryland, USA. 2019. 4. Wang ML, Dorer DJ, Fleming MP, Catlin EA. Clinical outcomes of near-term infants. Pediatrics. 2004 Aug 1; 114(2):372-6. 5. Lawn JE, Cousens S, Zupan J. Lancet Neonatal Survival Steering Team. 4 million neonatal deaths: when? Where? Why? The lancet. 2005 Mar 5; 365(9462):891-900. 6. Saigal S, Doyle LW. An overview of mortality and sequelae of preterm birth from infancy to adulthood. The Lancet. 2008 Jan 19; 371(9608):261-9. 7. American College of Obstetricians and Gynecologists, Committee on Obstetric Practice. Committee opinion no. 677: antenatal corticosteroid therapy for fetal maturation. Obstetrics and gynecology. 2016 Oct; 128(4):e187-94. 8. Gomella TL, Cunningham MD. Neonatology 7th Edition. McGraw-Hill Prof Med/Tech; 2013 Jul 21. 9. Liggins GC, Howie RN. A controlled trial of antepartum glucocorticoid treatment for prevention of respiratory distress syndrome in premature infants. Pediatrics. 1972 Oct 1; 50(4):515-25. 10. Foix-L’Hélias L, Marret S, Ancel PY, Marchand L, Arnaud C, FressonJ. Impact of the use of antenatal corticosteroids on mortality, cerebral lesions and 5?year neurodevelopmental outcome
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Anti-diabetic Effect of Ethanolic Extracts of Cissus Quadrangularis linn Fruits and Michelia Champaea Leaves in Alloxan Induced Hyperglycaemic Rats and in 3T3L1 Cell Lines     English5259Jasti DeepthiEnglish D. V. R. N BhikshapathiEnglish Palanati MamathaEnglish Puttaswamy NirmalaEnglish Background: Diabetes is a metabolic disorder that results in increased blood sugar. This study came up with a search for alternative medicines with no or fewer side effects for antidiabetic therapy. Materials and methods: The plants are extracted and screened for the phytochemical study of crude extracts. Anti-diabetic activity in alloxan-induced hyperglycaemic rats, in a single-dose study, multiple-dose treatment was investigated. In vitro cellular assay using 3T3L1 cell line was performed to check the cell viability with increasing plant extract treatment. Results: Phytochemical investigation reveals the presence of alkaloids, flavonoids, saponins, tannins, steroids, triterpenoids, carbohydrates, and glycosides in both plant extractions. In acute toxicity studies, no mortality was observed with either of the extracts even at a dosage of the level of 5000 mg per kg of body weight. The ethanolic extracts showed a noteworthy decline in blood glucose level in alloxan-induced rats in both single and multiple dosage methods. Significant changes were observed in the serum glucose and body weight from day 0 to day 14. The cell viability of the extracts was also comparable with the standard. Conclusion: Our results report that CQ fruits and MC leaves have potent antidiabetic action and on further studies, can be a credible resource in antidiabetic therapy. EnglishCissus Quadrangularis Linn Fruits, Michelia Champaea Leaves, Anti-diabetic activity, 3T3L1 cell line, Cyototoxicity, Wistar rats. INTRODUCTION Diabetes mellitus (DM) is a syndrome characterized by chronic hyperglycemia and disturbances of carbohydrate, fat, and protein metabolism associated with absolute or relative deficiencies in insulin secretion and/or insulin action1. It is a metabolic disorder comprising of micro and macrovascular complications that result from insignificant morbidity and mortality. It is a major cause of death worldwide 2. There are an estimated 143 million people worldwide diagnosed with DM and this number will probably double by the year 2030 3. Despite significant advancement in the treatment of DM using oral hypoglycemic agents, exploration for newer drugs continue due to several limitations of synthetic drugs. In recent times, there has been a renewed interest in plant remedies 4-5.  The medicinal properties of CQ were known since the distant past. Cissus was also used in ayurvedic medicines for treating injured bones, ligaments, and tendons. In Siddha medicine CQ finds its application as an analgesic, and in treating broken bones. The Magnoliaceae belong to the fossil plant family dated back to 95 million years. These are characterized by large, cup-shaped flowers with no distinct petals. Some species, including the champak (Michelia champaca) and Michelia doltsopa are grown for their flowers, both on the tree and as cut flowers. Champak flowers are also used to produce essential oil for perfume. A few species have been introduced to gardens or as street trees outside of the Indomalaya region, including Michelia figo, M. doltsopa, and M. champaca6-8.  The current paper deals with a screening of Cissus quadrangularis linn fruits and Michelia champagne leaf extracts for anti-diabetic activity in alloxan-induced hyperglycaemic rats. MATERIALS AND METHODS Materials Experimental Animals Adult Wistar albino rats (150-200 g), housed in the institutional animal house and used for the study. Animals caged in polypropylene cages in a controlled environmental condition (22± 30C, 55 ± 5% humidity, and a 12 h light/ dark cycle). The animals were provided with a regular rodent diet and water ad libitum. The animals were allowed to adapt to these conditions for a week.  Methods Plant collection and authentication  The CQ fruits and MC leaves were obtained from the local places of Tirupati, AP. The CQ fruit was authenticated by Dr. K. Madhava Chetty, M.Sc., M.Ed., M.Phil., Ph.D., PG DPD., Assistant Professor, Department of Botany, Sri Venkateswara University, Tirupati, Andhra Pradesh. Extraction by maceration Fresh leaves of MC and fruits of CQ were washed with water to get rid of contaminants like dirt and other impurities and were shade-dried. These dried leaves and fruits were ground and sieved to get a uniform, coarse powder. Powdered plant material was weighed (1Kg) and immersed in 95% ethanol and kept for maceration for 7 days with occasional stirring. On the 8th day, the solvent was filtered by pressing with a muslin cloth and was evaporated in a rotary evaporator at 40oC. The resultant extract was put in a desiccator to remove any ethanol left in it. The dried ethanolic extract of Michelia Champaea (EEMC) and ethanolic extract of Cissus Quadrangularis (EECQ) were packed in an air-tight bottle and put in a dry place for further studies. Qualitative evaluation of phytoconstituents The EECQ were screened for the presence of various phytoconstituents like carbohydrates, flavonoids, polyphenolic compounds, saponins, tannins, triterpenoids, etc. Cell culture 3T3L1 cell line was procured from the National Centre for Cell Science, Pune. Cells were cultured in Dulbecco’s Modified Eagle Medium (DMEM) (high glucose) with 10% FBS (Invitrogen, Canada), 10,000 U Penicillin G, 10,000 μg/mL streptomycin sulfate (Invitrogen), and 10 mM 4? (2?hydroxyethyl)?1?piperazineethanesulfonic acid. Cultures were maintained at 37°C in 5% CO2 in a humidified incubator. 3?(4, 5?dimethylthiazol?2?yl)?2,5?diphenyltetrazolium bromide assay 3?(4, 5?dimethylthiazol?2?yl)?2, 5?diphenyltetrazolium bromide (MTT) assay is a colorimetric assay to determine the toxicity of a compound on the cells based on the conversion of MTT to formazan crystals by the lactate dehydrogenase present in live cells 17,18. The 3T3L1 cells were seeded at an initial density of 20 × 104 cells per well/200 µL in 96 “well” plate and cultured overnight. The cells were then treated with desired concentrations of plant extract (25–400 µg/mL) for 24 h in the same culture conditions. Post-treatment, the medium was aspirated, 0.5 mg/mL of MTT reagent was added to cells and incubated at 37°C for 2 h. MTT reagent was then removed, and formazan crystals were dissolved with 20 µL of dimethyl sulfoxide (DMSO). Absorbance at 570 nm was measured by a microplate reader. Percentage viability was determined using the formula: Evaluation of anti-diabetic activity 9, 10 For the study of the anti-diabetic activity of various extracts of EEMC and EECQ, the study was divided into two phases I) Activity in normoglycaemic animals       II) Activity in alloxan induced hyperglycaemic rats                                    a) Single-dose study                                    b) Multiple-dose study (14 days treatment) Activity in normoglycaemic animals Method of oral administration of extracts An 18-gauge needle was suitably covered with flexible polythene tubing, where the edge was made blunt. The needle was fixed to a 1ml tuberculin syringe. The rat was held firmly in the left hand. The tubing was moistened with glycerin and inserted right into the oesophagus and gently pressing plunger for drug administration, and this was followed by 0.2ml of distilled water to ensure administration of the correct dose of the drug. Experimental design Twenty-four animals were categorized into four equal groups. Animals (Wister rats) were fasted for 18 h but were allowed free access to water before and throughout the experiment. The study was approved by the institutional animal ethical committee with No: 1447/PO/Re/S/11/CPCSEA/15/A. Group-I: Administered with vehicle (distilled water) & served as Normal control. Group-II: Administered with standard drug Glipizide (5mg/kg). Group III   : Administered EECQ (100mg/kg). Group IV   : Administered EECQ (200mg/kg). Group V    : Administered EEMC (200mg/kg). Group VI   : Administered EEMC (400mg/kg). Blood samples were withdrawn from the retro-orbital venous plexus with capillary tubes under ether anesthesia and with Sodium citrate as an anticoagulant. Serum was separated by centrifugation. The glucose level in blood was measured after 0, 1, 2, 4, 8, 12& 24 h of administration of the single dose of test samples.  Estimation of serum glucose by GOD/POD method11 This method utilizes two enzymes Glucose Oxidase (GOD) and Peroxidase (POD) along with chromogen-4-amino antipyrine, phenol and is intended for in vitro quantitative determination of glucose in serum, plasma, and cerebrospinal fluid. There was no interference due to the creatinine, fructose, galactose, reduced glutathione, ascorbic acid, and xylose. Hemoglobin or bilirubin up to 10mg does not affect the test.  Single Dose Study 12 Induction of diabetes The animals were allowed to fast for 24 h and rendered diabetic by injecting a single dose of alloxan at 150mg/kg body weight administered as a 5% w/v in distilled water by i.p. route. It produces diabetes by selected necrosis of b - cells of islets of Langerhans of the pancreas.  After 48 h of injecting alloxan, diabetes was confirmed by testing blood sugar with Erba CHEM 5 Plus Auto analyzer. The animals with a sugar level of more than 250mg/dl were selected. Animals were maintained for four days in diabetic conditions for good establishment of diabetes. Standard: Glipizide at the dose of (5mg/kg) was used as a standard drug. Experimental Design: Animals were categorized into 5 different groups of six animals each. The animals (Wister rats) were fasted for 18 h but were allowed free access to water before and throughout the experiment.  Blood samples were collected from the retro-orbital venous plexus with capillary tubes under ether anesthesia and with sodium citrate as an anticoagulant. Serum was separated by centrifugation. Multiple-dose treatment (14 days treatment) The animals used for this study are the same animals used for the single-dose study, had free access to feed and water during this period. The chronic study involved repeated administration of extracts of EEMC, EECQ, and Glipizide for 14 days(once a day) to the groups used for single-dose study at a prefixed time and the glucose levels in blood estimated in samples withdrawn after 2 h on day 0,7th and 14th day. Statistical analysis  The result analysis was carried out by the one-way ANOVA method followed by Dunnett&#39;s multiple comparison tests. RESULTS  Preliminary phytochemical screening Results of phytochemical screening were elucidated in Table-1. The preliminary phytochemical screening indicated the presence of various phytoconstituents like flavonoids, phenolic compounds, triterpenoids, tannins, saponins, amino acids, proteins, and carbohydrates in EECQ. The preliminary phytochemical screening showed the presence of various phytoconstituents like flavonoids, phenolic compounds, triterpenoids, tannins, saponins, amino acids, proteins, and carbohydrates in EEMC. Cytotoxicity assay on 3T3 L1 cell line 3T3?L1 cells were treated with different concentrations (25 μg–400 μg/mL) of EECQ and EEMC were assayed for their cytotoxic effect. The extract displayed no cytotoxic effect on cells. The concentrations of the extract used and the respective percent cell viability were tabulated and plotted [Table 2 and Figures 1]. Body weight The changes in body weight of the different groups of animals during the period of study was given in Table 3 and represented in Figure 2 which shows an increase in the mean body weight (± SEM) of normal rats from 230.33 ± 1.47g on day 0 to 240.00 ± 1.06g on day 7, 249.2 ± 0.94g on day 14. This shows that the group of normal rats gained body weight during the treatment period of 14 days.  Effect on normoglycemic rats The fasting serum glucose of the different groups of animals during the single-dose treatment period of study is given in Table 4 and presented in figure 3. which shows that the mean (±SEM) fasting serum glucose values of the normal group of rats was 95.16 ± 1.81, 95.16 ± 1.078, 95.83 ± 1.49, 96 ± 1.00, 97.33 ± 1.60, 96 ± 0.85 and 95.83±0.60 mg/dl, on 0, 1, 2, 4, 8, 12 and 24 h respectively.  Effect on alloxan-induced hyperglycaemic rats The fasting serum glucose of the different groups of animals during the single-dose treatment period of study is given in Table 5. and presented in figure 4, which shows that the mean (±SEM) fasting serum glucose values of the normal group of rats was 95.76 ± 3.248, 96.2 ± 3.21, 96.86 ± 3.47, 97.3 ± 3.26, 97.96 ± 3.29, 98.65 ± 3.15 and 97.68±3.44 mg/dl, on 0, 1, 2, 4, 8, 12 and 24 h respectively.  Multiple-dose study The fasting serum glucose of the different groups of animals during the chronic study is given in Table 6 and presented in figure 5. which shows that the mean (±SEM) fasting serum glucose values of the normal group of rats was 94.63±3.54,96.27 ±3.60, 97.29±3.09 mg/dl on day 0, day 7, and day 14 respectively. The above values show that the fasting serum glucose in the normal group of rats was maintained within the normal range throughout the study. DISCUSSION In cytotoxicity assay on 3T3 L1 cell line, the lowest concentration of EECQ and EEMC (25 µg/mL) showed 98.6% and 99.7% viability respectively, and the highest concentration (400 µg/mL) showed 89.45% and 88.9% of viability respectively after 24 h of exposure. These results indicated that EECQ and EEMC are not toxic to mammalian cells even at higher concentrations and could be used to analyze other parameters of antidiabetic studies. Metformin (100 µM) treatment – positive control – also had a percent viability of 97.4% post 24?h exposure13,14. During the period of treatment, the diabetic group of rats has shown a change in body weight from a mean (± SEM) value of 190.5 ± 1.2g on day 0, 160. ± 1.28g. On day 7 and which decreased further to 132.8 ±1.07g on day 14. The glipizide (5 mg/kg) treated group body weight was found to have been increased. The body weight gain in this group of rats from day 0 through day 7 to day 14 was relatively less when compared with the normal group15-17. The EECQ (100 mg/ kg) treated group of diabetic rats was found to have a mean body weight (± SEM) of 174.3±2.30 g on day 0, 178.00±1.4 g on day 7, 202.3±0.9 g on day 14 . The EECQ (200 mg/kg) treated group of diabetic rats shows mean (± SEM) body weight of 164 ±1.25 g on day 0, 172.80 ± 1.9 g on day 7, 195.80 ± 1.13 g. on day 14. The EEMC (200 mg/kg) treated group of diabetic rats shows mean (± SEM) body weight of 161±1.12g on day 0, 169±2.21g on day 7, 194±2.11g  on day 14. The EEMC (400 mg/kg) treated group of diabetic rats shows mean (± SEM) body weight of 158±1.23g on day 0, 165±1.43g on day 7, 192±1.44, on day 14. Effect on normoglycaemic rats was studied by measuring glipizide (5 mg/kg) treated normal rats show a mean (±SEM) fasting serum glucose of 96.83 ± 0.60, 94 ± 1.29, 86 ± 1.29, 79.16 ± 0.94, 74 ± 1.03, 69.66 ± 0.33 and 92.16 ± 0.83mg/dl on 0, 1, 2, 4, 8, 12 and 24h respectively. The EECQ and EEMC treated normal rats showed mean fasting serum glucose of reduced levels respectively with doses. These changes in fasting serum glucose values illustrate that the normoglyceaemic rats treated with EECQ and EEMC show a progressive and significant reduction. 18 Effect on alloxan induced hyperglycaemic rats was studied by measuring mean fasting serum glucose (±SEM) in the diabetic control group of rats was found to be 262.16 ± 07.96, 266.5 ± 7.39, 275.5 ± 7.20, 285 ± 7.42, 296.16 ± 6.84, 316.5 ± 4.61 and 326.16 ± 4.76mg/dl on 0, 1, 2, 4, 8, 12 and 24 h respectively, which was found to be significantly (p≤0.01) higher when compared with the normal rats. 19 In the multiple dose study the mean fasting serum glucose (±SEM) in the diabetic control group of rats was found to be 269.64±2.89, 337.73±9.899 and  386.5±17.92 mg/dl on 0th, 7th and 14th day respectively, which was found to be significantly (p≤0.01) higher when compared with the normal rats. These elevated fasting serum glucose levels were found to have been maintained throughout the 14 days of the treatment period indicating that the rats are rendered diabetic. The glipizide (5 mg/kg) treated diabetic rats show a mean (±SEM) fasting serum glucose was reduced from day 0 to day7 and then to day 14, a similar reduction was also observed with multiple doses treated groups.20 CONCLUSION Phytochemical evaluation of EECQ and EEMC showed the presence of carbohydrates, flavonoids, tannins, terpenoids, saponins, proteins, amino acids, and phenolic compounds. According to the literature, EECQ and EEMC were found to be safe in the dose used and there was no mortality up to 5000 mg/kg dose. The results indicate that the EECQ fruits and EEMC leaves have good anti-diabetic activity. The ethanolic extracts of CQ fruits and MC leaves displayed noteworthy anti-hyperglycaemic activity in alloxan-induced hyperglycaemic rats without any major variation in body weight; they also enhanced the condition of DM that was indicated by body weight, serum creatinine, serum urea, and serum alkaline phosphatase. The study also displayed damage of the pancreas in alloxan-treated diabetic control rats and leads to regeneration of cells by glipizide and extract treatment group. ACKNOWLEDGEMENT The authors sincerely thank Professor Dr. D V R N Bhikshapathi for rendering his suggestions and helping them in each and every step of completing this research paper successfully. CONFLICT OF INTEREST No conflict of interest FUNDING INFORMATION Self financed AUTHORS’ CONTRIBUTION Jasti Deepthi developed the theoretical formalism, performed the analytic calculations and numerical simulations. Both Jasti Deepthi and D V R N Bhikshapathi contributed to the final version of the manuscript.   Englishhttp://ijcrr.com/abstract.php?article_id=4545http://ijcrr.com/article_html.php?did=4545
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare In-Vitro Antioxidant Activites of Novel Synthesized Copper (II) Complexes English6064Muhammad TahirEnglish Muhammad Shahab KhanEnglish Muhammad BilalEnglish Ashfaq AhmadEnglish Mukhtar AhmadEnglish Introduction: The term radical is originally implied, to a portion of a molecule that cannot exist independently in nature. The Development of these radicals is driven by thermal hemolysis, high-energy radiation and photolysis. Free radical attacks cause cell damage and homeostatic disruption. Targets of free radicals are all kinds of molecules in the body, such as lipids, nucleic acids and proteins are the major targets. Antioxidants are substances capable of slowing or stopping oxidation pathways that occur under the effect of reactive oxygen moieties or free atmospheric oxygen. Objectives: The main objective of the present study was to judge the advantages of the newly synthesized Copper (II) complexes in contrast to oxidative stress caused by free radicals utilizing different assays. Methods: The antioxidant ability of Cu (II) complexes were measured employing different assays including, DPPH free radical scavenging ability, ferric reducing antioxidant potential (FRAF) and total antioxidant ability assay. Results: In the DPPH scavenging potential assay, ferric reducing antioxidant potential and total antioxidant ability assay, RI-1 complex was studied to be more spectacular among the copper(II) complexes. Inhibiting ability of the complexes was RI-1 > NM-3 > AM-2 > SR-3. The Antioxidant scavenging potential was conformed as dose-dependent which increases with the increase of complex concentration. Conclusion: The Copper (II) complexes were found to have high antioxidant abilities. EnglishAntioxidants, Cu (II) complexes, DPPH, Free radicals, FRAF, Total antioxidant ability assay INTRODUCTION The current development in the formation of free radicals, reactive Nitrogen species (RNS) and reactive oxygen species (ROS) is producing a medical revolution in science. Antioxidants and free radicals have become usually a main term in modern discussions of disease mechanisms.1 Numerous radical lacking stability and are profoundly reactive in nature. They either give an electron or accept an electron from other molecules.2 These are highly reactive species, fit into the nucleus and in the layers of the cells harming biologically significant molecules such as DNA, proteins, carbohydrates and lipids.3 Free radical reactions can bring irreversible deleterious changes in individuals during their lifetime. These problems can appear in the form of hereditary and environmental changes.4 These seemed as infections, in particular stages induced by hereditary and ecological elements. Cancer and atherosclerosis are two main reasons of death, are remarkable “free radical” infections disorders. It is probable that endogenous radical responses, similar to that started by ionizing radiations may bring about tumor formation.5 Studies on atherosclerosis find out the like hood that the disorders may be because of the free radical’s responses, containing diet-determined lipids in the blood vessels and serum to produce peroxides and different other compounds. These compounds incite endothelial cell damage and bring alterations in the arterial walls.6 Many scientific observations give proves that RNA and DNA are exposed to oxidative damage. Especially it has been investigated that DNA is the major target in ageing and cancer.7 Oxidative nucleotide for example glycol and 8-hydroxy-2-deoxyguanosine is found to be increased during oxidative damage to DNA under UV radiation or free radical damage. It has been reported that mitochondrial DNA is highly susceptible to oxidative damage that have part in various diseases and malignancy. It has been recommended that 8-hydroxy-2-deoxyguanosine can be used as a natural manufacturer for oxidative stress.8 All of the higher classes of biomolecules may be attacked by free radicals but lipids are probably the most susceptible. Cell membranes are the best sources of polyunsaturated fats (PUFAS) which are readily attacked by oxidizing radicals and the process is as known as lipid peroxidation, which is more harmful because it is a self-perpetuating chain reaction.9 The peroxyle radicals are the carriers of the chain reactions they can oxidize PUFA compounds and start new chain reaction to initiate lipid hydroperoxide (LOOH) that can breakdown to yet more radical’s species and to a wide range of compounds, especially aldehydes.10 Antioxidants are known to be free radical scavenger, hydrogen donor, electron transporters, peroxide composer singlet oxygen liquor, catalyst blocker and metal chelating specialists.11 Both catalytic and non-enzymatic cancer prevention agents found in intercellular and cellular condition to decrease toxicity. Man-made and natural food antioxidants are used in food, mostly those containing oils and fats are more important because they inhibit oxidation in foods. Phenolic and butylated hydroxytolune (BHT) are the best examples. The food industry and medical industry have broadly used these complexes as antioxidant.12However, high volatility, instability and cancer-causing nature of butylated hydroxytolune and BHA at high temperature have changed the user’s priority from synthetic to natural antioxidants. The value of certain compounds in medical treatment and genomic research is based on the capacity of the compounds to bind or break double-standard DNA. The hydrolytic and oxidative breaking pathways are tangled in the DNA-breaking reactions. Oxidative cleavage of DNA is bringing about by different methodologies.13 The binding potential of target compound with DNA is the major source for making the comparison of cleavage efficiency of the complexes to that of the control.14 Copper is one of the most important microelement in all living forms and also part of many biological enzymes in the last years, many investigations have shown that the Cu amount of antibody and tissues are considerably higher in the cancer of breast, prostate, lung and brain. Moreover, Cu is also related to angiogenesis, which is essential for tumor proliferation, invasion and metathesis.15 Cu has been utilized in olden days in metal base analyses.16 Cu is a bio, essential element and performs a vital role in life processes and its compounds are selecting agents for a growth malignancy cure.17 MATERIALS AND METHODS  Chemicals and reagents 2,2-Diphenyl-1-picrylhydrazyl radical (DPPH), Ascorbic acid, iron (III) chloride, EDTA, Tris buffer, o-phenenthroline, sulfuric acid, sodium phosphate, ammonium molybdate and ethanol purchased from Sigma Aldrich Pakistan at analytical grade. DPPH Free Radical Scavenging Ability A stock solution of 85 M DPPH in ethanol and stock solution of 6000 M of test compound is prepared and different concentration of samples is mixed with a fixed amount of 2,2-diphenyl-1-picrylhydrazyl (DPPH) mixture. Absorbance from all tests are measured immediately up to 2 hrs. Vitamin C is used as a standard.18 The results were intimate as percentage inhibition calculated according to the equation given below:  Inhibition (%) =(Ab - Ac/Ab) ×100 (Where Ab = Absorbance of the control and Ac = Absorbance of the sample) Iron Reducing Power assay The reducing powers of sample drugs were measured by using the reported method. The complexes of different concentrations were mixed with Iron (III) chloride, phosphate buffer (PH 6.6) and o-phenanthroline. The absorbance was measured at 490 nm. The increase in absorbance showed the reducing power of the compounds. Ethylenediaminetetraacetic acids (EDTA) were used as a positive control and mixture without the drug were used as a blank.19 Reducing the power of the tested compounds was calculated by using the following formula:  Reducing power (%) = (Ac – Ab/ Ac) × 100                                                                                                    (Where, Ab = Absorbance of the blank and Ac = Absorbance of the sample) The total antioxidant assays of the tested complexes were determined by using the reported method. All compounds in different concentrations were mixed with sodium phosphate, ammonium molybdate and sulfuric acid into Eppendorf tube. All tubes were heated in the thermal block at 95 0C for 1.5 hrs. After cooling the mixtures to normal temperature, the increase in absorbance was calculated at 695 nm using Vitamin-C as standard.20 Reducing ability of the compounds and ascorbic acid was measured by employing the following formula:   Reducing power (%) = (Ab – As/ Ab) ×100                                            (Where, Ab = Absorbance of the blank and As = Absorbance of the sample) Graph pad prism version 6 was used to calculate IC50 ± SEM values. RESULTS DPPH radical scavenging assay Percentage inhibition of the DPPH radicals at different concentration of copper(II) complexes are graphically indicated in graph 1. The IC50 along with SEM values for ascorbic acid was found to be 56.48 + 12.52. The IC50 values for the copper(II) complexes RI -1, NM-3,AM-2 and SR-3 were found to be 12.08 + 9.303,38.25+ 6.081,44.045 + 5.215 and 300.25 + 5.182. Among the copper(II) complexes, scavenging potential of the RI -1 complex was studied to be more spectacular, NM-3 complex represents low ability, the complex AM-2 showed least ability and the complex SR-3 was found to be satisfactory. The DPPH scavenging potential was conformed as amount dependent which increases with the increase of complex concentration. Ferric reducing activity The copper (II) complexes were evaluated for the antioxidant properties in 0- phenanthroline color method. Graph 2, illustrates the % reduction ±SEM, IC50 ±SEM which shows the significant values of ferric ion indicates the reductive abilities of different evaluating compounds. The IC50 value along with SEM for the ethanolic solution of the standard was found to be 24. 56±8. 544. The IC50 for the copper(II) complexes, RI-1, NM-3, AM-2 and SR-3 were found to be 169. 189±5. 465,121. 075±3. 750,219. 26±3. 180 and 120. 15±11. 16 respectively. Among the copper(II) complexes the compound SR-3 was recorded as high ability to reduce power, NM-3 complex showed less ability, the complex AM-2 and the compound RI -1 was recorded to be satisfactory. Total Antioxidant capacity The phosphomolybdate method has been utilized for the evaluation of total antioxidant capacity of the copper(II) complexes using ascorbic acid as a standard. Graph 3, illustrates the % reduction mean at different concentrations with IC50± SEM. The IC50±SEM value of the standard was found to be 61. 74±10. 44. And the IC50±SEM values for the copper(II) complexes RI-1, NM-3, AM-2 and SR-3 were found to be 224. 17±3. 215,422. 26±2. 044,504. 12±1. 412 and 568. 60±2. 622 respectively. Among these compounds RI-1 was found to be better, the compound NM-3 showed less potential, the compound AM-2 and SR-3 were found to be satisfactory. DISCUSSION DPPH radical scavenging, ferric reducing antioxidant potential (FRAF) and total antioxidant activity assays are widely used techniques for understanding, finding and determining the antioxidant ability of the compounds in view of the responsive capability to find active components at small amount. The absorbance of DPPH radicals is decreased when it interacts with antioxidants. In the present study the DPPH radical scavenging capacity of the copper(II) complexes in ethanol solution was also investigated by using ascorbic acid as a standard. The ferric ion-reducing properties are also dose-dependent and higher activities were recorded at higher concentrations of the compounds comparable with that of standard ascorbic acid. The obtained results present that all compounds in Copper(II) complex actively reduces Mo(VI) ion to Mo(V), Fe(III) ion into Fe(II) ion and also show the reactivity towards DPPH radicals. Of these mechanisms, copper (II) complexes clearly have antioxidant parts that can give an electron or a hydrogen atom. All compounds have a remarkably significant and concentration-dependent antioxidant activity. Conclusion: The methods used in the current study to evaluate the anti-oxidant properties of copper(II) complexes were well established. Nonetheless, these investigations confirmed the insight into the antioxidant nature of Copper(II) complexes as a beginning of synthetic antioxidants, but due to the complexity and different mechanisms from in vitro, this solution cannot be applied to in vivo system. The research methodologies followed in this work for copper(II) complexes to confirm as a source of synthetic antioxidants are accepted worldwide. In future research, these results should be widened in a mixture of antioxidant methods in vitro and in vivo from the determination of antioxidant content. Research involving other synthetic compounds is also worth investigating in future research. Abbreviations BHT: Butylated hydroxytoluene; SEM: Standard error of the mean; ROS: Reactive oxygen species; RNS: Reactive nitrogen species SOD: superoxide DNA: Deoxyribonucleic acid; LOOH: Lipid hydroperoxide; EDTA: Ethylenediaminetetraacetic acid; FRAF: ferric reducing antioxidant potential. Acknowledgments The authors are thankful to Higher Education Commission (HEC) of Pakistan. Also, the authors acknowledge Malakand Institute of Medical sciences Dargai, KPK, Pakistan, for providing the facilities for the conduct of the study. Authors’ contributions Muhammad Bilal, Ashfaq Ahmadand Mukhtar Ahmad performed the total antioxidant activity assay experiment. Muhammad Tahir and Muhammad Shahab Khan performed the DPPH and FRAF assays experimental work, supervise the whole project and wrote the manuscript. All authors read and approved the manuscript for submission. Funding No funding. Availability of data and materials The data associated with this study are available from the corresponding author. Consent for publication Not applicable. Conflict of interest The authors declare that they have no potential competing interest. Englishhttp://ijcrr.com/abstract.php?article_id=4546http://ijcrr.com/article_html.php?did=4546 1. Bagchi K, Puri S. Free radicals and antioxidants in health and disease: a review. EMHJ-East Mediterr Health J 4 2 350-360 1998. 1998; 2. Chapter 1 Introduction to free radicals. In: Laboratory Techniques in Biochemistry and Molecular Biology. Elsevier; 1991. p. 1–18. 3. Young IS, Woodside JV. Antioxidants in health and disease. J Clin Pathol. 2001 Mar 1;54(3):176–86. 4. Sharma RA, Kumari a. Phytochemistry, pharmacology and therapeutic application of oxalis corniculata linn. - a review. 6(3):7. 5. Lea AJ. Dietary factors associated with death-rates from certain neoplasms in man. Lancet. 1966;2:332–3. 6. Harman D. Role of Free Radicals in Aging and Disease. Ann N Y Acad Sci. 1992;673(1):126–41. 7. Woo RA, McLure KG, Lees-Miller SP, Rancourt DE, Lee PWK. DNA-dependent protein kinase acts upstream of p53 in response to DNA damage. Nature. 1998 Aug;394(6694):700–4. 8. Hattori Y, Nishigori C, Tanaka T, Uchida K, Nikaido O, Osawa T, et al. 8-Hydroxy-2’-Deoxyguanosine Is Increased in Epidermal Cells of Hairless Mice after Chronic Ultraviolet B Exposure. J Invest Dermatol. 1996 Nov;107(5):733–7. 9. Phaniendra A, Jestadi DB, Periyasamy L. Free Radicals: Properties, Sources, Targets, and Their Implication in Various Diseases. Indian J Clin Biochem. 2015 Jan;30(1):11–26. 10. Aruoma I. Peroxyl Radical Scavenging Activity of the Antihypertensive Drug Carvedilol. :5. 11. Ofoedu CE, You L, Osuji CM, Iwouno JO, Kabuo NO, Ojukwu M, et al. Hydrogen Peroxide Effects on Natural-Sourced Polysaccharides: Free Radical Formation/Production, Degradation Process, and Reaction Mechanism—A Critical Synopsis. 2021;33. 12. Zhu F. Triticale: Nutritional composition and food uses. :47. 13. Nobili S, Lippi D, Witort E, Donnini M, Bausi L, Mini E, et al. Natural compounds for cancer treatment and prevention. Pharmacol Res. 2009 Jun;59(6):365–78. 14. Schatzschneider U. Photoactivated Biological Activity of Transition?Metal Complexes. Eur J Inorg Chem. 2010;17. 15. Wang M, Wang LF, Li YZ, Li QX, Xu ZD, Qu DM. Antitumor activity of transition metal complexes with the thiosemicarbazone derived from 3-acetylumbelliferone. :4. 16. Akinmoladun AC, Obuotor EM, Farombi EO. Evaluation of Antioxidant and Free Radical Scavenging Capacities of Some Nigerian Indigenous Medicinal Plants. J Med Food. 2010 Apr;13(2):444–51. 17. Puntel RL, Nogueira CW. Krebs Cycle Intermediates Modulate Thiobarbituric Acid Reactive Species (TBARS) Production in Rat Brain In Vitro. :11. 18. Choi CW, Kim SC, Hwang SS, Choi BK, Ahn HJ, Lee MY, et al. Antioxidant activity and free radical scavenging capacity between Korean medicinal plants and flavonoids by assay-guided comparison. Plant Sci. 2002 Dec;163(6):1161–8. 19. Zhao G, Xiang Z, Ye T, Yuan Y, Guo Z. Antioxidant activities of Salvia miltiorrhiza and Panax notoginseng. Food Chem. 2006;99(4):767–74. 20. Kumaran A, Joel KR. In vitro antioxidant activities of methanol extracts of five Phyllanthus species from India. LWT - Food Sci Technol. 2007 Mar;40(2):344–52.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Comparing the Effectiveness of Live Online Lectures vs Recorded Video Lectures as Means of Learning in Medical Education During Covid 19 Lockdowns English6570Kirandeep Kaur AulakhEnglish Prachi Saffar AnejaEnglish Susmita SahaEnglish Savita BansalEnglish Introduction: Traditional classroom teaching has been the mainstay of learning in the medical field, especially in India. In the present situation of widespread lockdowns due to Covid 19 other means of learning have to be explored in place of traditional classroom teaching. These include live online lectures and recorded video lectures. There is a need to evaluate the effectiveness of these methods and whether they meet our requirements of imparting good quality medical education. Aims: To find the effectiveness of live online lectures and recorded video lectures as means of learning, to study their advantages and disadvantages and compare them. Methodology: A cross-sectional study was conducted through a digital Google survey on 369 undergraduate students of MBBS, BDS and BPT students of SGT University, Gurugram, Haryana, India. Out of these 274 were female students and 95 were male students. A 5-point Likert scale was used (1- strongly disagree; 2- disagree; 3- undecided; 4- agree; 5- completely agree). Statistical Analysis: Categorical variables are presented in number and percentage (%). The qualitative variable is compared using the Chi-Square test. A p-value of EnglishLive online lectures, Efficacy, Recorded video lectures, E-learning, Medical education, Online learning INTRODUCTION Medical education comprises a vast and ever-expanding curriculum that needs to be completed within a limited time duration. Traditional classroom teaching has been the mainstay of learning in the medical field, especially in India. This has often been supplemented by online methods of learning either by the faculty or students themselves. There has been a dramatic increase in community-based education of health profession students but it faces many challenges in such a large and diverse population of community-based faculty.1 In the present situation of widespread lockdowns due to Covid 19 other means of learning have to be explored instead of traditional classroom teaching. These include live online lectures and recorded video lectures. Since these online resources are being increasingly used as a means of learning there is a need to evaluate the effectiveness of these methods and whether they meet our requirements of imparting good quality medical education. A study conducted on first-year medical students suggests that digital lectures seem to be an acceptable alternative to face-to-face delivery.2 A randomized trial was conducted comparing live attending of the lecture series with viewing a CD-ROM-based multimedia version of the same lecture series.3 Medical students in India have been using online resources for understanding and learn various topics in anatomy, physiology and biochemistry.4 To meet students’ requirements during these times of Covid 19 lockdowns, the Department of Anatomy, Faculty of Medicine and Health Sciences, SGT University, Haryana has started uploading video recordings of lectures as well as started live online lectures through Webex. To find the effectiveness of such methods a questionnaire-based Google survey was done on undergraduate students of MBBS, BDS and BPT students of SGT University, Gurugram. Numerous studies are available that compare online teaching with traditional classroom teaching in medical education.5,6,7 But this study focuses on the two online teaching methods i.e. comparing live online lectures and recorded video lectures. There is limited literature available on this topic, especially in Indian medical education. This study hopes to overcome this shortcoming. AIMS AND OBJECTIVES 1. To find the effectiveness of live online lectures as a means of learning. 2. To find out the advantages and disadvantages of live online lectures. 3. To find the effectiveness of recorded video lectures as a means of learning. 4. To find out the advantages and disadvantages of re-corded video lectures. 5. To compare both the above online methods of learning i.e. live online lectures and recorded videos. 6. To find if there are any significant differences between males and females in the above parameters. MATERIAL AND METHODS A cross-sectional study was conducted through a digital Google survey on 369 undergraduate students of MBBS, BDS and BPT students of a private university in Gurugram, Haryana, India. Out of these 274 were female students and 95 were male students. Ethical clearance was taken from the Institutional Ethical Committee of SGT University for waiver of consent. Participation of students was completely voluntary and students could choose not to respond. Information was kept strictly confidential and no information was taken which could lead to the identity of the participant. SEC/FMHS/F/13/05/20-3 The participants needed to attempt all the questions before submitting. A 5-point Likert scale was used (1- strongly disagree; 2- disagree; 3- undecided; 4- agree; 5- completely agree).2 only the completed questionnaires were assessed and results were calculated. Questionnaires that were not filled were rejected. The students were asked to grade the effectiveness of online live lectures and recorded videos as a method of learning according to the questionnaire appended below. Type of Study:-Prospective Observational Cross-sectional Study. A pilot study was conducted on 10 students to calculate the sample size. Sample Size n>=((pc*(1-pc)+pe*(1-pe))*(Zα + Zβ )2 )/(pc-pe)2 with pc= Proportion of students agreed with recorded videos pe= Proportion of students agreed with online live lectures Where Zα is the value of Z at a two-sided alpha error of 1% and Zβ is the value of Z at a power of 99%. Calculations: n>=((.7*(1-.7)+.5*(1-.5))*(2.58+2.33)2 )/(.7-.5)2 >=277.24=278(approx.) Statistical Analysis Categorical variables are presented in number and percentage (%). The qualitative variable is compared using the Chi-Square test. A p-value of Englishhttp://ijcrr.com/abstract.php?article_id=4547http://ijcrr.com/article_html.php?did=4547
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Multivariate Analysis of Human Adult Femur Length by Various Parameters of Neck of Femur English7176Ganjewar ManjiriEnglish Shroff GautamEnglish Mandhana VaishaliEnglish Introduction: Bones forms the main framework of the human body. Bone structure is different in different individuals depending upon race, sex, height, work, nutrition and geographical area. The femur is the bone that is the longest and strongest in human body and shows highest correlation with stature. Aims: This study has been done to determine the relationship of neck measurements with femur length in Maharashtrian population. Methodology: In the present Study, 54 human femur bones were studied for the following parameters using standard procedures. We took femur length (FL), neck length (NL), neck diameter at the narrowest site (NDN) and neck diameter at widest site (NDW) in mms. Results: The data was analysed through SPSS software. The descriptive statistics was analysed. Univariate and Multivariate Regression equations were derived to estimate Femur Length from various neck parameters. In univariate analysis, FL was 344.06 + 2.856 NL with R value 0.513 and in multivariate analysis, FL was 209.457+ 0.89 NL + 10.85 NDN -2.98 NDW with R value 0.867. Conclusion: It has been concluded that femur neck length has a positive correlation with total length of femur and femur length can be calculated if measurements of one or more neck parameters are available. EnglishStature Correlation, Multivariate Analysis, Femur length (FL), Neck length (NL), Neck diameter narrow (NDN), Neck diameter widest (NDW). Introduction Homo sapiens are biped organisms. Due to shift in posture for walking, he needs strong bone structure and well-developed muscles and proper joint structure, especially in lower limbs. The femur is the lower limb bone, bone of the thigh. It is the longest and strongest bone of the body.1 It is involved in two very important joints which have a crucial role in standing and walking i.e. hip joint and knee joint. If femur is fractured, the working of both hip and knee joints will be disrupted. The fractured femur is very difficult to heal. Hence, in case of a hip replacement or implant surgery for a proximal segment of the femur, we need to have accurate measurements of the femur so that we can provide best possible replacement or corrective surgical measures for that clinical condition.  Femur bones have one of the highest correlations with stature and hence regression equations can be derived for the estimation of stature from available femur length (FL).2             Bone structure is different in different persons depending upon race, sex, height, work, nutrition and geographical area.3 Hence, we need to have adequate data related to bone dimensions from local population. Laishram had formulated the linear regression equation for the estimation of FL from various parameters of proximal segment of femur specifically diameter of head of femur.4 This study has been undertaken to determine the relationship between neck measurements and FL in the Maharashtrian population. Materials and method After scientific and ethical committee approval, this study was conducted on 54 dry femurs from Bone bank of the Department of Anatomy, MGM Medical College during the year 2019-20.(Fig. 1) Bones with obvious deformities in shape or size, the bones with visible fracture lines or injuries or surgical corrections were excluded from the study. After the exclusion of the deformed bones, 54 bones irrespective the side were included in study and given tags. Dry weight of the bones was measured on a weighing scale. Simultaneously, the total length of these bones was also measured on bone osteometric board thrice and the average of all 3 entries was taken as final length for that femur. Both entries were promptly entered in master chart. As this study is aimed to find the femur length from the measurements of proximal segment of femur following measurements were taken in mms. Side of femurs were identified and tabulated in excel sheet.5 1. Femur length (FL) – Femur was placed on an osteometric board with internal rotation and it was measured from highest point of head of femur to the lowest point of medial condyle. (Fig no 2.) 2. Neck length (NL)– It is the distance between the lowest margin of head and lowest point on the intertrochanteric line. It was measured with measuring tape. (Fig no 3) 3. Neck diameter – We have drawn a parallel line to the axis of neck. Diameters were measured at its narrowest (NDN) and at the widest part (NDW) (Fig no 4 and 5) Measurements were first entered into Microsoft Excel (2010) then transferred to the SPSS version 20 for statistical analysis. After the data met the normality test, descriptive statistics were derived to calculate, mean, standard deviation and proportion of segmental measurements with the MFL (MFL – Mean Femur Length) for each side. Test of significance was applied. Finally, linear regression models were derived for estimating the MFL from different measurements of neck of femur. Results The MFL was 438.59 mm with a ±SD value of 24.38 mm. The mean NL was 33.10 mm with std. deviation of 5.15mm. The mean NDN was 29.84 mm. The NDW was 41.78 mm with a standard deviation of 5.07 mm. MFL in the study was found to be 344 mm, minimum NL was 43.76 mm, NDN was 24.38mm and of NDW was  31.51 mm.(Table no.1) (figure1,2,3,4) The skewness of all the measurements was within -0.5 to 0.5 and hence it suggests that the data obtained was fairly symmetrical.  Kurtosis value for FL is 1.48 and it is less than 3. This distribution is platykurtic. Similarly, kurtosis for the NL is -0.79 which is also platykurtic. NDN and NDW also show the platykurtic distribution. (Table no .2) As shown in Table no 3, Out of 54 Femurs 26 bones were left-sided while 28 were right-sided. The MFL of left-sided femurs was 434.40 mm and of right-sided femurs were 442. 49 mm. Similarly, there was a difference between the means of NL of right and left side femurs. The difference in parameters of right and left MFL and right and left femur NL may be related to the dominant use of right side in the majority of the population and needs to be studied further in detail. Mean NDN was found to be 29.88 mm and 29.81 mm on left and right side respectively. Mean NDN on left and right side were found to be 29.88 mm and 29.81mm whereas mean NDW were 42.69 and 40.93mm respectively. (table no.1)  As shown in Table no 4, the values indicate that there is a positive correlation between FL and NDN and negative correlation between FL and NDW. The univariate equation was derived for estimating FL from measurements of NL. Femur length = 344.06 + 2.856 NL with R value 0.513. This formula can be used to predict FL from the available neck length. It is also useful to derive the neck length for the prosthesis in surgeries if femur length is available. For the calculation of FL from fragments of proximal segment of femur, a regression equation was derived from NL, NDN and NDW. For this, FL was used as a dependent variable and NL, NDN and NDW were used as independent variables. The multivariate was done. Multivariate equations were derived to estimate FL from different neck measurements. As R-value for the multivariate equation is significantly higher than that of univariate equation for the calculation of FL, it is better to predict FL from the multivariate equation when all the relevant dimensions are available. Femur length = 209.457+ 0.89 NL + 10.85 NDN -2.98 NDW with R-value 0.867. Discussion The femur is one of the most important long bone for the erect posture of Homosapiens, and neck of the femur is one of the important factors for weight transmission, stabilization of posture and versatile movements at the hip joint. The measurements of the neck plays important role in femur implants too. Hence, due to scarcity of such data in Indian population, this study has been done to estimate FL from various parameters of femur neck The MFL is 438.59 mm with std deviation of 24.38 mm. Similar results were seen in study done by Pillai .6 In this study, MFL was 437.4mm. Micheal studied the linea aspera variations of femur while Shivshankarappa and Shakil et al. both studied the neck shaft angle in the femurs in different populations.7, 8 All these studies guide us to understand the anatomy of femur more precisely and objectively. We wanted to determine the correlation between the proximal segment measurements with femur length. Hence, we have decided to derive equations so as to predict MFL by using the neck measurements. On the literature search, we have found similar such studies. Ravichandran studied NL and neck diameter (ND)of femur in 578 specimens and mean NL and ND were 31.88 mm and 30.99 mm while in our study NL was 33.10 mm ,NDN was 29.84mm and NDW was 41.mm.9 Bhavna Nath stated in their study, lower limb bone like tibia followed by fibula and then femur have high correlation with stature of the individual. They also derived the regression equation for estimation of stature from FL. S = 77.99 + 2.15 (MFL) ± 3.80 with r value 0.743.10 Seyed Vaghefi et al derived the mean ±SD value of FL in their study and it was 40.31 cm and 43.3 cm in females and males respectively and this difference was found to be significant (PEnglishhttp://ijcrr.com/abstract.php?article_id=4548http://ijcrr.com/article_html.php?did=4548 1. Standring S. The Anatomical Basis of Clinical practice. Gray’s Anatomy. 40thed. London: Churchill Livingstone Elsevier 2008.p.1360-1390. 2. Asha KR, Vinaykumar K, Bindurani MK, Kavyashree AN, Subhash L. Reconstruction of femoral length from its proximal fragments and diaphyseal segments in south Indian population. Res J. Pharm. Biol. Chem. Sci. 2014; 5(5):920-25. 3. Singh S, Nair SK, Anjankar V, Bankwar V, Satpathy DK, Malik Y. Regression equation for estimation of femur length in central Indians from the inter-trochanteric crest. J Indian Acad Forensic Med. 2013; 35(3):223-26. 4. Laishram D, Chandrasekaran S, Shastri D. Derivation of regression equation for estimation of stature by using measurement of femur. Asian J Med Sci. Oct 2021; 12(10):147- 151. 5. Khanal L, Shah S, Koirala S. Estimation of Total Length of Femur from its Proximal and Distal Segmental Measurements of Disarticulated Femur Bones of Nepalese Population using Regression Equation Method. J Clin Diagn Res. 2017 Mar; 11(3): HC01–HC05. 6. Pillai TJ, lakshmi Devi CK, Sobha Devi T. Osteometric Studies on Human Femurs. IOSR J. Dent. Sci.(IOSR-JDMS)e-ISSN: 2279-0853, p-ISSN: 2279-0861. Feb. 2014;13(2) I:34-39. 7. Polguj M, Bli?niewska K, J?drzejewski2 K, Majos A, Topol M. Morphological study of linea aspera variations: proposal of classification and sexual dimorphism. Folia Morphol. 72(1) :72–77. 8. Khan SM, Shaik HS. Study on neck-shaft angle and femoral length of south Indian femurs. Int J Anat Res. 2014; 2(4):633-35. 9. Ravichandran D, Muthukumaravel N, Jaikumar R, Das H, Melani R. Proximal femoral geometry in Indians and its clinical applications. J. Anat. Soc. India 60(1) 6-12 (2011):6-12 10. Bhavna, Nath S. Estimation of stature on the basis of measurements of the lower limb. Anthropology Today: Trends, Scope and Applications. 2007;Anthropologist (3): 219-222. 11. Vaghefi SHE, Elyasi L, Amirian SR, Raigan P, Akbari H, Sheikhshoaiee M, Borbor A. Evaluating Anthropometric Dimensions of the Femur Using Direct and Indirect Methods. Anatomical sciences. May 2015; 12(2):89-92 12. Dwivedi AK, Airan N, Bhatnagar R. Estimation of Length of Femur from its Proximal Segment in Maharashtrian Population. Int. J. Anat. Radiol. Surg. 2019, Jan;8(1): AO01-AO05.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Histomorphological Study of Non-Neoplastic Skin Lesions: A Retrospective Approach English7785Arpita NishalEnglish Himani BajajEnglish Rasik HathilaEnglish Mubin PatelEnglish Pinal ShahEnglish Archana PatelEnglish Rishikesh BalvalliEnglishEnglishPemphigus Vulgaris, Epidermoid cysts, Borderline Tuberculoid leprosy INTRODUCTION Despite advancement in molecular techniques in diagnosis and prognosis, morphology still remains the basis of diagnosis for most neoplasms and many inflammatory dermatoses.1 Non-neoplastic skin disorders encompass a wide spectrum of pathologic processes ranging from autoimmune to infectious to diseases of unknown etiology. In contrast to neoplastic lesions, the histopathology of inflammatory skin diseases frequently does not exhibit a one-to-one correlation with a single diagnosis and requires correlation with the Clinical presentation for a definitive diagnosis. In some cases, a specific histologic diagnosis is not required by the dermatologist while few others, accurate histological diagnoses plays a critical role of role in determining the course of treatment.2 The pattern of skin diseases shows variation from country to country and even region to region within a country due to different ecological factors, genetics, hygienic standards and social customs.3 Majority of skin lesions presenting in skin outpatient department can be diagnosed on the basis of clinical history and presentation. Only in lesions where clinical findings are insufficient to reach a conclusion biopsy is sent to assist in diagnosis. The aim of the dermatopathologist should be to provide the submitting physician with a clinically relevant differential diagnosis (in the standard language of clinical dermatology) based on a description of the microscopic pathology, and, when possible, a specific diagnosis. 4 Commonly used skin biopsy techniques are punch biopsy, superficial and deep shave biopsy, deep incisional biopsy, complete excision, and curettage. 1 As the understanding of inflammatory skin disorders is incomplete and continues to evolve, it becomes obvious that no single uniform classification of disease has been or is likely to be perfect for all uses. Instead, as many disorders as possible are classified by presumed etiology, and the rest are classified based on their most distinctive features.4 Our study aimed at describing the histopathological profile of non-neoplastic dermatological disorders in a Tertiary Care Institute in Gujrat. AIMS AND OBJECTIVES Our study aims To study the histomorphological spectrum of non-neoplastic skin lesions received at a tertiary care institute To study the age and sex distribution To classify the lesions into major categories that predict clinically important attributes such as prognosis or response to therapy and determine the incidence of each subcategory. MATERIAL AND METHODS STUDY DESIGN- Observational study (retrospective) Study Location- Study was conducted in department in a tertiary care hospital in South Gujrat Study duration- 1 year (1st February 2019 to 30th January2020) Sample size –205 Inclusion criteria- All biopsies that showed definite signs of any specific non-neoplastic pathology were included. Exclusion criteria- All skin biopsies that didn’t showed definite signs of any specific pathology or were inadequate were excluded. All skin biopsy specimen showing neoplastic etiology The present study is an observational retrospective study undertaken in Department of Pathology in a tertiary care hospital in South Gujrat. The study included a total of 205  biopsy specimens of skin(punch biopsy, excision biopsy and shave biopsy) received in the histopathological section over a period of one year from February 2019 to January 2020 in which a conclusive diagnosis of non-neoplastic skin lesion was made. The specimens were fixed in 10% Neutral Buffered Formalin.  Specimens measuring 3 mm or less were submitted in toto, those measuring 4–6 mm were cut through the center and both halves submitted while those measuring 7 mm or more were cut in 2–3 mm slices and then submitted for processing. Tissue processing was done as per standard procedure and paraffin-embedded blocks were made. Tissue sections of 5 µ thick were cut using rotary microtome and stained by Haematoxylin and Eosin followed by microscopic examination. Special stains such as Ziehl Neelsen stain, Wade Fite stain, PAS (Periodic Acid Schiff) and Masson Trichrome were performed whenever required. Detailed patient history, clinical examination findings were noted from the histopathological requisition form sent alongside the specimen RESULTS A total of 205 cases were included in this study. Out of these, 152 cases were male patients while 53 were female patients. Male: Female ratio was 2.8:1. Patients’ age ranged from 3 years to 85 years. Most cases belonged to 31-40 years and 21-30 years age groups with 54 cases(26.3%) each.(Table I) Histopathological examination results revealed a wide spectrum of skin lesions despite similar clinical presentation in different patients (Table II). As no single classification can perfectly encompass all lesions of skin so an attempt was made to classify the non-neoplastic disorders on the basis of etiology, location in skin and pattern of inflammation.  The cases were classified into Genodermatoses, Non-infectious erythematous papular and squamous diseases, infectious disorders, Vesicobullous disorders, connective tissue disorders, vasculitis, pigment disorders, deposition disorders, disorders pertaining to skin appendages(hair and nail) , photosensitivity disorders and Cutaneous cysts.(Table III)(Figure I) Category-wise, Infectious disorders of skin constituted maximum number of cases with 73 cases(35.65%) followed by Cutaneous cysts (72cases;35.1%) and distantly followed by Vesicobullous disorders  (11 cases;8.2%). Non-infectious erythematous papular and squamous diseases comprised 17 cases (7.8%).), disorders pertaining to skin appendages 6 cases(2.9%), pigment disorders 4 cases (1.9%), and connective tissue disorder  9 cases (3.9%) and  Deposition disorders 4 cases Uncommon categories were Photodermatosis (2 cases) and Vasculitis (1case) and Genodermatoses(1case). Epidermoid cysts with 64 cases (31.2%) was the most common skin lesion closely followed by Lepromatous cases (60 cases; 29.2%). Infectious Disorders Among 73 infectious skin lesions, bacterial etiology was found in 65 cases followed by viral etiology in 8 cases. Among bacterial diseases, 61 cases were of Hansen’s disease 2 while 4 cases were of Tuberculosis. Among 61 cases of Hansen’s Disease, most common was Borderline Tuberculoid leprosy (Figure II) with 15 cases (24.5%) followed by Tuberculoid Leprosy (14 cases;22.9%) and Lepromatous Leprosy (11 cases; 29.5%). Borderline Lepromatous lesions and Midborderline lepromatous lesion were 6 cases (9.8%) each. 4 cases (6.5%)of Indeterminate and 3 cases of Histoid Leprosy (4.9%) (Figure III) were also reported. Among Lepromatous Reactions, 2 cases of Type II Leprosy reaction Erythema Nodosum Leprosum were reported. (Figure IV) 21-30 years age group was the most common age group seen in 32.7% cases followed by 31-40 years. Males were more commonly affected than females(M:F=4.0:1). There were 4 cases of cutaneous tuberculosis comprising of 2 cases of Lupus Vulgaris and 1 case each of Scrofuloderma and Tuberculous Verrucosa Cutis. All 8 cases of cutaneous viral infections were of Verrucosa Vulgaris. Cutaneous Cysts Out of 72 cases of cutaneous cysts, 64 cases were epidermoid cyst and 8 cases were of Trichilemmal cyst. Epidermoid cyst were most commonly seen in 21-30 Years (11 cases; 35%) and 70% cases belonged to 11-40 years age group. Male preponderance was seen (M:F= 1.6:1) Vesicobullous diseases Among the 17 cases of Vesico-Bullous Diseases, most cases were Intra-Epidermal Blisters ( 15 cases; 88.2%) while Sub-Epidermal blisters constituted only 2 cases( 11.7%). Sub classifying Intraepidermal blisters on basis of location of blister, there were 2 cases of Corneal/Sub-corneal blisters, 7 cases of spinous Layer blister and 5 cases of Supra basilar blisters. Spinous layer blister comprised cases of Hailey-Hailey disease, Transient Acanthotic diseases and Spongiotic Dermatitis Most common vesico-bullous disease was Spongiotic Dermatitis(5 cases) followed by Pemphigus Vulgaris (4 cases).(TableIV) Non-Infectious Inflammation of the Epidermis and Dermis “Papulosquamous” disorders is defined clinically and is rather a heterogenous group in terms of pathogenesis. In a histologic classification, most of these conditions fall into the general category of diseases of the superficial cutaneous reactive unit. These disorders are characterized by superficial predominantly lymphocytic inflammation, with variable effects on the other structures of the superficial integument—the epidermis, the vessels of the superficial capillary-venular plexus, and the papillary dermis and includes basic patterns of perivascular, lichenoid, and psoriasiform dermatitis.1 In our study, 7 cases of Psoriasiform Dermatitis, 7 cases of Lichenoid Dermatitis and 2 cases of Perivascular inflammatory dermatoses were seen. Psoriasiform Dermatitis was seen in Psoriasis Vulgaris (2 cases)(Figure V), Parapsoriasis (2 cases) and Prurigo Nodularis (3 cases). Among cases of Interface Dermatitis, Lichenoid Interface Dermatitis was seen in Lichen Planus (3 cases), Pityriasis Lichenoid (2 cases) and Pityriasis Lichenoides et Varioliformis Acuta (PLEVA) (2 cases). Perivascular Dermatitis was seen in urticaria and Pityriasis Rosea. Connective tissue disorders of skin comprised of 5 cases of Discus Lupus Erythematosus, 3 cases of Morphea and one case of Solar Elastosis were seen. Non-neoplastic Pigment disorders included 3 cases of Ashy Dermatosis, one case of Melasma. Deposition disorders included one case each of Non-Granulomatous Inflammatory Tattoo Reaction, Ochronosis and Calcinosis Cutis. DISCUSSION In the present study, 205 skin biopsies of non-neoplastic lesions with a conclusive opinion were received over a period of one year were analysed. Age groups 31-40 yrs and 21-30 years showed equal predominance. 21-30 years age was the most common age group affected in Veldurthy5, Kumar et al.6 while 31-40 years was the most common age group affected in studies done by Gupta et al.7 Male predominance was observed in this study (M: F=2.8:1). This is consistent with most studies like Kumar et al.8, Veldurthy5. This can be explained on the basis that epidermoid cysts(64 cases) and Hansen’s disease (61 cases) formed the bulk of the cases and both had shown male predominance. As most patients visiting government hospital belong to lower socio-economic group hence illiteracy, occupation and social inhibition may be responsible for less reporting of cases in females in India. Infectious disorders were the most common categories in our study followed by Non-Neoplastic cutaneous cysts. The epidermoid cyst was the most common non neoplastic skin lesion with 64 cases (31.2%) closely followed by Hansen’s disease (60 cases; 29%). Hansen’s Disease was the most common lesion in studies done by Mittal et al.9, Kumar et al.8 and  Yalla et al.10. Non infectious erythematous papulosquamous lesions was the most common category in studies done by Gupta et al.7 and Gulia et al.3 On the other hand non infectious and vesicobullous Disease was the most common category in studies done by Adhikari et al.6 due to large number of spongiotic Dermatitis cases. As most studies on the histomorphological spectrum of skin lesions are done on punch biopsy hence epidermoid cyst has not been included in many studies. It is however one of the most common lesion of skin seen. If the epidermoid cyst is excluded, Leprosy with 61 cases (48.7%) will be the most common non-neoplastic skin lesion of this study. Leprosy was the most common infection in our study (84% cases). This is consistent with most studies like George et al.11 , Yalla et al.10, Mittal et al.9, Kumar et al.8 and Agarwal et al.12.  India continues to account for 60% of new cases reported globally each year.13 Skin biopsy is of vital importance in Hansen’s disease for not only diagnosis but also for correct histological classification, bacillary index and follow-up of treatment response and disease activity. It is also helpful in differentiating relapse from reversal reaction and categorising lepromatous reactions into type 1 and 2. In our study, among cases of Hansen disease, most common lesions were Borderline Tuberculoid leprosy with 23.3% cases followed by Tuberculoid Leprosy. Borderline Tuberculoid Leprosy was the most common form of leprosy reported in George et al.11 and Mamatha et al.14 and  Roy et al.15 while Tuberculoid Leprosy was the most common lepromatous lesion in Yalla et al.10 and Agarwal et al.12(Table V) Diagnosis of Leprosy can be made on the basis of clinical findings and skin biopsy is indicated if the diagnosis is in doubt, as in indeterminate leprosy and when other granulomatous disorders like lupus vulgaris or sarcoidosis cannot be ruled out. Indeterminate, polar Tuberculoid (TT) and Borderline Tuberculoid (TT) patients are included in the Paucibacillary group. The Multibacillary group includes Midborderline(BB), Borderline Leprosy( BL), polar Lepromatous Leprosy(LL).16 Since Multibacillary Leprosy forms can easily be diagnosed clinically therefore lesser skin biopsies from these lesions are sent to histopathology for confirmation. Hence BT and TT forms the bulk of the cases received in histopathology department. Borderline Tuberculoid Leprosy is the most common form of leprosy in India. Mid-borderline (BB) group is unstable and very prone to reactions, and may upgrade to BT or downgrade to BL. Ridley indicated that the BB group is very uncommon because “it is unstable”. For these reasons some authors have not included this borderline group in their classification.16 Leprosy was more commonly seen in males than females. This consistent with Veena et al.17, Vasikar et al.18 Male predominance may be because of many factors such as industrialization, urbanization and more opportunities for contact in males, social customs and taboos may account for the smaller number of females reporting for treatment to the hospital. Vesico-bullous diseases constituted 5.8% cases of all cases and 8.2% of all non-neoplastic non-cystic diseases. Intra-epidermal blisters with 85% cases comprised most of the vesiculobullous cases as compared to sub-epidermal blisters (15%) which is consistent with literature. The most common vesico bullous disease in our study is spongiotic dermatitis 5 cases; 29.4%) was the most common vesicobullous disease closely followed by Pemphigus Vulgaris (4 cases; 23.5%). This is consistent with studies done by Gupta et al.7 and Adhikari et al.6. Pemphigus Vulgaris was the most common vesicobullous lesion in studies done by Mamatha et al.14, Narang et al.19, Kumar et al.8 While clinical findings like age, location and distribution of blister, gross blister characteristics, arrangement of blisters, associated inflammatory background and medical history can help in assessing a blister and forming a differential diagnosis, a biopsy is essential to form a definite diagnosis.4 Histopathological examination is required for assessing the blister separation plane the mechanism(s) of blister formation and the character of the inflammatory infiltrate.1 In our study, lichenoid interface dermatitis and psoriaform dermatitis show equal predominance with 7 cases each. Psoriasis Vulgaris was the most common case of psoriaform dermatitis and Lichen Planus most common form of Interface (Lichenoid) Dermatitis.  Lichen planus  was the most common noninfectious erythematous papulosquamous disease followed by Psoriasis in studies done by George et al.11, Chavan et al.20, Barman et al.21 and D costa et al.22 Psoriasis was more common than lichen planus in studies done by Adhikari et al.6, Yalla et al.10 and Agarwal et al.12 Connective disorder constituted 3.6% of cases, pigment disorders constituted 1.9%, adnexal disorders constituted while genodermatoses and Vasculitis constituted less than 1%. In studies done by Adhikari et al.6, connective tissue disorder, pigment disorders, and non-neoplastic disorders of adnexal structures constituted 2.4%, 0.7%, 1% while, genodermatoses and vasculitis comprised 2.1% and 1% respectively. In Studies done by Gupta et al.7, connective tissue disorder, pigment disorders, non-neoplastic disorders of adnexal structures comprised 7.32%, 0.4%, 0.98%, 0.98%, 1.95%. Other studies have shown similar distribution.  It is to be noted that no classification is perfect and overlapping can be seen in several categories. For example, Discus Lupus Erythematosis has been included in connective tissue disorders in our study but it is also a type of interface dermatitis (Vacuolar Degeneration). Similarly, Darier’s Disease has been included in intra epidermal vesico-bullous disease   in our study but it is also a type of Genodermatoses and included in that category by studies done by Gupta et al.7 CONCLUSION Despite advancements in molecular techniques in diagnosis and prognosis, morphology still remains the basis of diagnosis for most neoplasms and many inflammatory dermatoses. Our study included 205 cases of non-neoplastic skin biopsy specimens and has documented the histopathological profile of skin lesions at our tertiary care center with a fairly high presence of infectious disorders and cutaneous cysts. Maximum biopsies received were in the age range of 21-30 years and 31-40 years. Males were predominantly affected. The most common non-neoplastic skin lesion in our study was an epidermoid cyst followed by Hansen’s disease. Borderline Tuberculous was the most common subtype of leprosy. Most common vesiculobullous disease was Spongiotic Dermatitis followed by Pemphigus Vulgaris.  The heterogeneity in the clinical presentation of skin diseases makes histopathological examination a  gold standard technique for final diagnosis and clinicopathological correlation. Acknowledgment–We acknowledge the support of our colleagues and technical staff of the department of pathology for their guidance as well department of dermatology. Conflict of Interest- None Source of Funding-None Authors’ Contribution Englishhttp://ijcrr.com/abstract.php?article_id=4549http://ijcrr.com/article_html.php?did=4549
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411413EnglishN2022July5Healthcare Inflammatory Markers as Predictors of Severity and Mortality in Coronavirus Disease: A Cross-sectional Study   English3035Saima JatoiEnglish Muhammad Adnan BawanyEnglish Sunil Dat MaheshwariEnglish Muhammad Akbar MemonEnglish Sheeza Saleem QureshiEnglish Hasham Masood QureshiEnglish Introduction: COVID-19 is a pandemic that demands swift, in-depth, and well-grounded research work. WHO (World Health Organization) has declared around 1 million deaths and confirmed about 35 million cases worldwide. Aim: To predict the role of three inflammatory markers (serum ferritin, C-reactive protein and lactate dehydrogenase) in severity and mortality in patients with corona virus disease patients admitted in the hospital. Methodology: Patients with traceable SARS-CoV-2 by polymerase chain reaction (PCR) were inducted into this study by simple random sampling. Patients with potential radiological scans but without positive SARS were not included in this study. The nasopharyngeal sample technique was used to check the presence of the virus. This viral load’s severity was checked via World Health Organization recommendations. All the information including the sociodemographic data, severity of disease and laboratory values of three inflammatory markers gathered on a semi-structured proforma designed for the study. Study Design: A Cross-Sectional study. Place and Duration: Isra University Hospital from 1st June 2021 to 31st December 2021. Results: 240 patients were included in the study; aged between 20 and 60 years. The values of the three inflammatory markers were found raised in the group of patients being studied (more frequently within the moderate and severe disease groups). C - reactive protein was raised in 122 patients, ferritin was raised in 83 patients and Lactate dehydrogenase was raised in 184 patients Conclusion: Measuring the values of CRP, LDH, and Ferritin at admission can be a reliable predictor of severity and mortality in SARs-CoV-2. Out of the three, ferritin is the best indicator and should be considered essential. EnglishCoronavirus disease, Mortality, Ferritin, CRP, Lactate dehydrogenase, Inflammatory Introduction COVID-19 is a pandemic that demands swift, in-depth, and well-grounded research work. The in-hospital presentation shows off an entire spectrum of symptoms in the affected population; from asymptomatic patients to patients with complete respiratory failure. The World Health Organization has declared around 1 million deaths and confirmed about a 35 million cases worldwide.1 According to the Pakistani Government, in Pakistan COVID-19 mortality rate has been recorded at 2.06%.2 Inflammatory markers are important in the assessment of this viral disease as inflammation plays an important role in its pathogenesis. When white blood cells in the body get activated as a result of viral infiltration, they release a large number of inflammatory chemokines and cytokines which in turn leads to the permeation of monocytes and neutrophils inside the lungs. As a result of which, the endothelium and the alveolar cells are damaged. This state of bodily conditions is termed acute respiratory distress syndrome or tissue hypoxia.3 C-reactive protein gets elevated in a COVID-19 infection and triggers a protective response in the body. This response allows it to bind itself with phosphocholine present on the surface of affected cells, which in turn activates the classical complement pathway and ejects the virus as well as the damaged cells from the host.4  Cytokine storms are the foremost reason for mortality in cases of severe disease. Interleukin-6 (one of the two inflammatory contributors) is the main protagonist. Unfortunately, in most Pakistani setups it cannot be routinely measured.5 C-reactive protein can instead be used as a substitute for reliable interleukin-6 testing, to measure these cytokine release storms.6 Inflammation is the main cause of death among patients as it can cause worsening of the respiratory function to the point where complete shut-down can occur in less than four days.7 In order to avoid this unfortunate situation, proper post-hospital care and monitoring can be instituted which can let the physicians keep track of the disease and introduce efficient and effective interventions in severe to critical patients. Many studies have been done in order to check the effectiveness of various inflammatory markers for COVID-19. Most of these markers that rank high in terms of reliability and effectiveness are not easily available and are also economically unfeasible. The three markers that were chosen for this study, serum ferritin, C-reactive protein, and lactate dehydrogenase are accessible at almost all laboratory settings. If certainty can be achieved in terms of the results of these three markers then this could mean that customized care is possible and can be given to individual patients to a great standard. COVID-19 is a disease that is relatively in its early period when it comes to the level of research done and meaningful/applicable medical literature gathered. Despite having accumulated a praise-worthy level of theoretical knowledge in terms of the disease itself, professional practitioners are unfortunately still lacking solid local data which could give concreteness to the inter-relationship of inflammatory markers and mortality. This piece of work is dedicated to establishing the reliability of the three inflammatory markers (namely serum ferritin. C-reactive protein and lactate dehydrogenase at hospital admission of infected COVID-19 patients for mortality, and to establish a definitive basis for best cutoff values for each marker.  Methodology This is a cross-sectional study and was conducted at Isra University Hospital from 1st June 2021 to 31st December 2021. The protocol for this study work was approved and allowed by the Ethics Review Committee of the said hospital. During the time period mentioned above the patients that had a confirmed case of the infection were considered valuable for study by simple random sampling. Consent was not taken from the patients as it was not considered a prerequisite for a study that was to publish the data anonymously in terms of the individual patient/participant. The diagnosis was made based on a positive polymerase chain reaction (PCR). Patients with potentially indicative radiological scans but without positive SARS test results (on more than one occasion) were specifically not included in the study. During the initial hit, the hospital data showed the mortality rate to be below 10%. A very recent study conducted in Pakistan showed the maximum AUC (Area under Curve) to be 0.875 for all three inflammatory markers.8 Keeping all the above in mind the following study group was considered. As per the institution’s protocol, a nasopharyngeal swab method for polymerase chain reaction (PCR) was used to ascertain the presence of the contagious viral infection in all patients prior to their admission to the hospital. The results were recorded qualitatively; either present or absent. Blood samples for the quantitative measurement of C-reactive protein, Ferritin, and LDH were taken within the first 30 minutes’ post-admission and were sent to Isra University Hospital laboratory. After the patients were discharged or post mortality the records for the total duration of in-hospital stay were also collected from the medical archives for the purpose of this study paper. Hospital’s lab information management software network was used in case of missing reports. After collecting and compiling all the hospital data against each individual patient, the disease severity for each case was marked using the World Health Organization assessment charts.9 As the number of patients falling within the critical disease category was meager, this category was merged with the severe disease category.   System IBM SPSS Statistics 20.0 Version was used for data analysis (IBM Corp, Armonk, NY). Data were expressed in the following two ways, Qualitative data: in terms of percentages and numbers/numeral figures and Quantitative data: in terms of mean±standard deviation. Interquartile range and median were used for variables that were continuous (interpolated) with the non-parametric distribution. Shapiro-Wilk test was used to check the normality of the data collected. All three categories of patients in terms of severity (keeping in mind that the fourth category ‘critical disease’ was made a part of the third ‘severe disease’ category) were tested using the Kruskal-Wallis method for the purpose of drawing comparisons between the interquartile and median ranges for the three inflammatory markers. Using the two outcome-based groups as a basis, levels of C-reactive protein, serum LDH, and serum ferritin were compared via independent-samples by Mann-Whitney U-test. Another indispensable test namely the Chi-square/ Fisher’s exact test was used to compare the proportionality of patients (of separate groups) with high ranges of inflammatory markers against each other. After all these tests were applied, the ROC (receiver operating characteristic) curve analysis was done to measure both the specificity and the sensitivity of CRP, LDH, and Ferritin as predictors of mortality. This curve was also used to determine their cut-off values in order to ascertain and justify the most appropriate times for intervention. IBM SPSS Statistics (the system previously referred to) automatically generated the AUC (area under the curve) values for each marker, hence helping with the study. This parameter throws light on how significantly efficient the statistical model is at differentiating. For instance, if the differentiation between the number of people dying in-hospital or getting discharged is good, then the model would show a raised value for AUC. In order to calculate the probability of the patients getting discharged, the study used the Kaplan Meier methodology. p 41.8 mg/L, acute complications are expected.19 Luo et al. CRP >41.4mg/L is 95% sensitive as a predictor as well as 77.6% specific when it comes to death in hospitalized patients.20 COVID-19 is not the only viral infection to have raised levels of LDH. Other viral diseases such as H5N1 and MERS-CoV also result in increasing LDH levels.21 If the level of LDH rises by two, then it becomes a very surefire marker of death in the hospital cohort. If LDH levels ≥1200 U/L then according to an American study, one is eight times more susceptible to death than one with levels less than 1200 U/L. A local study (in Pakistan) done by Asghar et al. took under the microscope 360 indoor patients afflicted by COVID-19.8 This study was done for the purpose of measuring a large number of parameters. Fortunately, this set of parameters also included the three inflammatory markers. All three markers showed lower values when compared to the results of the study at hand. Surprisingly, they deduced serum ferritin as the weakest mortality predictor. Despite this interesting inference, we would still encourage the use of ferritin as the first priority. The distribution of males and females per each class of severity was unequal in this study despite as per the fact that males overall greatly outnumbered the females 22. This is not surprising as the data from Global Health 50/50 Research Initiative also shows a percentage as high as 74% of the affected population in Pakistan to be only males.23 This is not the case with European countries. Their datasets show the number of male and female confirmed case affected to be approximately equal in number.24 This discrepancy could be because of the conservativeness of our society which renders the females to be less outgoing and hence contracting less disease. One thing to note, which makes this dataset consequential, is that the blood sampling for all patients was done strictly within the first 30 minutes post-admission. This was because of the hospital protocol. Consequently, in order to avoid partiality, patients who could not be assessed within this time period upon admission were entirely excluded from the study population. For this study, the authors studied the inflammatory markers only in the beginning. It would be fascinating to know how these markers fluctuate throughout the stay of the patient; how hospitalization affects the results. Even though some inflammatory markers are already established as reliable, such as interleukin-6 and procalcitonin, the authors could not test them due to a number of reasons, most of which were of a financial nature. This was a period of intense workload for the participants performing the analysis. For this reason, no standardized textbook format was used to document the data. The negative impact of this was that the authors could not include within this research the study of the factors that adversely affect the levels of the three inflammatory markers, specifically CRP. One such example is the patients with cirrhosis. Their CRP levels are naturally lower than the rest. Another example consists of those patients that are on medications like statins.25 They also have a decreased level of CRP in their blood. Conclusion Serum C-reactive protein, LDH, and Ferritin if measured at the time of admission can prove to be reliable predictors of severity and mortality in COVID-19 disease. Out of the three, ferritin is highly sensitive and should be considered essential. FUNDING SOURCE None. CONFLICT OF INTEREST None. PERMISSION Permission was taken from the ethical review committee of the institute Englishhttp://ijcrr.com/abstract.php?article_id=4550http://ijcrr.com/article_html.php?did=4550