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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareHEPATOCELLULAR CARCINOMA TREATMENT; NONSURGICAL APPROACHES
English0104Mohammed AlnaggarEnglishPrimary liver cancer (PLC) is one of the common cancers with high incidence and poor prognosis. PLC has become one of the major diseases that causes serious harm to human health and life. In recent years, domestic and foreign researchers have studied and summarized the current status of primary liver cancer treatment, and have made great progress as well. Significant progress in terms of early diagnosis, surgical treatment, and comprehensive treatment of liver cancer results in improvement in patient’s quality of life. So far, there are many available methods that can be used to improve the quality of life in these patients, but still there are many issues that need to be addressed intensively. The progress in the study of liver cancer may bring about a new hope for the treatment of liver cancer.
Non-surgical treatment plays an important role in the treatment of primary liver cancer, which includes transcatheter arterial chemoembolization, percutaneous ablation therapy, radiation therapy, chemotherapy, etc
EnglishPrimary liver cancer; Non-surgical treatments progress, Quality of lifeINTRODUCTION 1.
Percutaneous ablation therapy
Percutaneous ablation is a curable treatment option for small tumors, which can be used for 1. tumors with diameters less than 5 cm; 2. The number of single HCC tumors is less than three ; 3. the diameter of a single tumor is less than 3 cm in hepatocellular carcinoma patients. Tumor recurrence and survival rate after ablation is almost the same as surgical resection of the tumor which is 2cm, Radiofrequency ablation (RFA) is more effective than PEIT, which can kill tumor cells by generating heat conducted by electrode alternating current [8-9]. Complete tumor destruction caused by RFA treatment is difficult to achieve especially for those tumors which are close to large vessels, sub-capsular or gallbladder, therefore orthotropic recurrence rate of tumor is higher. therefore, the insufficiency of RFA can be avoided by binding it to PEIT, resulting in complete tumor destruction. The radiofrequency treatment for tumors on the first hilar region should be done carefully to avoid damage to the bile duct. Uehara et al [10] pointed that the damage can be reduced by the formation of ascites because it can increase the gap between diaphragm and abdominal wall. Because of similar indications of RFA and PEIT, Seror ea al [11] compared the differences in efficacy between RFA and PEIT, and found that 2-year overall survival rates were 91.2% and 70.8%, tumor-free survival rate were 80.7% and 68.5%, and complication rate were 15% and 6.9% respectively. Few other researches [12] showed that, the efficacy of RFA is superior to laser treatment. The use of microwave thermal effects can cause coagulative necrosis of tumor. The effect of microwave coagulation therapy for small hepatocellular carcinoma is good. the time interval between each therapy is shorter which means more frequent treatment regimens [13], tumors less than 3 cm in diameter, can be treated by a multi-multi-point needle and other combined ways to improve the efficacy of radiation. Seki et al [14] presented the data of 68 patients with small hepatocellular carcinoma which shows that microwave treatment can be carried out laparoscopically for small tumors near the surface of the liver. The results indicated that 1, 3 and 5-year survival rates were 97%, 81% and 43% respectively. Besides, the incidence of complications is lower. Cryosurgery – The needles are introduced into the tumor to freeze and kill the tumor cells. The temperature of superconducting tip can be reduced to -140°C in a few minutes when the argon gas released in high pressure and normal temperature. With the release of helium, the temperature can increase to 45°C. Argon-helium refrigeration has higher efficiency and more reliable efficacy compared with the traditional technique with frozen liquid nitrogen. Other percutaneous ablation therapies include percutaneous laser hyperthermia in the tumor and high-intensity focused ultrasound et al?. Multi-point fiber laser treatment has a freezing range that can be extended under the guidance of ultrasound. Laser hyperthermia also has a hemostatic effect that can stimulate the body’s immune function to kill tumors. However, currently reports have showed that multiple laser hyperthermia can be used in the treatment of multiple primary liver cancer with diameter Englishhttp://ijcrr.com/abstract.php?article_id=205http://ijcrr.com/article_html.php?did=2051. Sala M, Llovet J M, Vilana R, et al. Initial response to percutaneous ablation predicts survival in patients with hepatocellular carcinoma [J]. Hepatology, 2004, 40(6): 1352-1360.
2. Lencioni R, Cioni D, Crocetti L, et al. Early-stage hepatocellular carcinoma in patients with cirrhosis: long-term results of percutaneous image-guided radiofrequency ablation[J]. RadiologyRadiological Society of North America, 2005, 234(3): 961-967.
3. Tateishi R, Shiina S, Teratani T, et al. Percutaneous radiofrequency ablation for hepatocellular carcinoma[J]. Cancer, 2005, 103(6): 1201-1209.
4. Omata M, Tateishi R, Yoshida H, et al. Treatment of hepatocellular carcinoma by percutaneous tumor ablation methods: ethanol injection therapy and radiofrequency ablation[J]. Gastroenterology, 2004, 127(5): S159-S166.
5. Teratani T, Ishikawa T, Shiratori Y, et al. Hepatocellular carcinoma in elderly patients[J]. Cancer, 2002, 95(4): 816-823.
6. Kurokohchi K, Hosomi N, Yoshitake A, et al. Successful treatment of large-size advanced hepatocellular carcinoma by transarterial chemoembolization followed by the combination therapy of percutaneous ethanol-lipiodol injection and radiofrequency ablation[J]. Oncology reports, 2006, 16(5): 1067-1070.
7. Okano H, Shiraki K, Inoue H, et al. Combining transcatheter arterial chemoembolization with percutaneous ethanol injection therapy for small size hepatocellular carcinoma[J]. International journal of oncology, 2001, 19(5): 909-912.
8. Shiina S, Teratani T, Obi S, et al. A randomized controlled trial of radiofrequency ablation with ethanol injection for small hepatocellular carcinoma[J]. Gastroenterology, 2005, 129(1): 122- 130.
9. Lin S M, Lin C J, Lin C C, et al. Radiofrequency ablation improves prognosis compared with ethanol injection for hepatocellular carcinoma≤ 4 cm[J]. Gastroenterology, 2004, 127(6): 1714-1723.
10. Uehara T, Hirooka M, Ishida K, et al. Percutaneous ultrasoundguided radiofrequency ablation of hepatocellular carcinoma with artificially induced pleural effusion and ascites[J]. Journal of gastroenterology, 2007, 42(4): 306-311.
11. Seror O, N’kontchou G, Tin Tin Htar M, et al. Ethanol versus radiofrequency ablation for the treatment of small hepatocellular carcinoma in patients with cirrhosis: A retrospective study of efficacy and cost[J]. Gastroentérologie clinique et biologique, 2006, 30(11): 1265-1273.
12. Ferrari F S, Megliola A, Scorzelli A, et al. Treatment of small HCC through radiofrequency ablation and laser ablation. Comparison of techniques and long-term results[J]. La radiologia medica, 2007, 112(3): 377-393.
13. Shibata T, Iimuro Y, Yamamoto Y, et al. Small hepatocellular carcinoma: comparison of radiofrequency ablation and percutaneous microwave coagulation therapy[J]. RADIOLOGY-OAK BROOK IL-, 2002, 223(2): 331-338.
14. Seki S, Sakaguchi H, Iwai S, et al. Five-year survival of patients with hepatocellular carcinoma treated with laparoscopic microwave coagulation therapy[J]. Endoscopy, 2005, 37(12): 1220- 1225.
15. Goldstein H M, Wallace S, Anderson J H, et al. Transcatheter Occlusion of Abdominal Tumors 1[J]. Radiology, 1976, 120(3): 539-545.
16. Vogl T J, Naguib N N N, Nour-Eldin N E A, et al. Review on transarterial chemoembolization in hepatocellular carcinoma: palliative, combined, neoadjuvant, bridging, and symptomatic indications[J]. European journal of radiology, 2009, 72(3): 505- 516.
17. Liu M T, Li S H, Chu T C, et al. Three-dimensional conformal radiation therapy for unresectable hepatocellular carcinoma patients who had failed with or were unsuited for transcatheter arterial chemoembolization[J]. Japanese journal of clinical oncology, 2004, 34(9): 532-539.
18. Tatsumi T, Takehara T, Kanto T, et al. Administration of interleukin-12 enhances the therapeutic efficacy of dendritic cell-based tumor vaccines in mouse hepatocellular carcinoma [J]. Cancer research, 2001, 61(20): 7563-7567.
19. Peng B G, Liang L J, He Q, et al. Tumor vaccine against recurrence of hepatocellular carcinoma[J]. World J Gastroenterology, 2005, 11(5): 700-704.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareANATOMIC CONFIGURATIONS OF EXTERNAL BRANCH OF SUPERIOR LARYNGEAL NERVE AND SUPERIOR THYROID ARTERY: A STUDY IN CADAVERS
English0508Swapnali ShamkuwarEnglish PS BhuiyanEnglishObjectives: Thyroidectomy is one of the commonly performed procedures in head and neck surgery. Injury to the external branch of superior laryngeal nerve occurs frequently in thyroid surgery which can result in voice changes in the patient. The aim of the present study is to study the anatomical relationship between external branch of superior laryngeal nerve and superior thyroid artery.
Methods: Sixty specimens of the thyroid gland of both sexes were studied. The distance between superior pole of thyroid gland and crossing point of superior thyroid artery and external branch of superior laryngeal nerve was measured and recorded.
Results: The external laryngeal nerve was categorized into three types. In 63 (52.5%) cases the nerve crossed the superior thyroid artery more than 1cm (type1) and in 47 (39.16%) cases it crossed the artery less than 1cm (type 2a) above the upper pole of the thyroid gland. In 10 (8.33%) cases the nerve crossed the artery under cover (type 2b) of upper pole of the thyroid gland.
Conclusions: A sound knowledge of the anatomy of the external laryngeal nerve and its relation to superior thyroid artery and superior pole of thyroid gland is helpful to minimize lesions of the nerve and perform safe surgery on thyroid gland.
EnglishSuperior laryngeal nerve, Superior thyroid artery, Thyroid glandINTRODUCTION
The superior laryngeal nerve (SLN)arises from vagus nerve after it leaves the skull base. It typically originates from the vagus at the no dose ganglion 1 and divides into an internal and external branch at the level of superior cornu of hyoid bone2 . The external branch of superior laryngeal nerve (EBSLN) first descends dorsolaterally to the carotid arteries and extends medially towards the larynxand usually crosses the superior thyroid artery(STA) near the thyroid gland. After giving off some twigs to the inferior pharyngeal constrictor, the EBSLN terminates mainly within the cricothyroid muscle3 . The course of the EBSLN in the neck places it at risk during thyroid or parathyroid surgery, carotid end arterectomy and anterior approaches to the cervical spine4 .Preservation of the EBSLN is important for optimal function of the larynx5 . It gives nerve supply to same side cricothyroid muscle6 to tense the vocal cord4 . Ipsilateral paralysis of cricothyroid muscle occurs due to damage of EBSLN5 which can lead to changes in voicequality and projection1 . EBSLN is highly vulnerable during ligation of superior thyroid artery of thyroid gland 6 . Because of the close relationship between STA and EBSLN it may be inadvertently stretched, ligated or transacted 4 .The topographical relationship to the STA and the upper pole of the thyroid gland represents the key point for identifying the EBSLN during surgery of the neck. When these two landmarks are considered, identification and protection of the nerve are easy3 .Cernea7 carried out a study to identify the EBSLN and analyze its anatomical relations with the superior pedicle of the thyroid gland.
THE CERNEA EBSLN CLASSIFICATIONSCHEME IS AS FOLLOWS:
The type 1 nerve crosses the superior thyroid vessels more than 1 cm above the upper edge of the thyroid superior pole The type 2A nerve crosses the vessels Englishhttp://ijcrr.com/abstract.php?article_id=206http://ijcrr.com/article_html.php?did=2061. Barczynski, M, Randolph G W, Cernea CR, Dralle H, DionigiG, Alesina PF, Mihai R External Branch of the Superior Laryngeal Nerve MonitoringDuring Thyroid and Parathyroid Surgery: International Neural Monitoring Study Group Standards Guideline Statement. Laryngoscope2013; 123: s1-s14.
2. Taytawat P. Viravud Y DDS, Plakornkul V DVM, Roongruangchai J DDS, Manoonpol C Identification of the External Laryngeal Nerve: Its Anatomical Relations to Inferior Constrictor Muscle, Superior Thyroid Artery, and Superior Pole of the Thyroid Gland in Thais. J Med Assoc Thai 2010; 93 (8): 961-8.
3. Kierner AC, Aigner M, Burian M. The External Branch of the Superior Laryngeal Nerve Its Topographical Anatomy as Related to Surgery of the Neck Arch Otolaryngol Head Neck Surg. 1998;124(3):301-303.
4. Morton R P, Whitfield P, Al-Ali S Anatomical and surgical considerations of the external branch of the superior laryngeal nerve: a systematic review Clinical Otolaryngology 2006;31:368–374.
5. Friedman M, LoSavio P, Ibrahim H. Superior laryngeal nerve identification and preservation in thyroidectomy. Arch Otolaryngol Head Neck Surg 2002; 128: 296-303.
6. Thiagarajan B, Ramamoorthy G. Preventing Nerve Damage During Thyroid Surgeries. Webmed Central otorhinolaryngology 2012;3(4):wmcoo3260.
7. Cerena CR, Ferraz AR, Furlani J, Monterio S. Identification of the external branch of superior laryngeal nerve during thyroidectomy. The American Journal of Surgery 1992Dec;164:634-9.
8. EstrelaF, LeãoHZ, JotzGP Anatomic relation between the external branch of the superior laryngeal nerve and the thyroid gland. Brazilian journal of otolaryngol 2011 March- April; 77(2):249- 58.
9. Bellantone R, Boscherini M, Lombardi CP, Bossola M, Rubino F, De Crea C, et al. Is the identification of the external branch of the superior laryngeal nerve mandatory in thyroid operation Results of a prospective randomized study. Surgery 2001; 130: 1055-9.
10. Cernea CR, Nishio S, Hojaij FC. Identification of the external branch of the superior laryngeal nerve (EBSLN) in large goiters. Am J Otolaryngol 1995; 16: 307-11.
11. Aina ENHisham ANExternal laryngeal nerve in thyroid surgery: recognition and surgical implications. ANZ J Surg 2001 April; 71(4):212-4.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareGOVERNMENT AND SOCIAL CONFLICTS BETWEEN TRADITIONAL RULERS AND PRESIDENTS-GENERAL OF TOWN UNIONS (TUS) IN ANAMBRA STATE, NIGERIA
English0913Andrew O. ObiajuluEnglish Makodi Biereenu-NnabugwuEnglishThis paper has investigated how financial releases and creation of care-taker committees by Anambra state government influence social conflicts between Traditional rulers and Presidents-General of TUs in some communities. About 524 respondents given the quantitative tool for this study were drawn from members of TUs within the three communities used for the study: Nri,Isi-agu and Amansea. Qualitatitve data were also derived for the study from: victims of TU conflict, members of the vigilante, government officials involved in resolving TU conflicts and community leaders. Findings showed that the state government is a pronounced source of social conflict between the institutions. It does that through her financial releases; creation of care-taker committees and fermenting conflict even in peaceful communities that are seen as her political opponents. Government officials associated with fermenting TU conflict should be prosecuted (Word count: 131).
EnglishSocial conflicts, Town unions, Presidents-General, Community leaders, Care-taker committees, Anambra stateINTRODUCTION
Town Unions are social organisations existing in many cultural areas of Nigeria. They are known by different names such as: development unions, progressive unions, people`s assembly etc.IThey arose to advance the primordial cultural value preferences of communities having them. Their members claim a common ancestry and developmental challenge as Nigerians. As agents of social change, they have demonstrated that, through collective action, they can improve on their material conditions of existence (Azikiwe, 2001), mobilise against the out-group (Nzimiro, 2001), and defend a common cause (Nwosu, 2009). Although TUs are locally initiated, their influence and cultural appeal transcends local confines. Their members believe that, through collective action, they can modify national policies to suit local realities, needs and challenges. In pre-colonial Igbo society, it exited as a well-structured social network that guaranteed civil society participation in governance namely: the village assembly (Afigbo, 1972), council of elders (Nzimiro, 1972), the okpala in family and lineage administration (Ifemesia, 1980), the age grade system (Nwosu, 2009) and so on. Through such associational life, members of a community indulge in self governance through dialogue, consultation, advocacy and consensus building. Lineages comprising a town or community are hierarchically organised. Thus, Nzimiro (2001:10), notes that “within a lineage are adopted lineages absorbed within specific lineage groups”. Most of the adopted lineages suffer some social disabilities. Consequently, when a TU is assumed to have a common ancestry, its internal structure has endemic social formations that predispose its members to fission. That notwithstanding, in Nigeria, TUs have tried to assist their members from colonial days to the modern era, meet their survival needs, especially the challenges of urban life (Nnoli, 2008), rural development (Nzimiro, 2001), political mobilisation against the out-group (Nwosu, 2009), scholarship programme (Azikiwe, 2001) and relating to the state on community development matters (Okafor, 2010). As agents of community development, TUs exist as: channels through which local needs and preferences are identified, expressed and addressed. To do this, they create the enabling environment for voluntary cooperation, selfhelp and mutual aid efforts to thrive among their members.
Structurally, every TU has a working constitution adopted by the members. This defines the roles, status and benefits of membership of the association (Aguda, 1998; Nwosu, 2009). TUs have male and female wings. Women`s wing of TUs are those whose husbands belong to the men`s wing. However, in a community like Mbieri, unmaried women who are up to 45years can become members (Nwosu, 2009).They are structured like men`s wing. Mbanefoh (1998:103) describes the Eziowelle women’s wing as having elected officers comprising president, vice-president, secretary, treasurer, financial secretary and provost. Women officers handle all matters affecting their wing,but they are expected to seek advice from the men`s branch in serious matters. This expectation reinforces the subordinate position of women in Igbo society.
Traditional rulers
According to Cap (148) of 1986, which established Anambra State Traditional Ruler`s Council, a traditional ruler is a recognized head of an autonomous community in the state. They are known by different names such as Igwe, Obi, Eze and so on.They are expected to be the gate keepers of their communities.They symbolise the collective spirit of the people they represent. When percieved as ancestors reincarnate many believe they can bless and curse their subjects .Although this institution never prevailed in some pre-colonial Igbo societies, not many people today can wish it away.
Conceptualising the relationship between the government, traditional rulers and PresidentsGeneral of TUs.
The process of acquiring, consolidating and using state power in Nigeria has been conflict -infested (Nnoli, 2012).The norm of civil society administration promotes prebendial politics at different levels of government. Co-existence of TUs, traditional rulers and state machinery of civil-society administration, is amply illustrated by the theory of two publics which face most Nigerians in their civic engagements namely: that associated with their primordial cultural preferences and that represented by the civic cultural equivalent (Ekeh, 1975). Members’ inclination to the former explains why they tend to shift their loyalty from the state towards the development of their homelands, often avoid payment of taxes to the state and periodically, honour a member that has attracted public amenities from the state to the homeland (Nwoga, 1987). In this way, TUs often serve as institutional mechanisms for struggling for collective resources at the state level. The government hardly constrains many members of TU from acting out their free will on community development matters (Igun, 2006, Okafor, 2010). Infrastructural facilities which TUs have built, through selfhelp exist in many communities of igboland.Because TUs are rallying points for socio-political mobilization, the government finds them useful in public service delivery. In Anambra state, a law which makes TUs independent of traditional rulers exists. Thus, whereas traditional rulers are described as custodians of cultural values of their people, PresidentsGeneral of town unions are entrusted with the day to day administration of their communities. Role conflict tends to arise between them often due to struggle over values (Coser, 1957). Moreover, TUs are expected to recommend political officeseekers before they are considered at state level (Atupulazi, 2011). Also, government makes periodic financial releases to the TUs for public service delivery (Ilozue, 2010). PresidentsGeneral of TU are members of Anambra State Association of Town Unions (ASATU), a socio-political organization where matters of state and national importance are unofficially discussed. Its` members are believed to be important stake holders in the political process of the state (Atupulazi, 2011; Ilozue, 2010). It`s members can be rewarded. Although Leadership struggle pervades many TUs (Onu, 2011, the government is not wonderfully disposed to it`s peaceful resolution. Government officials have been implicated in exacerbating conflicts between traditional rulers and presidents-general of TUs in communities like: Isiagu, Isuofia, Awka Etiti (Onwuegbusi, 2011); Aguleri (Ibeanu, 2003); Alor (ADI, 2014); Nawfia (Nwakwesili, 2012); Ekwulobia (Maduabuchi, 2013) etc. In these communities, government imposes care-taker committees to manage the affairs of communities it defines as having conflict-infested TUs their objection, notwithstanding.
Traditional ruler’s involvement in TU affairs
While the TUs can be said to have evolved from the cultural preferences of the people, the traditional rulership cannot be so described. Igbo society is described as acephalous. Kings existed only in centralized polities like: Nri (Onwuejiogwu, 2001); Onitsha and Oguta (Nzimiro, 1972); Osomari and Aboh (Wandeers, 1990). It is only among these riverine Igbo people that kings existed as in such centralized polities like Oyo, and Benin, (Afigbo, 1972); Wandeers,1990; Nwosu, 2009). Colonial rule, through the 1916 Ordinance, created and imposed warrant chiefs on the Igbo people. The warrant chiefs were arbitrarily chosen by the colonialists. They became the channel of communication between the colonialists and the colonised. They were used in tax collection and settlement of disputes in colonial courts. The conflict and social disapproval surrounding their appointment and roles were some of the factors that led to the Aba Womens Riot of 1929 (Ananaba, 1980).The women objected to an envisaged taxation of women by the colonial masters through the warrant chiefs. Following the military coup of January 1966 in Nigeria, the hieftaincy institution was suspended. However, in 1978, an edict was enacted reinstating it. Many families that produced the warrant chiefs saw it as their birthright. Conflict arose in many communities when many of them were resisted (Nwosu, 2009). The military was not prepared to interrogate these conflict situations. Some wealthy indigenes who were influential enough to ‘buy’ the position, did so. Many of them became traditional rulers. Rulers who emerged in this way were extensively used by the military to stay in power. They became one of the agents of conflict suppression under military rule in Nigeria. Under the prevailing democratic dispensation, traditional rulers are still seen as custodians of primordial cultural values of their people. This often makes their roles to conflict with that of TU leadership. In communities like Onitsha (Azikiwe, 1976); Ekwulobia, Ogbunike (Okafor,2010), the traditional rulers and their TUs have been in court. Also, the government created the Traditional Rulers Council where government-recognised traditional rulers periodically meet and network with state government officials on matters of state policy and direction. In this way government manipulates local institutions at will. Government hardly investigates role conflicts between traditional rulers and Presidents-General of TUs. For example, in Ekwulobia, the traditional ruler connived with the Commissioner for Local Government and Chieftaincy Matters to proscribe their TU. He ignored an order given by the Aguata High Court to restore the TU. Also in Ebenebe, the same commissioner was said to be very reluctant bringing the President-General of their TU to order. Although Edict 22 of 1986 expects that TUs will elect their traditional rulers according to the culture of the community, the document makes mockery of the TUs because the culture in question has no room for traditional rulers position, hence the imposition of the body on the people. Town unions are also expected to present the elected traditional ruler to the chairman of their local government who will, in turn, present the ruler-elect to the government (Nwosu, 2009). This provision is based on a false notion of representativeness. The provision little addresses endemic social arrangements that make such a selection elitist and unrepresentative of the people’s value preferences and needs. The provision has created a situation where some of those opposed to a particular traditional ruler–elect, have taken to the formation of a parallel TU. Nwosu (2009:18) avers that: ‘from all indications, the eze established by governments statutes, crowned by the government, paid by the government and removed at will by the government cannot be said to enjoy a high level of autonomy`. Research questions How has government`s financial releases to communities, influenced the relationship between traditional rulers and presidents-general of TUs in Anambra state? 1. Has the creation of care-taker committees by Anambra state government enhanced the relationship between traditional rulers and presidents-general of TUs?
Methodology
The study adopted a cross- sectional survey design. Nri was selected through simple random sampling method from a list of 5 communities with two TUs in the state where one should exist. Likewise, Isiagu was selected from a list of 12 communities with care-taker committees. Amansea was selected purposively from list of 160 communities with functional TUs as the study locations. A semi-structured questionnaire was used to collect quantitative data from 516 respondents. The sample frame was the list of TU members as held by ward leaders in the towns. Participants were selected as follows (Nri-128; Isiagu-204 and Amansea-184) using simple random sampling method. Whereas 12 in-depth interviews were conducted on members of vigilante (6), victims of TU conflicts (6), 23 key informants interview were conducted on traditional ruler`s representatives (6), ward leaders (15) and government officials (2) to obtain qualitative data for the study. The quantitative data collected were analysed using descriptive statistics, Chi-square test at 0.05 level of significance. Qualitative data were content analysed.
RESULTS
State Governments’ financial releases as a source of TU conflict In Isiagu, 75.6% of respondents saw this variable a significant source of TU conflict (x2 =52.8; p.001). In Nri, 53.3% of respondents held a contrary view but this was not statistically significant (x2 .53; p.5). Also in Amansea, 98.4% did not see the release as a source of their TU conflict (x2 =39.5; p.001). It can be inferred that State Government’s financial releases to TUs is a source of conflict in Isiagu and to an extent Nri. Qualitative data from Nri upholds that: Financial releases to communities in the state through town unions don’t reach us. The road network to our section of Nri town is not tarred. When government gives allocation for the renovation of roads, they simply trip laterite on some of our roads and leave it to be washed by the rains (KII, Secretary Ikenga Nri). Here again, The President-General and his loyalists thought governments’ financial allocation to Nri town should be appropriated by the town union alone. When they discovered the palace is entitled to partake in its disbursement, they took an avoidance approach. For this reason Eze Nri is often compelled to go to the state government for the money (KII, community leader Nri).
In Nri therefore, the financial release is a source of conflict within members of NPU and between them and members of Ikenga-Nri, the parallel TU. In Isiagu, a school block initiated by the caretaker committee, with two million naira released to them by the state, could not be completed. Both members of caretaker committees, and elected TU officials never explained to anybody, how they spent the finance released to the TU. “Leadership of our TU has been characterized by the leaders trying to intimidate and silence those who tried to probe into how the financial releases were utilized” (KII, ward leader Isiagu). In Amansea, the financial release was not seen as a source of conflict by President-General of the TU. He contended that the traditional ruler does not get involved in the utilisation of the fund. This is at variance with what we found at Nri and what a government official involved in the disbursement remarked. To exclude royal fathers in the disbursement of such monies is to put cracked palm kernels in a perforated sack. Royal fathers exist to ensure the finance is judiciously utilised (KII, government official).
Creation of caretaker committee by the state as a source of TU conflict.
In Isiagu, 57% of the respondents saw the creation as an external source of TU conflict (x2 =3.9, p 0.5). In Nri, 78.9% of respondents did not see such a creation as a source of TU conflict. This is not different from the responses got from Amansea where 79.9% did not see the creation of caretaker committee as a source of TU conflict. Thus but for Isiagu, where respondents were divided on this, the creation of care taker committee was not seen as a source of TU conflict in communities without such a committee in Anambra State. The finding is not at variance with some of our respondents` view during the KII and IDI sessions. In Isiagu, (the only community that experienced the caretaker committee), the source of the conflict was inordinate ambition of the selfstyled kingmaker to dictate how TU should be run. Caretaker was an aftermath of this quest.
In 2008 while our town union election was in progress, a very rich man from Ebe (one of the factions to the conflict), stormed the venue of the election with a team of mobile policemen. He was opposing a candidate nominated and presented by Umuzo (another party to the conflict), according to the constitution of our TU. They were asked to leave. They did. On hearing that the election had been held, the man used his connections with the state governments’ ministry of local government and chieftaincy matters to nullify the election and impose a caretaker committee on us. We challenged the government by obtaining court injunction restraining the government from imposing the caretaker committee. Government ignored this court order (KII, Community leader, Isiagu). This finding shows how conflict suppression has permeated institutions for civil society administration in Nigeria. It was entrenched by colonial rule, sustained after it , perfected by the military while in power and has remained resilient virus threatening the evolution of true democratic culture in Nigeria. Discussion of findings Financial releases to TUs are poorly accounted for. Nigerian leadership has been criticised for being incurably corrupt (Beckman, 1985; Joseph, 1992; Nzimiro, 2001, Achebe, 2012). Nzimiro(2001)and Igun (2006), associated the corruption to the character of Nigeria’s dependent capitalist economy. It is an economic arrangement that encourages skewed distribution of collectively owned resources by agents of the state. This study showed how the practice prevails at the grassroots. Nri and Amansea had not experienced caretaker committee. Nri people attributed this to their cultural proscription of shedding human blood. Their land abhors bloodletting (Okonkwo, 2007). In Amansea, the traditional ruler is said to be working hand in hand with the president general. It respected by the state government. Conflict suppression is a pronounced strategy of using state power in Nigeria. To Albert,(2003), the method is a mere expression of social conflict arising from unequal power relations.
CONCLUSION
This study has shown how two efforts of the government to facilitate community development, influenced the emergence of social conflict in the communities studied. This is partly because some top government functionaries who are expected to be objective in managing communal conflicts actually ferment the same. At a time when most ethnic groups in Nigeria complain of being marginalized, this study has shown that identity politics prevails even within communities considered culturally homogenous. Thus even if TUs are made states, the problem of social exclusion will be far from being over. It is therefore necessary that public functionaries be made to be universalistic in thinking. This entails their de emphasizing primordial sentiments in matters of state policy formulation and implementation.
ACKNOWLEDGEMENT
We acknowledge help from the scholars whose works are cited in this study, and also, that this study benefitted significantly from Obiajulu, Andrew (2014) Perception of Sources, Effects and Resolution Methods of Conflicts in Town Unions in Anambra State, Nigeria a Ph.D Dissertation submitted to the Department of Sociology, University of Ibadan, Nigeria
Englishhttp://ijcrr.com/abstract.php?article_id=207http://ijcrr.com/article_html.php?did=2071. Achebe, C. 2012. There was a country personal note of Biafra Allen Lane: Penguin.
2. ADI, 2014. Alor Development Initiative “Anambra State acts of meddlesomeness in internal affairs of Alor community and continuous acts of marginalization and persecution against Alor indigenes” in 247 U Report of May 18.
3. Afigbo, A. 1972. The Warrant Chiefs. London: Longman.
4. Albert, O. I. 2003. The Odi Massacre of 1999 in the context of the Graffiti left by the Invading Nigerian Army. Ibadan: Programme on Federal and Ethnic Studies (PEFS).
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8. Azikiwe, N. 1976. Let us forgive our children. Onitsha: Tabansi Press.
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10. Coser, L. 1957. The functions of social conflict Glencoe: The free press. 11. Ekeh, P. 1975. Colonialism and the two publics In Africa: A theoretical exploration. Studies In Society and History Vol.17, No 1
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18. Mbanefo, V. 1998. Eziowelle Improvement Association Home Town Associations Indigenous Knowledge and Development, Honey , R .and Okafor, S. (eds) Ibadan:Sam Bookman Publishers.
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21. Nwosu, A. C. 2009. Episodes in encounter between the town unions and the Eze institution over issues of good governance downloaded @ ttp//www.assatashakur.org/forum/hanescircle/34548-episodes encounter between town unions – Eze institution.html/ posted November 2.
22. Nzimiro, I.1972. Studies in Igbo political systems: chieftaincy and politics in four Niger States. London: Frank CASS. 23. Nzimiro, I. 2001. Strangers at our gate: the Igbo nationality in Nigeria Oguta: Zim Pan Press.
24. Okafor, B. 2010. Conflict mapping in 3 crisis-prone communities (Aguleri, Ogbunike and Akpu) in Anambra State. A research report submitted to the United Nations Development Programme UNDP as part of its 7th UNDP-FGN Programme of Assistance to Anambra State (2009 -2012).
25. Okonkwo, N. 2007. .Nri Kingdom:a lost Igbo race. Lagos: Intra Prints.
26. Onu, N. 2011. Anambra State community peace under threat. The Nation 30th September.
27. Onuorah, J. 2011. Our people no longer return home: Anambra group laments. The Sun. 28th September.
28. Onwuegbusi, C. 2011. Isuofia youths threaten war path over Igwe stool. Nigerian Compass, 13th September.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareA STUDY OF SHORT-TERM OUTCOME OF ACUTE CORONARY SYNDROME PATIENTS WITH SPECIAL REFERENCE TO SERUM URIC ACID AT PRESENTATION
English1420Kapildev MondalEnglish Soumabrota DuttaEnglishBackground: Acute coronary syndrome is very common course of death worldwide. It is the most common life Threatening cardiological disease. Assessment of prognosis of acute coronary syndrome patient with respect of Uric acid level as a risk factor to prevent mortality and morbidity have great impact on public health.
Aim of the study: Very few Literatures are available regarding this. Our objective is to find out the Effect of Serum Uric acid level on short term outcome of acute coronary syndrome patient.
Materials and Methods: We did retrospective study in general medicine department of SSKM HOSPITAL; Kolkata, with acute coronary syndrome patients on 2009-2010.
Our study included 100 patients of acute coronary syndrome of various severity. We also proposed to do a detailed laboratory investigation including serum uric acid level in every patient. We did Detailed Clinical Examination and Relevant laboratory investigation. We collected Data according to Hospital regulation after approval by Hospital authorities. Then we analyzed data with help of statistical method BY using software.
Results: In our study serum uric acid levels correlate with severity of cardiac failure. There was statistically significant correlation found between serum uric had higher levels of uric acid as compared to patients of class l and ll.
Discussion: Out of 100 patients, six expired during 7 day follow up. Patients who had myocardial infarction in past have higher serum uric acid levels and are in higher Killip class. Combination of Killip class and serum uric acid level after acute myocardial infarction is a good predictor of mortality after ami.
Conclusion: Hyperurecemia is found to be associated with less chance of good outcome of acute coronary syndrome patients.
EnglishHyperurecemia, Investigation, ArthritisINTRODUCTION
Acute coronary syndrome (ACS) is usually one of three diseases involving the coronary arteries-ST elevation myocardial infarction (30%), Non ST elevation myocardial infarction (25%) and Unstable angina (38%). ACS should be distinguished from stable angina, which develops during exertion and resolves at rest. In contrast with stable angina, unstable angina occurs suddenly, often at rest or with minimal exertion, or at lesser degrees of exertion than the individual’s previous angina (“crescendo angina”). New onset angina is also considered unstable angina, since it suggests a new problem in a coronary artery. Diabetes (with or without insulin resistance)is the single most important risk factor for ischaemic heart disease (IHD). others risk factors are tobacco smoking, hypercholesterolemia, low HDL, high triglycerides, high blood pressure, family history of ischaemic heart disease (IHD),obesity (defined by a body mass index of more than 30 kg/m²), age (men acquire an independent risk factor at age 45, Women acquire an independent risk factor at age 55)stress, prolong intake of alcohol. There are ongoing research in the field of emerging risk factors and factors determining ultimate outcome. Epidemiological studies shows direct relationship between the levels of the natural antioxidant uric acid and the risk of coronary ischaemic events Assuming the importance of oxidative stress in patients with brain ischaemia and the antioxidant property of uric acid, in our study this relationship is evaluated in 100 patients of acute coronary syndrome. Aims of the study: Evaluation of A.C.S. patients clinically, evaluation of serum uric acid for all these patients at presentation and assessment of coexisting risk factors making regular check up of all these till discharge or death. Objectives: To find out effect of serum uric acid level on Short term outcome of Acute Coronary syndrome patient. Materials and Methods: We conducted the study in the Department of Medicine and cardiology department I.P.G.M.E.and R and SSKM Hospital during 2009-2010. Selection Criteria: we ,selected ACS patients presenting within 72hrs of onset, excluded Patients of below 40 yrs ,Patients suffering from other co-morbid conditions which itself may be the determining factor of outcome of patients, any patient with a condition known to elevate uric acid level and Any acute coronary syndrome secondary to ventricular aneurism and vasculitis .
METHODS
We included 100 patients of ACS of various severity (Any patient who were diagnosed as ST segment elevated acute myocardial infarction (STEMI) or non-ST segment elevated acute myocardial infarction (NSTEMI) on the basis of clinical history, examination, ECG changes, biochemical markers, and admitted in Cardiology and Medicine ward of S.S.K.M Hospital, Kolkata)(severity is assessed with killip scale both on admission and on discharge). We put the result of the study in tables and performed statistical analysis with the help of SYSTAT statistlcal software.
COUNCELLING: We explained the nature of study to each patient and patient's fellow and took informed consent.
PROCEDURES: A through history and clinical evaluation has done a in each patient and also imaging studies and biochemical test conducted meticulously special reference to Killip class.
STUDY TECHNIQUE: The presentstudy is a restrospective, observational epidemiological study We took history and did proper clinical examination. Patients were treated as decided by attending physician. Patients were followed up till hospital stay i.e. 7 days. Serum uric acid level was measured on day 0, 3 and 7 day of MI.
RESULTS
100 patients of ischaemic stroke presenting within 72 hours, of either sex were studied in Medicine and cardiology indoor, I.P. G.M.E and R Kolkata. We excluded patients of age below 40 and patients suffering from other co-morbid conditions which itself may be the determining factor of outcome, e.g., cerebral stroke, hepatic encephalopathy, renal failure. Elaborate clinical examination and laboratory investigations were done in every patients to evaluate relevant confounding factors and outcome Predictors. Outcome in ischaemic ACS patients greatly varies, from complete recovery to death. So, researchers at different time tried to evaluate the outcome of ACS. There are observed data where we found beneficial effects of serum uric acid (5,6)and in some deleterious effects (7) is documented in outcome of ACS. Therefore we examined the effect of serum uric acid on outcome of ACS stroke patients. Acute coronary syndrome(ACS) was measured on admission and discharge by killip scale done with the help of SYSTAT software. General Least square Method with two dependent variables and single dependent variable were used to analysis relevant confounder and potential predictors such as Age, Sex, ACS Severity on admission, Diabetes, Hypertension, Atrial Fibrillation, Sodium and Potassium, Smoking, Previous History of AMI, FBS- Urea and Creatinine. In statistical analysis, we found significant effects of Age, sex, Stroke Severity on admission, Diabetes, Hypertension, Atrial Fibrillation, lschaemic Heart Disease, Smoking, Previous History of Stroke, FBS, Urea and creatinine in outcome of stroke in our study, as found in other studies (13,32,35) also. Hyperuricaemia is found to be associated with less chance of good outcome. This finding is corroborating with other studies (6 ,1,9).
DISCUSSION
We, used the study as referral study, we © JAPI • VOL. 56 • OCTOBER 2008 www.japi.org 761 tried to find correlation between serum uric acid and Killip class and their prognostic value in our patients. Present study was conducted in 100 patients of acute Coronary syndrome, who presented to hospital with in 24 hrs of onset of symptoms. Out of 100 patients, 65 had ST-elevation myocardial infarction (STEMI), while 35 patients were of non-ST elevation myocardial infarction (NSTEMI).
Sixty one patients were thrombolysed while four were not thrombolysed due to delayed presentation. Uric acid was treated as a continuous variable and as a categorical variable, and variables were divided into quartiles according to serum uric acid concentrations same as in referral study by Kojima et al. There was no significant correlation (p=0.396) between serum uric acid level and patients who were known or found to be hypertensive on admission (Table 2). This is different than other studies which showed that hypertensive patients had more hyperuricaemia. Thirty three percent patients were known diabetic in our study. Non-diabetic and diabetic patients had comparable serum uric acid levels on Day0 (Table 2). This finding is consistent with study by Tuomilheto et al in which there was no significant association between serum uric acid level and diabetic status. In our study patients with hyperuricaemia is significantly associated with type 2 diabetes mellitus. Twenty one percent patients had history of ischemic heart disease. There was significant difference between serum uric acid concentration at the time of admission and h/o ischemic heart disease (Table 2). Also, Patients who were known case of IHD were in higher Killip class (Table 3). There was a correlation between serum uric acid level and Killip class on day of admission (Table 4). patients of Killip class lll and lV In our study serum uric acid levels correlate with severity of cardiac failure (Tables 4, 5 and 6). There was statistically significant correlation found between serum uric had higher levels of uric acid as compared to patients of class l and ll. This finding is consistent with referral study.9 .There is statistically significant association (p=Englishhttp://ijcrr.com/abstract.php?article_id=208http://ijcrr.com/article_html.php?did=2081. Alderman M, Aiyer KJ. Uric acid: role in cardiovascular disease and effects of losartan. Curr Med Res Opin 2004;20:369-79.
2. Kroll K, Bukowski TR, Schwartz LM, Knoepfler D, Bassingthwaighte JB. Capillary endothelial transport of uric acid in guinea pig heart. Am J Physiol 1992, 262:H420-31.
3. Castelli P, Condemi AM, Brambillasca C, et al. Improvement of cardiac function by allopurinol in patients undergoing cardiac surgery. J Cardiovasc Pharmacol 1995;25:119–25.
4. Kogure K, Ishizaki M, Nemoto M, et al. Evaluation of serum uric acid changes in different forms of hepatic vascular inflow occlusion in human liver surgeries. Life Sci 1999;64:305–13.
5. Anker SD, Doehner W, Rauchhaus M, et al. Uric acid and survival in chronic heart failure: validation and application in metabolic, functional, and haemodynamic staging. Circulation 2003;22:1991–97.
6. Ochiai ME, Barretto AC, Oliveira MT, et al. Uric acid renal excretion and renal in sufficiency in decompensated severe heart failure. Eur J Heart Fail 2005;7:468–74.
7. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med 2005;21:1685–95.
8. Fest a A, Haffner SM. Inflammat ion and cardiovascular disease in patients with diabetes: lessons from the Diabetes Control and Complications Trial . Circulation 2005; 11 :2414–15.
9. Kojima S, Sakamoto T, Ishihara M, et al. Prognostic usefulness of serum uric acid after acute myocardial infarction (Japanese Acute coronary Syndrome Study) . AmJ Cardiol 2005 ; 96 :489-95.
10. Bickel C, Rupprecht HJ, Blankenberg S, et al. Serum uric acid as an independent predictor of mortality in patients with angiographically proven coronary artery disease. Am J Cardiol 2002;89:12-7.
11. Johnson RJ, Rodriguez-Iturbe B, Kang DH, et al. A unifying pathway foressential hypertension. Am J Hypertens 2005;18:431-40.
12. Tuomilheto J, Zimmet P, Evawolf. Plasma Uric acid level and its association with Diabetes Mellitus and some Biologic Parameters in a Biracial Population of FIJI Am J Epidemiol 1988;127:32136.
13. Safi AJ, Mahmood R, Khan MA, Haq A. Association of serum Uric Acid with type II diabetes mellitus. J Postgrad Med Inst 2004;18:59-63.
14. Cicoira M, Zanolla L, Rossi A, et al. Elevated Serum Uric acid levels are associated with diastolic dysfunction in patients with dilated cardiomyopathy . Am Heart J 2002;143:1107-11.
15. Olexa P, Olexova M, Gonsorcik J, et al. Uric acid a marker for systemic inflammatory response in patients with congestive heart failure? Wien KIin Wochenschr 2002;28:211–15.
16. Harison’s Internal medicine 17th edition(Chapter 220,221,238,239).
17. Braunwald’s Heart Disease 8th edition(Chapter 50,51). 18. Davidson’s principle and practice of medicine 21th edition (chapter 18).
19. Hare JM, Johnson RJ. Uric acid predicts clinical outcomes in heart failure: insights regarding the role of xanthine oxidase and uric acid in disease pathophysiology. Circulation 2003;107: 1951-3.
20. Mercuro G, Vitale C, Cerquetani E, et al. Effect of hyperuricemia upon endothelial function in patients at increased cardiovascular risk. Am J Cardiol 2004;94:932-5.
21. War d HJ . Uric acid as an independent risk factor in the treatment of hypertension. Lancet 1998;352:670-1.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareMETASTATIC OVARIAN CYSTOSARCOMA PHYLLOIDES OF BREAST
English2125Papa DasariEnglish Haritha SagiliEnglish Priyanka Yoga PuraniEnglishBackground: Cystosarcoma Phylloides is a rare breast neoplasm constituting ? 1% of all breast neoplasms. These are mostly benign and reccur. Malignant cystosarcoma Phylloides can recur and metastasize to lung, bone and abdominal viscera. Metastasis to Ovary is not reported in literature.
Case: A 46 year old multiparous lady was diagnosed with a recurrent cystosarcoma of right breast and a large Ovarian mass which was causing her dyspnoea. The mass was of 30 weeks size and was firm and tender. CECT showed a large solid abdominopelvic mass with irregular enhancing septate extending from pelvis to infracolic area with minimal free fluid. Uterus and Ovaries could not be delineated. FNAC from the mass was reported as low-grade malignant mesenchymal tumour. CA 125 was within normal range. Laparotomy revealed a large fleshy mass with jelly like material which was adherent to intestines and pelvic and parietal peritoneum. Right ovary is not visualized. Left ovary parially visualised and incorporated into the mass. Excision of the mass with TAH and BSO was carried out. There was diffuse ooze from the pelvic and peritoneal cavity which was managed by packing, blood product transfusion and tranexamic acid. She received massive transfusion and survived. Later she developed haemoptysis and underwent tracheostomy and feeding ileostomy and was managed in ICU for 8 weeks. Palliative mastectomy and adjuvant Radiotherapy and chemotherapy were differed by Oncologists and hence she was discharged after 4 months of admission.
Conclusion: Managing ovarian metastasis from cystosarcoma phylloids can be challenging and the quality of life is poor when the primary disease is not managed adequately.
EnglishPalliative mastectomy, Phylloid tumours, Ovarian tumourINTRODUCTION Phylloid tumours account for less than 1% of breast masses and occur rarely. They affect women at young and middle age unlike adenocarcinomas which occur at a later age. .They most often reccur locally and 20% to 40% develop distant metastasis. The most common sites of distant metastases are lung, bone and abdominal viscera1 .The abdominal visceral metastasis is reported in duodenum and Pancreas.2 Metastasis to ovaries is not found in literature. Hence this rare case is reported.
CASE REPORT A 46-year-old para2 live 2 whose child birth was 14 years back underwent simple mastectomy for a right sided breast mass one month ago at a private hospital, the histopathology was consistent with cystosarcoma phylloids. The breast mass re-appeared at the same site with in one month of surgery. FNAC from the recurrent breast mass revealed cystosarcoma phylloids with stromal elements. She also developed sudden onset of pain abdomen and distension of abdomen of one month duration and decreased urine output, difficulty in breathing and constipation of 12 days duration. CT scan of abdomen and pelvis reported a large solid mass in abdomen and pelvis with minimal free fluid in pelvis.
The mass is not separately seen from uterus and ovaries. She was referred to our Institute with a diagnosis of recurrent cystosarcoma phylloids with Ovarian tumour. Her Obstetric and gynecological history revealed that she had 2 normal deliveries and underwent tubectomy 14 years back and there was no family history of malignancies. She had polymenorrhea .She gave history of loss of weight and loss of appetite for the past 6 months.She also had urinary retention and hence she was on continuous bladder drainage for one week. She complained of fever with chills of 10 days duration. On examination she was emaciated, tachypnoeic, febrile, pulse was 108/min regular, BP 100/60 mm Hg. No significant lymphadenopathy. There was a hard mass of 10x6x3 cm in size on the lateral aspect of right breast with local rise of temperature and tenderness. Left breast was normal. Respiratory system was normal.
Cardiovascular system was normal except for tachycardia. Abdomen was grossly distended in sub- umbilical and umbilical region. There was a hard immobile tender mass of 30 weeks size arising from pelvis. Bowel sounds were normal. General surgical opinion was recurrent or residual cystosarcoma phylloides (as the resected margins were reported positive) with Ovarian tumour and advised to manage the ovarian tumour first. Her abdominal USG was reported as a large abdominopelvic complex mass with minimal ascites displacing the bowel loops laterally suggestive of Ovarian mass. Her CECT at our Institute after one week of admission reported as a large abdominopelvic dense mass with irregular enhancing septate extending from POD to infra colic areas.
Ovaries are not visualized separately. FNAC from the abdominal mass was reported as a low grade malignant mesenchymal tumour. She was taken up for laparotomy 2 weeks after admission after surgical oncologist opinion. On laparotomy there was hemorrhagic ascites of more than 500ml. There was a large fleshy mass with jelly like material with a breach on the surface suggesting tumour rupture. The mass was of 28 week size occupied pelvis and lower abdomen and extended up to the root of the mesentery and covered by small bowels which were closely adherent. There was lot of mucoid material within the mass appearing like myxoid degeneration (Fig1a). Both ovaries incorporated in to the mass and right ovary could not be recognised and left ovary was only partially recognized (Fig 1b) Both fallopian tubes were free. Uterus was 10 weeks size and anterior to the mass which was densely adherent to POD, lateral pelvic walls and rectosigmoid.
The mass was separated from the intestines and excised with the help of surgical oncologist. Total abdominal hysterectomy with bilateral salphingo opherectomy was carried out. There was lot of oozing from the intestinal surfaces and peritoneal surfaces of POD. Multiple haemostatic sutures were taken and bilateral internal iliac arteries were ligated. As the oozing persisted from the peritoneal surfaces , pelvis and abdomen was packed. Blood loss was 1000 ml and she received 5 units of FFP, 4 packed cells. In view of poor general condition she was ventilated and was kept on SIMV mode. Abdominal pack was removed after 48 hours under general anaesthesia. She was monitored in post-operative ward and received 22 units of FFPs, 4 units of platelets,3 units of Packed cells, 12 units of cryoprecipitate over a period of 8 days. She also received intravenous tranexamic acid during surgery and for 48 hours following surgery.
Mastectomy was deferred at the time of laparotomy though it was planned to do earlier by the surgical oncologist. She could be started on oral fluids after a week and was shifted to ward after 10 days of surgery. On 14 th postoperative day she developed sudden dyspnoea and was managed conservatively with oxygen and sedation. Her fever persisted despite of 3 broad spectrum intravenous antibiotics. She had superficial wound gaping and developed dyspnoea again with decreased saturation. She was kept on mechanical ventilation. X Ray chest P/A revealed minimal left sided effusion with basal atelecatsis. She underwent tracheostomy after 4 days as prolonged ventilation was required . She produced thick sputum which required mucolytic and frequent suctioning. After 10 days she was weaned off ventilator and was maintaining 100% saturation.
The histopathological report was metastatic malignant cystosarcoma Phylloids to ovary and parametrium. Fallopian tubes and uterus and cervix were free of tumour. Tumour showed high cellularity and moderate nuclear atypia and high mitosis 16/10 high power field with extensive myxoid change. (Fig 2 a, b,and c) This was consistent with previously diagnosed and treated malignant phylloids. Her haematological parameters were with in normal limits. She was given one course of Ifosphamide and MESNA which she tolerated well. She was given total parenteral nutrition for almost one month. After seven days of receiving chemotherapy she became dyspnoeic and right sided air entry decreased and she was shifted to RICU(Respiratory Intensive care Unit) under care of the anaesthetists. Her abdominal wound healed by secondary intention. She was given ICU care and underwent feeding jejunostomy . She was decanulated after 8 weeks of tracheostomy. The breast mass increased in size 20x10 cms, infected and displaced to right lateral side of chest. Surgical Oncologists deferred in doing any kind of palliative surgery and medical oncologists and Radiation Oncologists deferred in giving chemotherapy and radiation therapy. She was in RICU for 6 weeks and received antibiotics as per the sensitivity of the organisms from wound swab, tracheal swab, infected breast mass swab etc.,.
The organisms were Acenetobacter, klebsiella, pseudomonas .The abdomen was scaphoid and there was no evidence of fluid or mass. She was asked to take over by Gynaecologists. As there was no gynaecological treatment necessary and the surgical Oncologists deferred in performing palliative surgery she was explained the inability to give further supportive treatment and discharged home.
local excision the resected margin should be free of tumour for 1 cm. Local recurrence is expected in 15 % of cases even with this modality of treatment3 . Cystosarcoma Phylloids are diagnosed to be benign, borderline and malignant based on histopathological characteristics and a clinical diagnosis of malignant variety is not made as recurrence and even metastasis can occur in benign tumours. A study correlating histopathological features with clinical presentation in 187 cases , found local recurrence in 27%, 32% and 26% of benign, borderline and malignant tumours respectively. Metastasis was present in two borderline and six malignant tumors out of 100 (8%). There were no specific histological features that correlated with local recurrence and metastasis but cytological atypia of stromal cells, stromal overgrowth and mitotic figures of >15 per 50 high power fields were present in those who showed metastasis.4 Flow cytometric analysis of s fractions greater than 0.05 was found to be a useful predictor of clinical outcome along with histological features of stromal overgrowth and and infiltrating margins5 . A literature review in 1999 to find out the predictors of recurrence after conservative surgery of cystosarcoma phylloids concluded that wide local exicision is also a suboptimal modality of treatment for borderline and malignant phylloid tmours because the recurrence rate is high (29% for borderline and 36% for malignant).6
The most common site of metastasis is lung7 and other sites reported are spine, brain, parotid gland, nasal cavity, forearm and mandible. The metastatic sites in the abdomen reported are pancreas, duodenum, jejunum and liver. Metastasis to genital organs is very rare and only one case report of metastasis to vulva 8 and another to Brenner tumour of ovary is found in literature9 . The metastasis to vulva occurred along with pulmonary metastasis a year after the management of primary by surgery and local radiation. The diagnosis in their case was made by PET-CT as the metastatic nodule was only 2x2cm and the diagnosis was confirmed by fine needle aspiration8 . The metastasis to ovary could not be diagnosed prior to laparotomy by fine needle aspiration in the present case. This is because FNAC has very high false negative rates in diagnosing cystosarcoma phylloids.10 Adjuvant therapy for management of metastatic Phylloids includes chemotherapy and Radiotherapy. Response to chemotherapy was observed in lung metastasis and abdominal metastasis but not in bone metastasis. Single agent and combined regimens have been used and response is long lasting with increase in progression free survival when Ifosfamide is used11. Radiotherapy has a role for loco regional control in recurrent benign as well as malignant Phylloids. However the control of primary tumour is important when metastasis had been taken care of to improve the survival rates as well as the quality of life.
The present case though she survived after laparotomy and complete removal of the large ovarian metastasis, she continued to suffer as the primary was not taken care of. Palliative surgery, chemotherapy and radiotherapy were deferred in the present case even after repeated discussions saying there is no role for surgery of primary in metastatic disease. But in this case the Ovarian metastasis was taken care of almost completely by surgery. Aggressive palliative surgery in metastatic Phylloids is reported to improve survival as well as quality of life. The physical and mental well being was improved after radical surgery for repeated recurrence that occurred twice . and this improved the nutritional status and immunity to undergo further treatment with chemotherapy7 .
The present case was unable to get up from the bed because of the weight of the tumour mass (breast) that progressed to large size and also because of poor nutritional status. Palliative breast surgery and palliative Radiotherapy under high risk consent may have improved her quality of life. A recent study which assessed the predictive factors for the local recurrence and distant metastasis of phylloides tumours of the breast in 192 cases concluded that histopathological type and margin status were independent predictors of distant metastasis- free survival and overall survival and it is essential to reduce the local recurrence to prevent distant metastasis.12
CONCLUSION Managing ovarian metastasis from cystosarcoma phylloids can be challenging and the quality of life is poor when the primary disease is not managed adequately. When an abdominal mass and a breast mass co-exist , metastasis from the breast mass to be considered as the first etiology rather than an association of different pathology until proved otherwise. Conflicts of Interests: None Sources of Funding: Nil
ACKNOLEDGEMENTS The authors acknowledge the immense help received from the scholars whose articles are cited and included in the manuscript. The authors are also greatful to authors/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=209http://ijcrr.com/article_html.php?did=2091. Parker SJ, Harries SA, Phylloid tumours. Postgrad Med J 2001;77:428–435
2. Ang TL Leong Ng VW, Fock KM, Teo EK, Chong CK. JOP. J Pancreas 2007; 8(1):35-38.
3. Chen WH, Cheng SP, Tzen CY, Yang TL, Jeng KS, Liu CL, Liu TP. Surgical treatment of phyllodes tumors of the breast: retro-spective review of 172 cases. J Surg Oncol. 2005 ;91(3):185- 194.
4. Grimes MM. Cystosarcoma phyllodes of the breast: histologic features, flow cytometric analysis, and clinical correlations.Mod Pathol. 1992;5:323-329..
5. Palko MJ1 , Wang SE, Shackney SE, Cottington EM, Levitt SB, Hartsock RJ. Flow Cytometric S fraction as a predictor of clinical outcome in Cystosarcoma Phylloides. Arch Pathol Lab Med. 1990 Sep;114(9):949-52.
6. Bharat RJ Jr. Histologic features predict local recurrence after breast conservating therapy of Phylloid tumours.. Breast Cancer Res Treat. 1999 ;57(3):291-5.
7. Kapali AS, Singh M, Deo SVS, Shukla NK, Muduly DK. Aggressive palliative surgery in metastatic Phylloids tumor: Im pact on quality of life.Ind J Palliat Care. 2010; 16 (2):101-104.
8. Khangembam BC, Sharma P,Singla S,Shingal A,Dhull VS, Bal C,Kumar R. .Malignant Phylloides tumour of the Breast metastasing to the Vulva.18 F-FDG PET-CT demonstrating rare metastasis from a rare tumour Nucl Med Mol Imaging .2012 46:232–233
9. Hines JR, Gordan RT, Widger C, Kolb T.Cystosarcoma Phylloids metastatic to a Brenner tumour of the ovary. Arch Surg 1976;111(3):299-300.
10. Jacklin RK, Ridgway PF,. Ziprin P,, Healy V, Hadjiminas D, and . Darzi A, “Optimising preoperative diagnosis in phyllodes tumour of the breast,”. J Clin Pathol, 2006; 59(5):454–459.
11. Hawkins RE,Wiltshaw E,Fisher C McKinna JA..Ifosphamide is an active drug for chemotherapy of metastatic Cystosarcoma Phylloides.Cancer.1992;69:2271-2275.
12. Wei J,Tan Yu-T, Cai Yu C, Yuan Z-Yu, Yang D, Wang SS.Predictive factors for local recurrence and distant metastasis of Phylloides tumours of the breast: a retrospective analysis of 192 cases at a single centre. Chin J Cancer; 2014; 33 (10):492- 500.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareEFFECT OF RIBAVIRIN ON HOSPITAL STAY OF MEASLES CASES
English2629Indrajit MandalEnglish Malay AcharyyaEnglish Mainak MukhopadhyayEnglishObjectives: We evaluated the effect of Ribavirin – a broad spectrum virustatic agent, in the hospital stay of measles cases both with and without complications.
Materials and Methods: This is a retrospective study where we examined the Bed Head Tickets of 100 randomly selected measles cases. One group was treated with Ribavirin along with antibiotic and other supportive measures and another group was treated with antibiotic and supportive measures only. We tried to evaluate the effect of Ribavirin on the hospital stay of Measles patients with or without complication.
Results: We found that there was absolute reduction in hospital stay for Ribavirin group than group treated without Ribavirin (4.018 ± 1.92 days versus 6.934 ± 2 days. p= 0.4). Mean hospital stay of measles with pneumonia treated with Rivavirin was 3.909 ± 1.02 days among 22 cases which was 8.5 ± 2.5 days among 10 cases treated without Ribavirin. This reduction was statistically significant (p= 0.02). Mean hospital stay of 12 cases of measles with encephalitis treated with Ribavirin was 5± 1.15 days while it was 8.16±2.07 days for 6 patients received antibiotic and supportive measures only (p=0.35). Case fatality rate in Ribavirin group was 0 %, against 4.34% for the group without Ribavirin.
Conclusion: Reduction in the hospital stay of measles cases even in those who had complications, is an encouraging finding. Further studies with large sample size and ramdomized controlled trials are required to evaluate the effectiveness of Ribavirin in measles along with other RNA viruses.
EnglishRibavirin, Measles, Measles pneumonia, Hospital stayINTRODUCTION
Ribavirin is a broad spectrum non interferon inducing virustatic chemotherapeutic agent, demonstrates activity against a wide range of RNA and DNA viruses including measles viruses. To date the best success as occurred in the use of Ribavirin to treat respiratory syncytial virus infection in infant and young children and to treat influenza A and B virus infection in young adult. Viral infection particularly viral pneumonia, are often life threatening in patients with Severe Combined Immunodeficiency Disease (SCID) and Ribavirin aerosol has been used successfully to treat RSV and parainfluenza virus infection in the immunodeficient children. The drug has also shown significant clinical benefit in treating Lassa fever virus. Additional studies demonstrate the drug efficacy in acute viral hepatitis, herpes virus infection and measles. Controlled clinical trials are underway to test the drug in patients infected with AIDS virus1 . Measles is a highly contagious disease which was responsible for high infant mortality before the advent of effective vaccine in 1963. In immuno-competent individual, measles virus infection triggers an effective immunoresponse that start with innate response and than leads to successful adaptive immunity, including cell mediated immunity and humoral immunity. The virus is cleared and life long protection is acquired. However, changing epidemiology of measles due to vaccination as well as severe immunodeficiency has created new pockets of individuals venerable to measles2 . In this study we tried to evaluate the effect of oral Ribavirin in the hospital stay of immuno- competent measles with or without complication.
MATERIALS AND METHOD
This study was conducted at Infectious Disease and Beliaghata General Hospital (ID and BGH) where measles cases are referred from different parts of West Bengal and different North Eastern States of India. We retrospectively examined the BHT of 100 randomly selected measles cases. one group was treated with Ribavirin along with antibiotic and other supportive measures and another group was treated with antibiotic and supportive measures only. We tried to evaluate the effect of Ribavirin on the hospital stay of Measles patients with or without complication. Case definition of measles - cases with 2-4 days of respiratory prodrome like malaise, cough, coryza, conjunctivitis with lacrymation and fever followed by appearance of erythematius, nonpruritic ,maculopapular rash which begins behind the hairline and spreads down the trunk ,limbs ,including palm and sole. Ribavirin was administered in a dose of 10 mg/kg/day for 5 days. Discharge criteria- when the patients became afebrile and became asymptomatic. Presenting symptom: Many of the cases had multiple symptoms at a time. Vomiting was a presenting symptom especially among infants. Clinical case definition for pneumonia was tachypnea with or without sub-costal suction with or without cyanosis or stupor. Suspected cases were confirmed radiologically.
RESULTS
Total 100 cases were examined retrospectively. Among them the minimum age was 6 month and maximum age was 62 years. Among the 100 cases, 62 were male, 38 were female, 68 were hindu, 32 were muslim. Incidence of complication: Among the 100 cases retrospectively examined 93 cases were having different complications and only 7 cases had no complications. Some of the cases had multiple complications present simultaneously. Effect of Ribavirin in hospital stay: Among the 100 cases 54 (Male – 38, Female -16) were treated with Ribavirin and their mean hospital stay was 4.018 ± 1 .92 days. 46 cases (M – 24, Female – 22) were treated without Ribavirin and there mean hospital stay was 6.934±2 days and there was an absolute reduction in hospital stay among Ribavirin group but it was not statistically significant (p= 0.4)
Effect of Ribavirin in hospital stay of measles with pneumonia : Among 32 pneumonia cases (M – 22, F-10) 22 were (M – 18, F – 4) treated with Ribavirin along with other supportive measures along with antibiotic and 10 (M – 4, F – 6) were not given Ribavirin and they were treated only with supportive measures and antibiotic. Mean hospital stay of pneumonia patients (n = 32) treated with or without Ribavirin was 5.34± 1.50 days. Whereas those treated with Ribavirin (n = 22) the hospital stay was 3.909 ±1.02 days and those treated without Ribavirin (n = 10), mean hospital stay was 8.5± 2.5 days. The reduction in hospital stay was statistically significant ( p= 0.02). Effect of Ribavirin is hospital stay of measles with encephalitis: Total case of measles with encephalitis was 18 among them 12 (M = 8, F = 4) were treated with Ribavirin and 6 (M = 4, F = 2) were treated without Ribavirin. Mean hospital stay in all cases (n = 18) was 6.65± 1.90 days whereas those treated with Ribavirin (n=12) it was 5± 1.15 days, and those without Ribavirin it was 8.16± 2.07 days. This reduction in hospital stay was not statistically significant (p=0.35) Effect of Ribavirin on out come of measles cases Case fatality rate(CFR) in the group treated with ribavirin was 0% but CFR in the group treated without ribavirin was 4.34 %. Though sample size was small it was a significant finding.
DISCUSSION
Measles with its complication can sometimes prove fatal. There is very few available specific therapy for measles pneumonia or encephalitis other than supportive care3 . Oguz Uzen et al. reported a case in Turkish Respiratory Journal in 2002 a case of severe measles pneumonia which is a rare condition in an immuno-competent adult. They reported a case, of 20 year old man. Diagnosis was based on clinical, radiologic and serological findings. Corticosteroid, Vit. A, Ribavirin where used in previous cases. But supportive care in this case completely improve the condition. S Gururangan et al from Dept. of Pediatric Oncology, Royal Manchester Children’s Hospital, Manchester, UK4 reported a case of 9 year old boy with Hodgkin’s lymphoma developed measles 1 month after completing 8 cycles of intensive anti cancer chemotherapy. 7 days of nebulized Ribavirin and intravenous Ribavirin therapy produced apparent recovery. 2 weeks later child presented with measles giant cell pneu-monia diagnosed on open lung biopsy. Ribavirin therapy was once again successful. Mustafa MM et al5 reported 2 young patients with sub-acute measles encephalitis in 20 year old male and 9 year old girl with acute leukemia. Histologic examination of brain tissue proved useful in establishing the diagnosis. They concluded therapy with iv Ribavirin is effective when administered early. In our study Ribavirin was administered orally but it has shown statistically significant reduction in hospital stay even in complicated cases of measles. And there was a favorable outcome pattern in patients who were treated with Ribavirin.
CONCLUSION
Incidence of measles has significantly reduced following introduction of measles vaccination. But it is still responsible for significant morbidity and mortality. In these days of increasing health care expenditure reduction in hospital stay even in complicated cases along with favorable outcome pattern in cases treated with Ribavirin is an encouraging finding, keeping in mind that his complication has no specific therapy other than supportive care which can alter the course of the disease. Further studies with large sample size and ramdomized controlled trials are required to evaluate the effectiveness of Ribavirin in measles along with other RNA viruses.
Englishhttp://ijcrr.com/abstract.php?article_id=210http://ijcrr.com/article_html.php?did=2101. Ribavirin : A Clinical Overview. H Fernandez et al., Dept of Drug Development – University of California at Los Angeles California 90024
2. D Nadlle et al. Barcelona center for International Health Research
3. Severe measles pneumonia in a immuno competent adult. Oguz Uzen et al. Turkish Respiratory Journal 2002; 3(1): 32-34
4. Ribvirin response in measles pneumonia. S Gururangan et al. Dept of Pediatric Oncology, Royal Manchester Children Hospital, Manchester UK, 1989
5. Clinical infectious disease 1993 16(5): 654-60. Mustafa MM et al. Sub-acute measles encephalitis in the young immuno compromised host, Reports of 2 cases diagnosed by PCR and treated with Ribavirin.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareEVALUATION OF POST OPERATIVE COMPLAINTS IN FIXED PARTIAL DENTURE WEARERS AND THOSES WITH CROWNS: A QUESTIONNAIRE BASED STUDY
English3034Nandhini G. AshokEnglish Sangeetha S.EnglishAim: To evaluate the post-operative complaints of patients having crowns and fixed partial dentures by means of a simple questionnaire.
Methodology: A sample questionnaire with 15 questions was prepared, pertained to the period of the prosthesis in place, the nature of complaint as told by patient in his or her own words, number of units involved, and the type of materials used in fabrication of prosthesis. The study was carried out in patients who visited Saveetha Dental College and Hospitals as outpatients from January 2016 to April 2016. A total of One hundred patients were randomly selected and interviewed.
Objective: All the patients of our dental college who underwent tooth replacement by means of a fixed partial denture and crowns were included in the study to evaluate the problems encountered after post-operative insertion of the prosthesis.
Reason: To create an awareness among the dentists about the problems encountered with our patients and to manage them accordingly as patients’ comfort is of at most importance to us.
Result: Most of the failures are due to poor patient care after insertion while the others occur as a result of defective design and inadequate execution of clinical and laboratory procedures. In this study, clinic survey was undertaken to access the patients discomfort after cementation of prosthesis. The most common problem encountered was looseness and repeated dislodgement. Other complains such as food impaction, inability to maintain oral hygiene, sensitivity, pain and esthetic issues were also encountered.
Conclusion: The knowledge regarding the clinical Fixed Partial Denture complications enhances students’ ability to complete a through diagnosis, developed most appropriate to patients and communicate realistic expectations to patients and plan time internals needed for post-treatment care in the dental institutions
EnglishFixed partial dentures, Post-operative complaints, Crowns, EvaluationINTRODUCTION
The conventional crown and fixed partial denture treatment modality is very common in practice and is highly successful in restoring the functions of lost or missing teeth. In this endeavour, the proper selection of the case, careful diagnosis, meticulous preparation, and a professional construction of prosthesis are mandatory to success and longevity of restoration and maintenance of health of biological investing tissues. Fixed Partial Dentures requires significant amount of tooth structure to be removed. In spite of tooth preparation, pulp vitality of the abutments should be maintained by protecting the prepared abutment with provisional fixed partial denture. This provisional fixed partial denture is an essential and key step in fixed prostheses. Most if the time patients reported with post cementation complaints and complications in their fixed prosthesis, especially when the prosthesis was cemented on teeth with vital pulp. The incidence of post cementation complaints and complications is often underestimated by most clinicians. Knowledge regarding the clinical complications that can occur in fixed prosthodontics enhances the clinician’s ability to communicate realistic expectations to patients, and plan the time intervals needed for post-treatment care. One of the purposes of this article is to present data regarding the incidence of clinical complications associated with fixed partial dentures and single crowns. The second purpose is to identify the most common complications associated with each of these restorations/prostheses.
MATERIALS AND METHODS
A sample questionnaire with 15 questions was prepared, pertained to the period of the prosthesis in place, the nature of complaint as told by patient in his or her own words, number of units involved, and the type of materials used in fabrication of prosthesis. The study was carried out in patients who visited Saveetha Dental College and Hospitals as outpatients from January 2016 to April 2016. A total of One hundred patients were randomly selected and interviewed.
RESULTS
A total of 100 patients took part in this survey, of which 57 were males and 43 were females. Among 100 patients, 56% of them had fixed partial dentures and 36% of them had crowns and about 8% of them had both. A majority of them of about 40% had a 3 unit fixed partial dentures, 16% had 2 unit fixed partial dentures, 12% had four unit fixed partial dentures. Of the crown wearers 30% of them had single crowns and 2% had multiple crowns. Regarding the material used, 52% of them had metal ceramic, 23% had all metal, and 25% had all ceramic. 21% of the patients interviewed had replaced their prosthesis of which 68% had replaced once, 22% replaces twice and 10% replaced thrice. 80% of them had post cementation complaints and discomfort in their prostheses. 20% of them were satisfied without any complaints. Regarding the nature of problems faced with the fixed partial denture and crown wearers, 52% of them reported with looseness and repeated dislodgment while 48% of them had no such complaints. The second most common problem encountered with the patients was inability to maintain proper oral hygiene. 51% of the patients found it difficult to main oral hygiene. 40% of the patients reported with complaints of food impaction and pain under the denture/crown. 38% of them found difficulty in mastication whereas the rest 62% were comfortable during mastication. Regarding the other factors, only less number of patients reported. Halitosis was also complained by 32% of the patients. 28% of them reported with sensitivity in that region. 27% complained of the color of the prostheses faded away. 16% of them had problems with esthetics.12% of them reported with breakage of prostheses. And only 8% reported with breakage of tooth under the prostheses.
DISCUSSION
A primary foundation of long term success with crown and Fixed Partial Denture is to achieve good patient recall compliance. Risk of course and Fixed Partial Denture failures are divided into 4 factors, patient related, infection related, load related and technique and design related factors. Most of the failures are due to poor patient care after insertion while the others occur as a result of defective design and inadequate execution of clinical and laboratory procedures. In this study, clinic survey was undertaken to access the patients discomfort after cementation of prosthesis. In this study, 80% of patients complaints of discomfort after cementation of prosthesis. Among these patients, the most common complaints were loss of retention and repeated dislodgement, difficulty in maintaining oral health hygiene. This report was consistent in other clinic survey done on patients to assess the cause of failures in crowns and Fixed Partial Denture. It might be due to improper preparation of tooth with too much taper of proximal walls improper cementations. 40% of patients reported with inability to chew food, food accumulation, color fading away, pain under denture, bad breath , sensitivity in that region. The least number of patient’s complaints of problems with esthetics, breakage of denture, breakage of tooth under crown. The report of this study was consistent with earlier literatures. This survey makes it mandatory in the dental students to strictly to basic principles of fixed bridge prosthodontics.
CONCLUSION
The knowledge regarding the clinical Fixed Partial Denture complications enhances students’ ability to complete a through diagnosis, developed most appropriate to patients and communicate realistic expectations to patients and plan time internals needed for post-treatment care in the dental institutions.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=211http://ijcrr.com/article_html.php?did=2111. Joanne N. Walton; F. Michael Gardner; John R. Agar – A survey of crown and fixed partial denture failures; J.Prosthet., Dent; October 1986; vol. 56, issue 4; 416- 421.
2. Lindquist F. Karlsson S.- Success rate and failures for fixed partial dentures after 20 years of service; Part 1; Int.J.Prosthodont.;1998;Mar-Apr;11 (2); 133 – 8.
3. Manappallil J.J. – Classification system for conventional crown and fixed partial denture failures; J. Prosthet. Dent.; 2008; Apr.; 99 (4);293 – 8 .
4. Charles J. Goodacre; Guillermo Bernal, et.al. - Clinical complications in fixed prosthodontics; J. of Prosthet. Dent.; 2003, July, 90 (1), 31 – 41.
5. Alex Selby – Fixed prosthodontic failure; A review and discussion of important aspects – Australian Dental Journal.; 1994, June, vol. 39, (3); 150 -6.
6. Marxkors R, Wulfes H. Die Einstückgussprothese. Teil V. Dental Labor 2002: 50 : 193-203.
7. Caesar H. Die Versorgung von Frau B. mittotalem Zahnersatz. Dent Labor 2003; 51(7): 1173-8.
8. Toogood GD, Archibald JF. Technique for establishing porcelain margins. J Prosthet Dent 1978: 40: 464–466.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareMORPHOLOGY OF PSOAS MINOR MUSCLE- A CADAVERIC STUDY
English3539Parveen OjhaEnglish Seema PrakashEnglish Anjali JainEnglishAim: To study prevalence of psoas minor muscle and its morphology Material and Method: The study was conducted at R.N.T. Medical College, Udaipur (Rajasthan) in thirty adult embalmed cadavers (23 males and 7 females) of the age group 50 to 60 years.
Results: Psoas minor muscle was present in eight (26.66%) cases. Morphology of muscle showed a wide variation its muscle belly and its tendinous mode of insertion on either pecten pubis (in five cases) or as merging with obturator fascia and iliac fascia (in three cases).
Psoas minor muscle though an inconstant muscle, if present is of clinical importance to radiologists, surgeons and physiotherapists as it can mimic certain abdominal emergencies.
EnglishPsoas minor muscle, MorphologyINTRODUCTION
Psoas minor muscle is absent in about 40% of the cases. This muscle lies anterior to psoas major, entirely within the abdomen. It arises from the sides of bodies of the twelfth thoracic and first lumbar vertebrae and from the disc between them. It ends in a long tendon which is attached to pecten pubis and iliopectineal eminence while laterally to the iliac fascia. The muscle is a weak flexor of the trunk and is innervated by a branch from first lumbar nerve.1 Though an inconstant muscle, if present and gets strained, can be a cause of psoas minor syndrome causing pain in lower quadrants of abdomen mimicking abdominal emergencies. It can also lead to difficult ambulation. This study was done to find prevalence of psoas minor muscle in our region and to discuss its clinical implications which can be of importance to Surgeons, Orthopaedist, Physiotherapists and Radiologists.
MATERIALS AND METHOD
This study was done on thirty adult embalmed cadavers at R.N.T. Medical College, Udaipur (Rajasthan) for a period of three years from 2013-2016. All the cadavers were of the age group 50-60 years. Out of thirty cadavers, twenty three were males and seven were females. None of the selected cadaver had any scar mark of injury or surgery on anterior as well as posterior abdominal wall. Dissection in the abdominal region was done according to the steps described in Cunningham’s Manual of Practical Anatomy.2 After studying the anterior abdominal wall peritoneum was incised. All the abdominal organs were studied, removed and preserved. Posterior abdominal wall was now exposed. Presence or absence of psoas minor was recorded and photographed.
Observations
Following parameters were recorded. Origin, insertion and total length of the muscle. Length and width of tendon of insertion. Measuring tape was used for recording various parameters.
RESULTS
Out of thirty cadavers studied, eight (i.e. six male and two female cadavers) showed the presence of psoas minor (prevalence was 26.66%). All the cases had psoas minor bilaterally. (Fig 1, Fig 2, Fig 3).
No variation was recorded in origin of the muscle and all the cases had normal origin i.e. from T12 and L1 vertebrae and the disc between them. In five cases (three males and two females) insertion was as a broad tendon on iliopectineal eminence and pecten pubis (Fig 5). Average width of tendon was 1.10cm (muscle belly was also thick in these cases). In three cadavers (all male) (Fig 4) - insertion was by a thin tendon which fanned out near iliopectineal eminence and merged with obturator fascia medially and iliac fascia laterally. Average width of tendon was 0.73 cm. (muscle belly was also thin in these cases). In one case belly was very thin (Fig 2) and short (length of the muscle belly was 6.5 cm). Genitofemoral nerve was seen posterior to psoas minor near its origin and then lateral to it near its insertion. Average length of the belly was 7.18 cm (Range 6.5cm8.5cm) Average length of tendon of insertion was 14.94cm (Range 11.5cm-17 cm) Average width of tendon was 0.94cm (Range 0.75cm - 1.20cm)
DISCUSSION
Psoas minor muscle is an inconstant muscle and is infrequently absent. This muscle is always absent in patients with Trisomy 18.Muscles differentiating late during development are generally affected in these patients. 3 Psoas minor muscle though a weak flexor of pelvis in human beings, is well developed in quadrupeds who uses all the four limbs in progression 4 and also in apes where brachiating is apparent and it is larger then psoas major muscle itself.5 Various authors have studied prevalence of psoas minor muscle. According to Anson B J 3 in a series of 182 subjects, muscle was present on both sides in 70 subjects and unilateral in 20 cases (12 on the right side and 8 on the left side). Sachin et al 6 have reported this muscle to be absent in 60% of cases while Faria et al 7 have reported it to be absent in 73.33% of cases. In our study of thirty cadavers we have found muscle to be absent in 73% of cases which is quiet similar to the study by Faria et al.7 Racial difference in prevalence have also been studied by Hanson et al.8 as psoas minor muscle was present bilaterally in 87% of white subjects and unilaterally in 9% of black subjects. Even morphology of muscle was different in blacks and whites. Belly of the muscle was thicker in whites as compared to blacks. Variation in morphology of muscle was also seen by us. In five cases muscle belly was thick and tendon of insertion was short and broad and was attached to iliopectineal eminence and pecten pubis. But in three cases muscle belly was thin and tendon of insertion was long which fanned out near iliopectineal eminence and merged with obturator fascia medially and iliac fascia laterally. Presence of psoas minor muscle with its variable size can also cause confusions during magnetic resonance imaging techniques where it may appear like adenopathies.9 Clinical implications of psoas minor muscle can be of importance to orthopaedist, physiotherapists, surgeons and radiologists who frequently deals patients with pain in lower abdomen or strained muscles. Psoas minor muscle if present and strained can be a cause of psoas minor syndrome 10 where due to tense muscle and tendon patient complains of pain in corresponding iliac fossa. Pain is aggravated by palpation of this taut tendon in lean individuals. Here it may be mistaken for appendicitis (if present on right side) or diverticulitis. Symptoms in this syndrome appear due to compression of the retroperitoneal neurovascular structures. Tenotomy is the treatment of choice in such cases. Psoas minor muscle can be strained in games like golf & football where playing with feet off the ground can lead to pain in the inguinal region extending towards the abdominal wall & testis and this can interfere with their ability to run or jump.11 Though psoas minor is an inconstant muscle yet its clinical importance cannot be overlooked by radiologists, physiotherapists and orthopaedist. Detailed knowledge of this muscle is must especially during making clinical diagnosis as well as in procedures carried out in iliac region.
CONCLUSION
Presence or absence of psoas minor muscle is not only of academic interest to anatomists but also for clinicians in making clinical diagnosis (especially in pain abdomen) and during imaging. Limitation to our study was lesser number of cases, but if we select a larger population and support our study by imaging techniques it can be of great use to surgeons and physiotherapists.
ACKNOWLEDGEMENT
This work was undertaken independently and there were no funding sources. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=212http://ijcrr.com/article_html.php?did=2121. Standing, S. Gray’s Anatomy: The Anatomical Basis of Clinical Practice 40th Ed. New York: Churchill Livingstone, 2008, pp2729-31.
2. Romanes G J: Cunningham’s Manual of Practical Anatomy. Vol 2 Thorax and Abdomen 15th Ed, 2003
3. Stevenson R E, Hall J G; Human malformations & related anomalies, 2nd Edn. Oxford University Press, 2006; pp 801
4. Barry J Anson. Morris; Human Anatomy, 12th edition; McGraw Hill Book 1953 pp 566
5. Basmajian J.V. Grant’s Method of Anatomy,*Th edition William and Wilkins, 1972 pp 264
6. Sachin P, Suchismita G, Neelam V Biometrics of Psoas Minor Muscle in North Indian Population Journal of Surgical Academia 2015; 5(1): 14-18.
7. Farias MCG, Oliveira BDR, Rocha TDS, Caiaffo V. Morphological and morphometric analysis of Psoas Minor Muscle in cadavers. J. Morphology. Sci.2012; 29 (4):202-205.
8. Hanson P, Magnusson SP, Sorensen H, Simonsen EB. Anatomical differences in the Psoas muscles in young black and white men. J. Anat. 1999; 194(2):303-307. [7].
9. Dyke JAV, Holley HC, Anderson SD. Review of Iliopsoas anatomy and pathology. Radiographics. 1987 Jan 1; 7 (1):53–84.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241816EnglishN2016August22HealthcareANAESTHETIC MANAGEMENT OF A PARTURIENT WITH EISENMENGER'S SYNDROME POSTED FOR EMERGENCY CAESAREAN SECTION
English4042M. S. Prasanth KumarEnglish A. K. KavithaEnglish S. MushahidaEnglish S. GiridharanEnglishPhysiological changes in pregnancy is poorly tolerated in patients with Eisenmenger syndrome (ES) thus increasing the maternal mortality to 30-50%. We describe the management of a 34 years old primigravida with Eisenmenger’s syndrome with pre eclampsia who was posted for emergency caesarean section.
EnglishAnaesthesia, Caesarean section, Eisenmenger?s syndromeINTRODUCTION
Pregnancy causes dramatic physiological changes in various organ system in the human body. Increased circulatory burden of pregnancy can unmask previously unrecognized heart conditions and worsen these condition to a lethal situation. A comprehensive understanding of the cardiovascular adaptation during pregnancy and early postpartum period is essential for appropriate management of pregnant patient with cardiovascular disorders. Patients with irreversible pulmonary vascular obstructive disease, secondary to an intracardiac shunt (Eisenmengers syndrome)1 are known to be at particularly high risk when undergoing Non cardiac surgery2 . This risk of Non cardiac surgery may relate to 1) the extent of the surgical procedure, 2) severity of pulmonary hypertension, 3) severity of tricuspid regurgitation and right ventricular dysfunction, and 4)additional acquired cardiac and systemic disease. These patients are very vulnerable to alteration in hemodynamics induced by anaesthetics or surgery. This includes a minor fall in systolic blood pressure that can increase right-to-left shunting and possibly potentiate cardiovascular collapses such as ischemic heart disease, and renal dysfunction. The principle of any anaesthetic technique chosen is to maintain systemic vascular resistance (SVR), avoiding its fall or increase in pulmonary vascular resistance (PVR).
CASE REPORT
A 34 years old elderly unbooked primigravida [Wt.- 59kg, Ht-161cm ] who had conceived after four years following infertility treatment at 29 weeks and 2days gestation was scheduled for emergency Caesarean section with the indication being Preterm breech, Pregnancy induced hypertension with absent diastolic flow. She is not a known case of Congenital heart disease, or Rheumatic heart disease, but currently presented with NYHA Class 4 breathlessness, central cyanosis with a blood pressure of 180/100mmHg. On further examination her Heart Rate was 118 beats per minute, O2 saturation was 87% in room air, 90% with O2 of 6L/min using Hudson Mask and Respiratory rate was 38 breaths per minute. Bilateral pedal edema was also present with pan digital clubbing. Systemic examination revealed bilateral creptations with normal vesicular breath sounds; S1, S2 heart sounds with a pan systolic murmur of grade- 3. On analysis of blood: ABG in Room air showed pH- 7.411,pO2- 52.0mmHg , pCO2- 30.8mmHg, HCO3- 19mmol/l, SaO2- 86.5%; Hb- 17.9g/dl, PCV-59.1%, Platelet count-65000/ mm3, TC- 10900; PT- 13.5s (13.0), INR 1.05, ApTT- 35.9s (30.0). Chest X-ray showed dilated Right pulmonary artery and Cardio- thoracic ratio was 55% with periphery pruning. Bedside Echocardiography showed perimembranous VSD of 14mm, bi directional shunt, IAS intact, with severe PAH (RVSP-70) and EF- 58%. After obtaining informed written consent. She was shifted to OT with O2 at 6l/min with Hudson mask after receiving anti aspiration prophylaxis. General anaesthesia was planned. Monitors such as ECG, pulse oximetry, NIBP were connected. Preinduction two wide bore venous access was secured. Internal jugular vein was cannulated using Seldingers technique and left radial artery was cannulated for beat to beat BP monitoring before induction to look for if any, hemodynamic embarrassment during induction. She was induced using Etomidate intravenously. Even though rapid sequence induction is what is suggested in pregnant patients for GA, we opted for titrated dose of the induction agent to avoid further compromise in her hemodynamics. Oxygen and air mixture (70-30%) along with Sevoflurane was used for maintenance. Muscle relaxation was achieved by Vecuronium. Oxygen saturation intra operatively was between 78%- 90%. The goal was to maintain a CVP of 5-6 cm of water. LSCS was done and a boy baby weighing 960gms with 7/10 and 9/10 Apgar at 0 and 5 mins was extracted. Post extraction of baby, 10 units of Oxytocin was given as a slow IV infusion. The blood pressure of the patient fell following the delivery of the baby, thus injection Noradrenaline at 0.02-0.08µg per kg per minute was started intravenously for maintenance of SVR. Following completion of LSCS, she developed PPH for which a balloon tamponade was done using Foleys catheter. One bag of packed red blood cells were transfused after control of the bleeding. She was shifted to the intensive care unit and was electively ventilated. Injection Noradrenaline was tapered and stopped in immediate postoperative period. IBP, Spo2, ECG, ABG were continuously monitored. On the second post-operative day she was extubated following a satisfactory ABG and improved chest signs. She comfortably maintained a saturation of 88-90% on 5L/min O2 Hudson mask with a respiratory rate of 20-25 breaths per minute. Mother and baby were stable and well on discharge after one week.
DISCUSSION
Eisenmengers syndrome is defined as the development of pulmonary hypertension in response to a left to right cardiac shunt with consequent bidirectional or reversal of shunt flow. Pregnancy is a cause of significant mortality in most published series of women with Eisenmengers syndrome. Pregnancy prevention and termination of pregnancy is preferred measure to improve survival changes in reproductive age group women.3,4,5 The hemodynamic changes of pregnancy are usually poorly tolerated in women with Eisenmengers syndrome. Most women with Eisenmengers syndrome are in a precariously balanced state and an important principle is to maintain that balance. The fall in peripheral vascular resistance that occurs during pregnancy can augment right to left shunting, worsening maternal hypoxemia and cyanosis.6 With any technique of anaesthesia, the chief consideration must be to avoid worsening of the degree of right to left shunt if already present. Thus it is imperative to maintain the SVR and prevent any decrease in it throughout the perioperative period. Whether regional or general anaesthesia is being administered, nearly all anaesthetic medication from inhaled volatiles, to IV, to epidural, or subarachnoid- produces a decrease in SVR, as a result the right to left cardiac shunt is effectively worsened.7
General anaesthesia is the preferred technique among the most anaesthesiologists for Eisenmengers syndrome presenting in pregnancy. But each technique has its own Pros and cons. Positive pressure ventilation would decrease venous return and systemic blood pressure which would increase the right to left shunt. Neuriaxial Anaesthesia has been used successfully in some cases. It has an advantage of avoiding myocardial depression but at the risk of fall in SVR. The choice of anaesthesia technique should be made on considering patients unique physiology and hemodynamic status. A multidisciplinary approach is what is advocated for the management of such patients, with involvement of Obstetricians, Cardiologist, and Anesthesiologists, Intensivists. In the above discussed case general anaesthesia was administered as the patient presented to us with cyanosis and respiratory distress. It was kept in mind throughout the procedure that even minute air bubbles can cause potentially serious effect in pulmonary microvasculature by obstruction. We used titrated dose of etomidate for induction so as to decrease the detrimental effect of GA on SVR. Nitrous oxide being a potential pulmonary vasoconstrictor was avoided in the above scenario. Both Isoflurane and Halothane are known to cause hypotension thus was avoided in this case and instead, Sevoflurane was used. Vecuronium was used for maintenance of muscle relaxation due to its cardiac stable property and absence of histamine releasing property.
The aim intra operatively was to 1) prevent hypercarbia so as to prevent acidosis and increased PVR which would worsen the shunt, 2) prevent hypoxia, 3) adequate depth of analgesia as pain can have adverse effects on PVR and SVR by increasing them, 4) Prevent Hypotension i.e., decrease in SVR , 5) well titrated volume status Monitoring plays a Pivotal role in these patients in reducing Morbidity and mortality. Basic monitoring included Pulse oximetry, ECG, NIBP, Temperature. CVP and Intra-arterial blood pressure was also being monitored, as these would give us an idea of Right .heart filling status and SVR respectively. Due to inconsistency in achieving proper terminal position of pulmonary artery catheter, its usage is controversial. TEE even though needs expertise, is necessary in case of surgeries involving major fluid shifts. We used Morphine to give adequate analgesia and titrated dose of noradrenaline to maintain SVR throughout the procedure. Oxytocin was given as a slow intravenous infusion after the extraction of the baby. Oxytocin as a bolus causes direct vasodilation and reduces SVR with compensatory increase in Heart rate and cardiac output.8 Because of the risk of pulmonary thromboembolism and paradoxical systemic embolization, heparin was given in a low dose.9 After successful completion of the LSCS, we decided to continue mechanical ventilation electively in her as the oxygen saturation was below 80%. All the monitors were continued to be used in post-operative period at ICU as hemodynamic instabilities are common in this period.
CONCLUSION
Eisenmengers syndrome undergoing caesarian section present many anaesthetic challenges, but an understanding of underlying physiology and the multidisciplinary approach can guide the perioperative management. Thus, the anaesthesia technique is to be tailored in such way so as to a fall in PVR, decrease in SVR, tachycardia, hypoxia, hypercarbia and hypothermia is avoided perioperatively.
ACKNOWLEDGEMENTS
We thank Department of Anaesthesiology for supporting us. We would like to thank Department of Obstetrics and Gynaecology and Department of Cardiology for their support. We acknowledge the immense help received from scholars whose articles are cited and included in references of this manuscript. We are also grateful to authors/ editors/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
List of Abbreviations
ES Eisenmengers Syndrome
SVR Systemic vascular resistance
PVR Pulmonary vascular resistance
NYHA New York Heart Association
ABG Arterial Blood Gas
PT Prothrombin Time
INR International normalised ratio
ApTT Activated prothrombin time
VSD Ventricular septal defect
IAS Inter atrial septum
PAH Pulmonary Arterial Hypertension
OT Operation theatre
ECG Electrocardiogram
NIBP Non invasive blood pressure
BP Blood pressure
GA General anaesthesia
CVP Central venous pressure
LSCS Lower section caeserian section
IV Intravenous
PPH Post partum haemorrhage
IBP Invasive Blood Pressure
TEE Trans Esophageal Echocardiogram
ICU Intensive Care Unit
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