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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcareASTIGMATIC CHANGES FOLLOWING PTOSIS CORRECTION SURGERY IN 30 CONSECUTIVE CHILDREN SEEN IN A REGIONAL INSTITUTE OF OPHTHALMOLOGY
English0104Garima AgrawalEnglish Swati RavaniEnglishIntroduction: Astigmatic changes induced by upper lid repositioning may be a cause of blurred vision after upper eyelid procedures. We designed a study to document the astigmatic changes after ptosis correction surgery in children. Aim: The study aims at documenting the changes in astigmatism after ptosis correction surgery in 30 consecutive children seen in a Regional Institute of Ophthalmology. Material and Methods: 30 consecutive paediatric patients (4-12 years of age) of blepharoptosis were enrolled. The patients were subjected to a complete ophthalmic examination and ptosis evaluation. Keratometry and cycloplegic refraction were done pre and post- ptosis correction surgery. Observations and Results: The average pre-operative astigmatism was 1.28 while the average observed post- operative astigmatism was 1.71. The average post- operative change in astigmatism was 0.43 which was statistically significant. Conclusion: There is a significant astigmatic change following ptosis surgery in children. Mandatory visual acuity testing, refraction and post mydriatic correction are recommended in all paediatric patients with ptosis at the time of presentation and three months post surgery.
EnglishAstigmatism, Paediatric patients, Ptosis correction surgeryINTRODUCTION Astigmatic changes induced by upper eyelid repositioning may be a cause of blurred vision after upper eyelid procedures. Procedures that reposition the upper eyelid alter pressure exerted on the opposing cornea and change pre-existing corneal curvature. Such changes potentially alter the corneal refraction and may be responsible for persistent blurred vision after upper lid blepharoplasty , ptosis repair and gold weight implantation. We designed a study to document the astigmatic changes after ptosis correction surgery in children.
AIM The study aims at documenting the changes in astigmatism after ptosis correction surgery in 30 consecutive children seen in a regional institute of ophthalmology.
MATERIAL AND METHODS 30 consecutive paediatric patients of blepharoptosis presenting to our regional institute of Ophthalmology were enrolled. Children less than 4 years of age who may not co-operate for full ophthalmic examination were excluded from the study. Children upto 12 years of age were included in our study. Other exclusion criteria includedcases of complicated ptosis, any corneal pathology, glaucoma, prior intraocular surgery and prior eyelid surgery. All patients were subjected to a complete ophthalmic examination visual acuity testing, ptosis evaluation, levator function, bell’s phenomenon and ocular movements. Ptosis was classified as mild, moderate or severe. Full cycloplegic refraction after dilation with homatropine eye drops, fundus examination and standardized keratometry with Bausch and Lomb keratometer were carried out. Surgical techniques for ptosis correction were fasanellaservat surgery, levator resection and frontalis sling surgery as per protocol. After surgery keratometry and cycloplegic refraction were repeated at one week, six weeks and three months post- operatively.
Observations and Results Table I shows the patient demographics. 17 (56.7%) children were between 4 to 7 years. 13(43.3%) children were between 8- 12 years of age. Ptosis was unilateral in 26 (86.7%) children and bilateral in 4(13.3%). Mild ptosis was seen in 5 (16.7%) cases, moderate in 10 (33.3%) and severe in 15(50%). Table II shows the levatorpalpebraesuperioris (LPS action). 13 (43.3%) patients had poor (8mm) LPS action. Table III documents the type of ptosis correction surgery performed as per the case. Fasanellaservat procedure was done in 9 (30%) cases, levator resection in 8 (26.7%) and frontalis sling surgery in 13 (43.3%) cases. Table IV shows visual function in paediatric patients with ptosis. Visual function was normal (best corrected visual acuity 6/6) in 15 (50%) patients. 12 (40%) patients were amblyopic while 3 (10%) children had strabismus. Table V documents the astigmatism in ptosis patients. With the rule astigmatism was documented in 19 (63.3%) patients, against the rule astigmatism was present in 6 (20%) patients and oblique astigmatism was seen in 2 (6.7%) patients. Table VI shows the astigmatism pre and post ptosis correction surgery. 3(10%) cases remained emmetropic. 27(90%) cases showed an astigmatic shift.Myopic astigmatism was seen in 14(46.7%) and hypermetropic astigmatism in 13(43.3%).
Average pre-operative astigmatism was 1.28. The average post- operative astigmatism was 1.71. The difference between the two was 0.43 which was statistically significant. 14 cases had an average pre-operative myopicastigmatic correction of 1.00 while the average post- operative myopic astigmatic correction was 1.50. The difference was 0.50 which again was statistically significant. 13 cases had a pre -operative hypermetropic astigmatic correction of 1.57 and an average post-operative hypermetropic astigmatic correction of 1.92. The difference between the two was 0.35. The results were statistically significant as evidenced by a p value of < 0.05.
DISCUSSION Our study documents the astigmatic changes seen following ptosis correction surgery in children. The study also documents the demography and clinical presentation of the recruited cases. Children between 4- 12 years of age were recruited. Majority of patients had unilateral(86.7%), moderate- severe (83.3%) ptosis. Most children had poor (43.3%) to fair (26.7%) levator action. Accordingly majority of the patients were subjected to either levator resection(26.7%) or frontalis sling surgery (43.3%). The documented visual function in paediatric ptosis patients was 6/6 with correction in 50% patients. Amblyopia (40%) and strabismus (10%) were observed in the remaining half. The observed astigmatism in ptosis patients was with the rule in most patients (63.3%). In paediatric patients with ptosis almost all (90%) showed association with astigmatism. The astigmatism was myopic in 46.7% and hyperopic in 43.3%. We documented the pre- operative astigmatism and final threemonth post -operative astigmatism. The average pre- operative astigmatism was 1.28 D while the average post- operative astigmatism was 1.71 D.
The difference 0.43 D had a p value of 2.5 D in congenital ptosis was 25.3%.4 The results of most of these studies were similar to those observed in our study group.
CONCLUSION We conclude that there is a significant astigmatic change following ptosis surgery in children. On documenting the demography and clinical presentation of paediatric patients with ptosis we observed that astigmatism was associated with paediatric ptosis in 90% cases while amblyopia was documented in 40% cases. We conclude that paediatric patients with ptosis must undergo careful visual acuity, cycloplegic refraction and post mydriatic correction at time of presentation. Three month cycloplegic refraction and post mydriatic correction after ptosis repair surgery are also recommended.
ACKNOWLEDGEMENT Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/ editors/publishers of all those articles journals and books from where the literature for this article has been reviewed and discussed. Ethical Clearance: Taken Informed Consent: Taken Source of funding : none Conflict of Interest: none
Englishhttp://ijcrr.com/abstract.php?article_id=305http://ijcrr.com/article_html.php?did=3051. Brown MS, Siegel IM, Lisman RD. Prospective analysis of changes in corneal topography after upper eyelid surgery. Ophthal Plast Reconstr surg. 1999;15(6): 378-83.
2. Cadera W, Orton RB. Hakim O. Changes in astigmatism after surgery for congenital ptosis. J Paediatr Ophthalmol Strabismus. 1992; 29(2):85-88.
3. Klimek DL, Summers CG, Letson RD, Davitt BV. Change in refractive error after unilateral levator resection for congenital ptosis. J AAPOS. 2001;5(5) :297-300.
4. Kao SC, Tsai CC, Lee SM, Liu JH. Astigmatic change following congenital ptosis surgery. Zhonghera Yi XueZaZhi. 1998;61(12):689-693.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcareTHE BETHESDA SYSTEM FOR REPORTING THYROID CYTOPATHOLOGY: A TWO YEAR INSTITUTIONAL AUDIT
English0511Salma BhatEnglish Nazia BhatEnglish Humaira BashirEnglish Summiya FarooqEnglish Ruby ReshiEnglish Mir Junaid NazeirEnglish Isma NiyazEnglishFine needle aspiration cytology (FNAC) of thyroid plays a significant crucial role in cytopathology worldwide. Thyroid FNAC is extremely useful in identifying a substantial proportion of thyroid nodules as benign and reducing unnecessary surgery for patients with benign disease. The present study was done with the aim of stratifying thyroid cytology smears by The Bethesda System For Reporting Thyroid Cytopathology (TBSRTC) into various diagnostic categories, analyze their cytological features using TBSRTC monograph, convey brief management plan to the clinicians, and correlate with histology of surgical specimens received Methods: This was a prospective study done on 600 cases of fine needle aspirations of thyroid nodules over a period of two years from July 2013 to June 2015. Results: Mean age of the patients included in the study was 36 years(11–73) and male to female ratio was 2:6. Out of total 600 cases, 40 cases were non diagnostic (Bethesda Category I), 492 cases were diagnosed as benign (Bethesda category II) and 12 were Bethesda category III while 41 cases were categorized as either malignant or suspicious for malignancy (Bethesda category V and VI). Histopathologic correlation was available in 113 cases. Conclusion: TBSRTC is an excellent reporting system for thyroid cytopathology. It also provides clear management guidelines to clinicians to go for follow up FNA or surgery and also the extent of surgery.
EnglishThyroid nodule, Cytology, The Bethesda system, HistopathologyINTRODUCTION
Fine needle aspiration cytology (FNAC) of thyroid plays a significant crucial role in cytopathology worldwide. Thyroid FNAC is very useful in identifying a substantial proportion of thyroid nodules as benign and reducing unnecessary surgery for patients with benign disease.1 To address terminology and other issues related to thyroid FNACs, The National Cancer Institute (NCI) sponsored the NCI Thyroid Fine-needle Aspiration (FNA) State of the Science Conference on October 22-23, 2007 in Bethesda, MD. The meeting concluded with the introduction of "Bethesda System for Reporting Thyroid Cytopathology (TBSRTC)" which summarizes matters regarding diagnostic terminology/classification scheme for thyroid FNA interpretation and cytomorphologic criteria for the diagnosis of various benign and malignant thyroid lesions.2 The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) has attempted to standardize reporting and cytological criteria in aspiration smears.3 TBSRTC is a six-category scheme of thyroid cytopathology reporting. Each category has an implied cancer risk, which ranges from 0% to 3% for the “benign” category to virtually 100% for the “malignant” category.4 The present study was done with the aim of stratifying thyroid cytology smears by TBSRTC into various diagnostic categories, analyze their cytological features using TBSRTC monograph, convey brief management plan to the clinicians, and correlate with histology of surgical specimens received.
MATERIALS AND METHODS
This was a prospective study done over a period of two years from july 2013 to june 2015. A total of 600 fine needle aspirations (FNA) of thyroid nodules were performed during this time period. Smears were stained with MGG and PAP stain. All fine needle aspiration cytology (FNAC) diagnoses were classified according to TBSRTC into NonDiagnostic/ Unsatisfactory (ND/UNS), Benign, Atypia of Undetermined Significance/Follicular Lesion of Undetermined Significance (AUS/FLUS), Follicular Neoplasm/Suspicious of a Follicular Neoplasm (FN/SFN), Suspicious for Malignancy (SFM), and Malignant2 . Histopathological correlation was done, where ever surgical material was available.
RESULTS
Mean age of the patients included in the study was 36 years(11-73) and male to female ratio was 2:6. Out of total 600 cases, 40 cases were non diagnostic (Bethesda Category I), 492 cases were diagnosed as benign (Bethesda category II) and 12 were Bethesda category III while 41 cases were categorized as either malignant or suspicious for malignancy (Bethesda category V and VI) as shown in Table 1. Histopathologic correlation was done in 113 cases which further underwent surgical intervention. For Bethesda V and VI category, 100% concordance was found, however for Bethesda category II, 5 out of 70 cases were found to have malignant diagnosis on final histopathology. The distribution of various categories from 600 evaluated thyroid nodules are shown in table 1. The present study had 40 (6.6%) cases in ND/UNS category. These cases were categorized as non-diagnostic when the adequacy criteria laid down by the Bethesda system was not fulfilled. In our study, 40 smears were unsatisfactory owing to presence of only cystic fluid, obscuring blood, overly thick smears or an inadequate number of follicular cells. 76.4% of all cases in the benign category were consistent with benign colloid/adenomatous colloid nodule.
Smears showed macrofollicular fragments with Hurthle cell features against a colloid background. Rare microfollicles were present. No significant pleomorphism or nuclear atypia was seen. High cellularity was not seen. Hürthle cells were present only in 4,7% cases and macrophages were present in 31.7% cases. Chronic lymphocytic thyroiditis constituted 17.6% of cases in the benign category. Aspirates of chronic lymphocytic thyroiditis were characterized by a population of lymphocytes, plasma cells, and lymphohistiocytic aggregates, and occasional cohesive clusters of follicular cells with oncocytic features (Hurthle cells). Lymphohistiocytic aggregates with associated folliclular dendritic cells and tingible body macrophages are often easily identified(Fig 1).
Aspirates of subacute thyroiditis were mostly hypocellular and consisted of multinucleated giant cells and loose aggregates of epithelioid histiocytes (granulomas). A variable amount of background mixed inflammatory cells including lymphocytes, plasma cells,eosinophils, and neutrophils was seen in 40% cases of subacute thyroiditis. In this study, category AUS/FLUS constituted 2% of all the cases. 65% of these were moderately cellular smears with occasional microfollicular pattern (Fig 2), 20% showed sparsely cellular smear with prominent microfollicles and scant colloid and 15% showed predominantly benign appearing smear with focal features of papillary thyroid carcinoma (PTC) including nuclear grooves, crowding, pale chromatin and alterations in nuclear contour and shape. There were 15 cases(2.5%) in the category of Follicular neoplasm/Suspicious of Follicular neoplasm.
Smears were highly cellular with predominant microfollicle formations and scant colloid (Fig 3). Lesions exhibiting Hurthle cell change predominantly and diagnosed as Suspicious for Hurthle cell neoplasm were also included. In cases of suspicious papillary carcinoma included in TBSRTC category V presence of nuclear enlargement, grooves, crowding along with thick colloid were considered were mainly cellular with crowded cell groups exhibiting nuclear and cytoplasmic pleomorphism with some occasional single atypical cells (Fig 4) Lesions were classified into Bethesda category VI category if they were diagnosed as frankly malignant with type specification. There were 10 and 31 cases in Bethesda category V and VI respectively in our study.
DISCUSSION
This study shows the two-year experience in reporting thyroid aspirations by TBSRTC in a Medical college hospital. The Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) improves the clarity of communication between cytopathologists and clinicians, predicts the cancer risk and reduces unnecessary surgery for patients with benign nodules and appropriately triages patients with malignant nodules for timely surgical intervention5 . TBSRTC does not recommend surgery for ND/UNS, benign and AUS/FLUS category. In the FN/SFN, SFM, and malignant categories, excision of nodules or partial/complete thyroidectomy was performed as per TBSRTC recommendations.
TBSRTC Category I-nondiagnostic or unsatisfactory (ND/UNS)
A thyroid FNA sample is considered adequate for evaluation if it contains a minimum of six groups of well-visualized follicular cells, with at least ten cells per group preferably on a single slide6 . The use of these well established criteria for adequacy is helpful because they improve the diagnostic efficiency of thyroid FNA and avoid unnecessary surgery for benign non- neoplastic thyroid lesions.7 Ten patients came back for a repeat FNAC after a 3 month period out of which one case after a repeat FNAC revealed features suspicious for PTC which was confirmed on histopathology. Renshaw9 found that patients with at least two non diagnostic FNAC had significantly lower risk of malignancy (0%) compared to those who had only one non diagnostic FNAC (20%).
TBSRTC Category II-benign
The benign category had 492cases (82%) with BFN being the predominant group followed by Lymphocytic thyroiditis and Granulomatous thyroiditis. The benign category comprised 80% of all cases stratified according to TBSRTC in a study by Mehra P et al3 .Surgical follow up was available in 35 cases diagnosed as BFN on cytology. 24 cases were reported as colloid goitre ,8 as Follicular adenoma and 3 as PTC on histopathology. Cases of PTC were incidental findings in thyroid specimen and were mural nodules in a cystic lesion. There were no lymph nodes in these cases and ultrasound features were not suspicious. Ultrasound guided FNAC that can obtain material from the wall and solid part of the cyst increases the accuracy of FNAC in cystic PTC10. The recommended management of this category is clinical follow up.
TBSRTC Category III-atypia of undetermined significance or follicular lesion of undetermined significance (AUS/FLUS) Cases considered as AUS/FLUS are those for which cytological findings are not convincingly benign, but the degree of architectural and cellular atypia is also not sufficient for a diagnosis of follicular neoplasm or suspicious for malignancy. In our series, the FLUS category represented 2%% of all thyroid FNAs over a 2-year period. Recent series that reported experiences with the TBSRTC categories showed that the AUS/FLUS category exhibited a marked variability in incidence (0.7-18%) and malignant outcome (6-48%) in resection specimens11. The recommended management protocol is repeat FNA after sufficient time gap. We advised the same in all our 12 cases.
TBSRTC Category IV-FN or suspicious for a FN (FN/SFN)
Aspirates with cytomorphologic features of moderate to high cellularity, scant or absent colloid, with predominantly microfollicular arrangement of follicular cells in repetitive pattern were grouped under the Follicular neoplasm/suspicious for a follicular neoplasm (FN/SFN) category. Aspirates with cytomorphologic characteristics of Hurthle cell neoplasm were also placed in this category. About 15-30% of these cases called FN/SFN prove to be malignant [12,13] the rest being FAs or cellular adenomatous nodules of MNG12 . TBSRTC recommends lobectomy for this category. Six specimens were received 1 of which turned out to be follicular variant of papillary carcinoma, 1 of follicular carcinoma (Fig 5)and the other 4 were follicular adenomas.
TBSRTC Category V- suspicious for malignancy Many thyroid malignancies like papillary thyroid carcinoma can be diagnosed with certainty by FNA. But the nuclear and architectural changes of some PTCs are subtle and focal. This is especially true for the follicular variant of PTC, which can be difficult to distinguish from a benign follicular nodule. If only one or two characteristic features of PTC are present and are only focal, or the sample is sparsely cellular a malignant diagnosis cannot be made with certainity. Such cases are best classified as suspicious for malignancy. Most (60-75%) of these cases prove to be papillary thyroid carcinomas and the rest are mostly adenomas14 .
The same general principle applies to other thyroid malignancies like medullary carcinoma and lymphoma, where ancillary tests help. Ancillary tests may be useful for patients with a diagnosis of suspicious for medullary carcinoma. An elevated serum calcitonin and/or a repeat FNA that shows strong immunoreactivity for chromogranin, synaptophysisn and calcitonin can convert a category V diagnosis of medullary carcinoma to a category VI or definite diagnosis of malignancy. TBSRTC recommends near-total thyroidectomy or surgical lobectomy for cases in this category.
TBSRTC Category VI-malignant This TBSRTC category is applied whenever the cytomorphologic features are conclusive for malignancy.
The criteria for reporting PTC are follicular cells arranged in papillary or syncytial like monolayers,cells with squamous metaplasia, altered follicular cells exhibiting characteristic nuclear features like enlarged oval or irregular molded nuclei, longitudinal nuclear grooves, intranuclear cytoplasmic pseudo inclusions, pale nuclei with powdery chromatin and psammoma bodies. In the present study we reported 21 cases of papillary thyroid carcinomas all of which correlated with histology (Fig 6 a and b). The criteria for reporting medullary carcinoma are cellular smears with plasmacytoid, polygonal or spindle shaped cells. Amyloid is often present and appears as dense amorphous material. In this study we diagnosed 6 cases of MTC. Histopathology was available in 4 which correlated with the cytological diagnosis.(Fig 7 a and b) Anaplastic carcinoma is a highly aggressive malignancy of the thyroid that has lost evidence of follicular cell origin. It accounts for less than 2% of thyroid malignancies, although rates vary geographically, and characteristically it occurs in older adults15. The criteria for reporting anaplastic thyroid carcinoma are neoplastic cells arranged in groups or individually with cells having epitheloid, spindled, plasmacytoid or rhabdoid shape. Nuclear pleomorphism, multinucleation and neutrophilic infiltration of tumor cell cytoplasm are other features16. Mitotic activity will be numerous and abnormal (Fig. 8). In our study we reported 2 cases one of which was confirmed on histopathology. Primary thyroid lymphomas are extremely uncommon neoplasms accounting for 5% of all thyroid malignancies. The criteria for reporting a lymphoma were cellular smears composed of dispersed monotonous lymphoid cells with vesicular chromatin and prominent nucleoli. One primary lymphoma of thyroid was diagnosed on FNAC. The patient received chemotherapy and responded well to the therapy. TBSRTC recommends near-total thyroidectomy for these cases of malignancy.
CONCLUSION
Our study is a prospective analysis of reporting thyroid FNA using the Bethesda system. TBSRTC is an excellent reporting system for thyroid cytopathology. Our study as well as previous various studies highlight the utility of FNAC in thyroid lesions as safe, cost effective, OPD procedure with minimal complications. It further obviates unwanted surgical intervention for benign lesions and provides clear management guidelines to clinicians to go for follow up FNA or surgery and also the extent of surgery.
ACKNOWLEDGEMENTS
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 FINANCIAL SUPPORT: None CONFLICT OF INTEREST: None
Englishhttp://ijcrr.com/abstract.php?article_id=306http://ijcrr.com/article_html.php?did=3061. Cibas E S, Ali SZ. The Bethesda System for Reporting Thyroid Cytopathology.Am J Clin Pathol. 2009;132(5):658-665.
2. Baloch Z W, LiVolsi V A, Asa S L et al. Diagnostic terminology and morphologic criteria for cytologic diagnosis of thyroid lesions: a synopsis of the national cancer institute thyroid fineneedle aspiration state of the science conference. Diagnostic Cytopathology. 2008;36(6):425-437.
3. Mehra P and A. K. Verma A K. Thyroid cytopathology reporting by the bethesda system: a two-year prospective study in an academic institution. Pathology Research International.2015; Article ID 240505, 11 pages.
4. S. Z. Ali and E. S. Cibas, Eds. The Bethesda System for Reporting Thyroid Cytopathology. Definitions, Criteria and Explanatory Notes, Springer, New York, NY, USA, 2010.
5. Jo VY, Stelow EB, Dustin SM, Hanley KZ. Malignancy risk for fine-needle aspiration of thyroid lesions according to the Bethesda System for Reporting Thyroid Cytopathology. Am J Clin Pathol.2010;134(3):450-6.
6. Crothers BA, Henry MR, Firat P, Hamper UM. Chapter 2; Non Diagnostic/Unsatisfactory. In: Ali SZ, Cibas ES, editors. The Bethesda System for Reporting Thyroid Cytopathology. New York, NY: Springer; 2010. pp. 5-7.
7. Haider AS, Rakha EA, Dunkley C, Zaitoun AM. The impact of using defined criteria for adequacy of fine needle aspiration cytology of the thyroid in routine practice. Diagn Cytopathol. 2011;39(2):81-6.
8. Schinstine M. A brief description of the Bethesda system for reporting thyroid fine needle aspirates.Hawaii Med J. 2010;69:176-8.
9. Renshaw AA . Significance of repeatedly nondiagnostic thyroid fine-needle aspirations. Am J Clin Pathol.2011;135 (5):750-2.
10. Cooper DS, Doherty GM, Haugen B R et al. Revised American thyroid association management guidelines for patients with thyroid nodules and differentiated thyroid cancer. Thyroid. 2009;19(11):1167-1214.
11. Ohori NP, Schoedel KE. Variability in the atypia of undetermined significance/follicular lesion of undetermined significance diagnosis in the Bethesda System for Reporting Thyroid Cytopathology: sources and recommendations. Acta Cytologica. 2011;55(6):492-498.
12. Yassa L, Cibas ES, Benson CB, et al. Long-term assessment of a multidisciplinary approach to thyroid nodule diagnostic evaluation. Cancer. 2007;111:508-516.
13. Yang J, Schnadig V, Logrono R, et al. Fine needle aspiration of thyroid nodules: a study of 4703 patients with histological and clinical correlations. Cancer. 2007;111:306-315.
14. Logani S, Gupta PK, LiVolsi VA, et al. Thyroid nodule with FNA cytology suspicious for follicular variant of papillary thyroid carcinoma: follow-up and management. Diagn Cytopathol. 2000;23:380-385.
15. Hassell, L. A., Gillies, E. M. and Dunn, S. T., Cytologic and molecular diagnosis of thyroid cancers. Cancer Cytopathology,2012; 120: 7-17.
16. Renuka IV, Saila Bala G, Aparna C, Kumari R, Sumalatha K. The Bethesda System for Reporting Thyroid Cytopathology: Interpretation and Guidelines in Surgical Treatment. Indian Journal of Otolaryngology and Head and Neck Surgery. 2012;64(4):305- 311.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcareANGIOLIPOMA CAUSING COLOCOLIC INTUSSUSCEPTION: A RARE CASE REPORT
English1213M. GanesanEnglish A. Ajay RajaEnglish A. AvinashEnglishIntussusception is defined as the telescoping of proximal segment of intestine into a distal segment of intestine. Intussusception is usually idiopathic, without an obvious anatomic lead point. Colocolic intussusception due to angiolipoma is very uncommon on the left side of the colon. The disease is diagnosed often late following disease progression which is attributed to its indolent course and its non specific symptomology. This cases is presented for its rarity.
EnglishIntussusception, Colocolic intususception, AngiolipomaINTRODUCTION Intussusception can cause a tear in the bowel , gangrene of bowel tissue and infection. Intussusception is the commonest cause of intestinal obstruction in children age less than 3. In older children, the incidence of the a pathological lead point is up to 12%, where meckel’s diverticulum is found to be most common lead point for intussusceptions. However, other causes such as intestinal polyps, inflamed appendix, submucosal hemmorage, foreign body, ectopic pancreatic or gastric tissue. We report two case in which Colocolic intussusceptions due to angiolipoma.
CASE REPORT A 55 years old man presented with lower abdominal pain for two days with no episode of vomiting, constipation and bleeding per rectum with no previous history of similar complaints. The patient was not tachycardic with normal blood investigations. A radiogram of the erect abdomen was taken which showed a few air fluid levels with no pneumoperitoneum. An early ultrasonography of abdomen revealed telescoping of bowel within bowel in the left iliac fossa with a well defined echogenic focal lesion in its distal portion. CECT scans revealed submucosal lipoma causing colo-colic intussusceptions in the left side of the colon. A diagnosis of colo-colic intussusception was made and the patient was managed initially by nil per oral, intravenous fluids and antibiotics and with Ryles tube aspiration and a decision of emergency laporotomy was made and proceeded.
At laprotomy the surgical team found the presence of colo-colic intussusception in the descending colon involving about 8cm of the descending colon and the lead point was found to be a submucosal lipoma of size 10x8x4cm. The intussusception was reduced and a descending colon of about 10-12cm was found to be gangrenous and that segment of the gangrenous part was resected and the proximal loop of the descending colon was brought out as a colostomy and the distal loop was sutured with anterior abdominal wall with 3-0vicryl. The colostomy was fixed with the skin by 2-0silk. Histopathological examination of the specimen revealed findings consistent with angiolipoma. The patient had an expected postoperative period. Oral feeds were resumed after 3 days. The patient was discharged after suture removal and asked to come after six weeks. After six weeks patient was prepared for colostomy closure, distal loop of colon is anastomised with colostomy end to end anastomosis done and patient had an expected postoperative period .the patient was discharged and asked to review after one week.
DISCUSSION Intussusception is a process in which a segment of intestine invaginates into the adjoining intestinal lumen, causing bowel obstruction. Intussusception also cuts off the blood supply to the part of the intestine that’s affected. Intussusception can lead to a tear in the bowel (perforation), infection and death of bowel tissue. Intussusception is the most common cause of intestinal obstruction in children younger than 3. Intussusception is rare in adults. Most cases of adult intussusception are the result of an underlying medical condition, such as a tumor. In this article, we reviewed the cases of Colocolic intussusception due to angiolipoma is very uncommon on the left side of the colon. This case highlights the fact that a high suspicion of a intussusceptions should be kept in mind in dealing with patient with intestinal obstruction.
CONCLUSION : It is telescoping or invaginating of one portion (segement) of bowel into the adjacent segment. Intussusception are two types antegrade and retrograde. In elderly intussusceptions colocolic is most common type, apex is formed usually by growth. It can be ileo-colic (most common type 75%), colocolic, ileoileocolic, colocolic. Intussusceptionis common in weaning period of a child (common in males), between the period of 6-9 months. It is the commest cause of intestinal obstruction in children of 6-18 months age.
ACKNOWLEDGEMENT The author acknowledgement the immense help received the scholars whose article are cited and included in references of this manuscript. The authors are also grateful to the authors/ editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=307http://ijcrr.com/article_html.php?did=3071. http://www.mayoclinic.org/diseases-conditions/intussusception/ home/ovc-20166951
2. Toso C, Erne M, Lenzlinger PM, Schmid JF, Büchel H, Melcher G, Morel P (2005). “Intussusception as a cause of bowel obstruction in adults” (PDF). Swiss Med Wkly 135 (5-6): 87–90. PMID 15729613.
3. Gayer G, Zissin R, Apter S, Papa M, Hertz M (2002). “Pictorial review: adult intussusception--a CT diagnosis”. Br J Radiol 75 (890): 185–90. PMID 11893645
4. Bailey and Love›s/25th Edition/ Chapter no 66/ acute intussusceptions.
5. Park NH, Park SI, Park CS, Lee EJ, Kim MS, Ryu JA, Bae JM (2007). “Ultrasonographic findings of small bowel intussusception, focusing on differentiation from ileocolic intussusception”. Br J Radiol 80 (958): 798–802. doi:10.1259/bjr/61246651. ISSN 0007-1285. PMID 17875595
6. Cera, SM (2008). “Intestinal Intussusception”. Clin Colon Rectal Surg 21 (2): 106–13. doi:10.1055/s-2008-1075859. ISSN 1531-0043. PMID 20011406
7. Bai YZ, Chen H, Wang WL. A special type of postoperative intussusception: ileoileal intussusception after surgical reduction of ileocolic intussusception in infants and children. J Pediatr Surg. 2009 Apr. 44(4):755-8.
8. Haas EM, Etter el, Ellis S, et al: Adult intussusceptions. Am J Surg 186:75,2003
9. Fraser JD, Aguayo P, Ho B, et al. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A. 2009 Aug. 19(4):563-5.
10. Niramis R, Watanatittan S, Kruatrachue A, et al. Management of recurrent intussusception: nonoperative or operative reduction?. J Pediatr Surg. 2010 Nov. 45(11):2175-80.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcareCORRELATION BETWEEN BMI AND ARTERIAL STIFFNESS IN MIDDLE AGED SUBJECTS
English1417Niruba R.English T. Kannan KumarEnglish Subha K. C.English VijiyalakshmiEnglishBackground: World wide prevalence of obesity has reached a pandemic proportion. Obesity and Arterial wall stiffness are independent predictors of cardiovascular diseases. We aimed to investigate how BMI affects arterial stiffness. Noninvasive method of measuring arterial stiffness can be applied to assess the elasticity of the vessel wall and reduce the cardiovascular morbidity. Study Design: Cross sectional observational study. Materials and Methods: Subjects n= 50 males, Age group 35-45 years. All participants had a sedentary life style, blood pressure and glycemic status were within normal limits. Subjects with history of peripheral vascular disease, smokers and any other illness that affects arterial compliance were excluded . Arterial stiffness was assessed from Augmentation index (AI) and stiffness index (SI). AI and SI was measured using IR1 model digital finger tip photo pulse plethysmograph. Results: Mean age = 38±2 years, Mean BMI = 26± 3, Mean Stiffness index = 7.4 ±1.4 m/s, Mean Augmentation index= 48 ±2.8 %.Pearson correlation was applied .BMI correlated positively with both augmentation index and stiffness index with r value is +0.437 and + 0.564 respectively. Conclusion: In our study both large and small artery stiffness were assessed. There was increase in arterial wall stiffness with increase in BMI. We conclude obesity affects arterial compliance, which might be the consequences of metabolic regulation, inflammatory pathways and other mechanisms
EnglishBMI, Augmentation Index, Stiffness IndexINTRODUCTION In the present era, besides the genetic predisposition, adoption of sedentary lifestyle, lack of regular physical exercise, excessive intake of junk foods, stress of competitive world has made the environment conducive to the development of obesity (1). Obesity is associated with impaired function of the large arteries, which might be the consequence of metabolic regulation, inflammatory pathways, obstructive sleep apnoea or other mechanisms (2,3). Pulse wave analysis can measure stiffness index and augmentation index the surrogate markers of arterial stiffness (4).Thus Obesity and arterial wall stiffness are independent predictors for cardiovascular diseases. Thus correlating BMI and arterial stiffness can reduce the morbidity due to cardiovascular disease in overweight and obese individual. Aim: Assessment of vessel wall compliance among normotensive normoglycemic middle aged individuals and correlating it with their BMI. Study Design: Observational/cross sectional study.
MATERIALS AND METHODS: All participants gave a written informed consent to participate in this study. Institutional ethical committee clearance was obtained. Information details about sociodemographic characteristics, disease history, family history, alcohol consumption, cigarette smoking, drug intake and occupational history were obtained by a structured questionnaire. All participants had a sedentary lifestyle.
SUBJECTS Inclusion criteria: 50 healthy volunteers normoglycemic, normotensive males with no paternal or maternal history of diabetes, Age= 35- 45 yrs, Blood pressure = < 140/90 mmHg, Fasting blood sugar = 90-100 mg/dl.
Exclusion Criteria: Subjects with history of peripheral vascular disease, smokers, and any other illness that affects arterial compliance , subjects with family history of diabetes and hypertension were excluded from the study. Anthropometric measurements were taken. Height was measured using stadiometer and weight was measured using precalibrated weighing machine. Quetlet’s index was used to calculate Body mass index (weight/height in m2).Blood pressure was measured using a standard mercury sphygmomanometer. Fasting blood glucose was measured to rule out diabetic mellitus.
Recording of digital volume pulse (DVP): Digital volume pulse was recorded by in house built instrument IR1 model digital finger photoplethysmography (5). The signal from the instrument placed on the right index finger was digitalized by digital converter with a frequency of 100 Hz which was connected to the computer. DVP was analyzed by software virtual oscilloscope. Digital volume pulse contains 2 peaks: Fig-1 1. Systolic peak. 2. Diastolic peak. Initially Systolic peak is formed by pulse wave transmitted from the left ventricle to the finger directly.(5) Second peak or diastolic peak arises from pulse wave transmitted along the aorta to the small arteries in the lower body, from where they are again reflected along the aorta as a reflected wave (5) (fig-1).This path length is proportional to the subject’s height (h). Pulse transit time (PTT or ΔT) is the time interval between systolic peak and diastolic peak. It was measured by software image tool . Magnitude of systolic and diastolic peak were also measured .Stiffness index is based on the subjects height (6). Stiffness index and Reflective index were calculated by the following formulas.
Stiffness index (SIDVP) = Subject’s height (h).
Pulse transit time (ΔT).
Reflection index (RI) = Magnitude of diastolic peak (b) × 100.
Magnitude of systolic peak (a).
RESULT Statistical analysis was done Using SPSS Software version 16.0. The descriptive statistics of BMI, Blood sugar, Systolic blood pressure, Diastolic blood pressure are mentioned in table 1. Pearson correlation was applied. Correlation between BMI with stiffness index and reflective index was analyzed among study group and it showed a positive correlation with r value is +.564 and +.437 respectively (Table 2).
DISCUSSION Our study showed a positive correlation of BMI with stiffness index and reflective index. Indicating increased body weight affects the vessel wall compliance. Reduction of weight can improve the elasticity in vessels as stated in study by alvarez et al and Abate et al that after weight loss, the increased stiffness is reversed in parallel with reduction of heart rate which might be due to neural sympathetic over activity(7,8). Obesity is the risk factors for diabetes mellitus and cardiovascular disease, such as ischemic heart disease and stroke (9,10). Calculating body mass index (BMI) is the easiest way to evaluate overweight and obesity (9).
Non-invasive measurement of vascular wall elasticity is an important diagnostic tool which allows one to collect information on the functional status of the arteries and enables early detection of pathologies before the onset of clinical symptoms (11,12). Central blood pressure and measures of arterial stiffness have been shown to be powerful predictors of major cardiovascular events, independent of the traditional risk factors (13), The augmentation index (AI), gives us small artery stiffness (13), calculated from the difference between the first and second systolic peaks expressed as a percentage of the pulse pressure, and a measure of systemic stiffness(14) .
The stiffness index is a measure of pulse wave velocity (PWV) in large arteries. It is a measure of the timing of the diastolic relative to the systolic component of PWV in the large arteries (height divided by time between systolic and diastolic peaks (15). Augmentation index (AI), a measure of enhanced wave reflection, has been proposed as a bedside measure of aortic stiffness (16). Indeed, high levels of leptin have been documented in individuals with obesity and found to be correlated with reduction in arterial distensibility (17). In addition to hypothalamic receptors, receptors for leptin have been observed on the vascular endothelium and on smooth muscle cell (18,19). Accordingly, leptin can exert receptor-mediated influence on vessel tone and growth and, in cell culture, stimulate vascular smooth muscle proliferation and migration (20).
In addition, leptin induces oxidative stress in endothelial cells, and this action triggers the transcription of oxidant-sensitive genes that participate in atherogenesis. Peripheral Pulse Pressure, central Pulse Pressure and augmentation index, which provide additional information on wave reflection, are considered “surrogates” of arterial stiff- cness (21,22,23). O Brein et al stated strong association exits between Ambulatory arterial stiffness index (ASSI) and most reliable parameters of arterial stiffness like pulse wave velocity and augmentation index (24). In our study we measured stiffness index (SI) and augmentation index (AI) which can assess large and small artery compliance respectively by noninvasive measurement. Dolan and Hansen et showed that relation between stiffness index and cardiovascular mortality was linear (25,26).
A positive relationship has been demonstrated between type 2 diabetes mellitus and increased large artery stiffness (27). It is noteworthy that in individuals with obesity, increased aortic stiffness also may contribute to the development of cardiac hypertrophy, in addition to hypertension (28,29,30). We conclude that in subjects without hypertension and diabetes, BMI correlated with stiffness of the large artery (stiffness index) and small artery wall (Augmentation index). Indicating overweight and obesity can independently contribute to altered vessel wall compliance.
CONCLUSION Vessel wall compliance as measured by arterial stiffness is altered in obese and overweight individual. Implicaion of Study: To improve the vessel wall compliance Life style modifications on diet and exercise are mandatory for obese and overweight and prevent further progression to cardiovascular diseases.
ACKNOWLEDGEMENT Authors acknowledge immense help received from the scholars who’s articles are cited and included in references of this manuscript. The authors are grateful to the authors/ editors/ publishers of all those article journals and the books from where the literature of this article has been reviewed and discussed. I sincerely thank Professor Dr.K.N. Maruthy, for his extensive guidance in this research project. Source of funding : None Conflict of interest : None
Englishhttp://ijcrr.com/abstract.php?article_id=308http://ijcrr.com/article_html.php?did=3081. Brozak J and Keys A. The evaluation of leanness-fatness in man: norms and interrelationships. Food and agricultural organization of the United Nations. Dietary Surveys 1949; Vol-62(3):194- 206.
2. Jelic S, Bartels MN, Mateika JH, Ngai P, DeMeersman RE, Basner RC.Arterial stiffness increases during obstructive sleep apneas. Sleep 2002;25: 850–855.
3. Hall JE. The kidney, hypertension, and obesity. Hypertension 2003; 41:625–633.
4. I.S. Mackenzie, I.B. Wilkinson and J.R. Cockcroft. Assessment of arterial stiffness in clinical practice, Q J med 2002; 95:67–74.
5. G Sivagami, Milind Bhutkar, A Comparitive study of arterial stiffness indices between normotensive and hypertensive subjects-NJBMS,2014 : 4(3); pg-177-179.
6. Chen CH, Nevo E, Fetics B et al .Estimation of central aortic pressure waveform by mathematical transformation of radial tonometry pressure. Validation of generalized transfer function. Circulation 1997;95:1827-36.
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9. Garrow JS, Webster J. Quetelet’s index (W/H2) as a measure of fatness. Int J Obes 1985; 9: 147–153.
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11. Oliver JJ, Webb DJ. Noninvasive assessment of arterial stiffness and risk of atherosclerotic events. Arterioscler. Thromb. Vasc. Biol. 2003; 23: 554–566.
12. Mattace-Raso F, Cammen T, Hofman A. et al. Arterial stiffness and risk of coronary heart disease and stroke. The Rotterdam Study. Circulation 2006; 113: 657–663.
13. Weber T, Auer J, O’Rourke M, et al. Arterial stiffness, wave reflections, and the risk of coronary artery disease. Circulation 2004; 109: 184–189.
14. Woodman RJ, Kingwell BA, Beilin LJ, Hamilton SE, Dart AM, Watts GF: Assessment of central and peripheral arterial stiffness: Studies indicating the need to use a combination of techniques. Am J Hypertens18 2005:249–260.
15. I.S. Mackenzie, I.B. Wilkinson, J.R. Cockcroft, Assessment of arterial stiffness in clinical practice, http://dx.doi.org/10.1093/ qjmed/95.2.67 67-74 , February 2002
16. Gary F. Mitchell, Yves Lacourcie`re, J. Malcolm O. Arnold, Mark E. Dunlap,Paul R. Conlin, Joseph L. Izzo, Jr ,Changes in Aortic Stiffness and Augmentation Index After Acute Converting Enzyme or Vasopeptidase Inhibition ,Hypertension. 2005;46:1111-1117.
17. Singhal A, Farooqi IS, Cole TJ, O’Rahilly S, Fewtrell M,Kattenhorn M, Lucas A, Deanfield J: Influence of leptin on arterial distensibility: A novel link between obesity and cardiovascular disease? Circulation 2002;106: 1919–1924.
18. Oda A, Taniguchi T, Yokoyama M: Leptin stimulates rat aortic smooth muscle cell proliferation and migration. Kobe J Med Sci,2001; 47: 141–150.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcareEVALUATION OF THE EFFECTS OF PH AND TEMPERATURE ON THE ADSORPTION ISOTHERM OF ACTIVATED MEDICOAL FROM NIGERIA PLANTS. MAGNIFERAINDICA, PERSEAGRATISSIMA AND PSIDIUMGUAJAVA
English1821Edwin N. OguegbuluEnglish Emmanuel A. NwokebothEnglishActivated charcoal, also referred to as medicoal is known to be a versatile tool in the field of Pharmaceutical Medicine. This was successfully prepared from the stem parts of Mangiferaindica (Mango), Psidiumguajava (Guava) and Perseagratissima (Avagado pear) by process of carbonization and thermal activation. Liquid phase study was conducted using Freundlich isotherm model to evaluate the equilibrium adsorption data generated for methylene blue (MB) sulphanephthalein dye stuff on activated medicoal test samples. Ultra violet spectroscopic method was used to assess the effect of variation of pH and temperatures on the adsorption profile of all the medical samples, including the commercially available standard. The results were found to be statistically significant using the one-tail analysis of variance (ANOVA) at confidence interval of p ≤ 0.05. The research showed that the availability of negatively charged groups at the adsorbent surface is necessary for the adsorption of alkaline dye - stuff, thus the pH increase resulted to an increase in adsorption. The investigation also indicated that adsorption of locally sourced medicoal increases with temperature. The adsorption pattern of Perseagratissima compared favorably with that of the commercially available standard whereas Psidiumguajava ranked lowest.
EnglishLocally sourced activated medicoal, Adsorption capacity, Function of, Temperature and pHINTRODUCTION Adsorption is the adherence of atoms, ions or molecules from a gas, liquid or dispersed solid to surface Abrowski, A. D. (2005). By this, a film of the adsorbate is created in the surface of the adsorbent. Adsorption being distinct from absorption is a surface phenomenon whereas the later involves the whole volume of the material. There are two types of adsorption with their characteristic features and several applications in Pharmaceutical Medicine. These uses extend to control of odour, remedy for toxins and flatulence as well as in chromatographic techniques. Oguegbulu and Nwoke (2015).
Some physico- chemical factors are known to influence the adsorption performance of materials; Solids, particularly in finely divided state have large surface area and therefore, charcoal, silica gel, alumina gel, clay, colloids, metals of finely divided particles, all act as good adsorbents Transtutor.(2013). Usually, smaller particles equilibrate more easily and nearly full adsorption capacity canbe attained. Piero (2013). The high contact time between the adsorbent and the adsorbate creates more complete adsorption process. Zhu et.al (2012),so also, do the effects of the following impact on adsorption; pH, degree of ionization of molecules, temperature and the affinity of the solute for the adsorbent. Christmann.(2010/2011). Generally, pH has been found to affect the; activity, solubility, stability and absorption of medicinal products Niebergall(1980).
An increase in temperature implies that the molecules attract a quantum of heat energy equivalent to a product of the heat capacity and such infinitesimal increase in temperature. The associated increase in temperature alters the kinetic energy (Entropy) at the surface region thereby resulting in enhanced enthalpy which favours the surface phenomenon of adsorption.
At constant volume, this temperature effect can be expressed by the following transformation derivable from ClausiusClapeyron equation as: ? s = 2.303Cv log T2 /T1 Where; ? s is the change in entropy, Cv is the heat capacity at constant volume, where T1 and T2 are the limits of changes in thermodynamic temperatures. Florence and Attwood (1981). Three isotherm models are indentified, namely: Langmuir, Freundlich and Brunauer, Emmett-Teller (BET). Of these models, the Freundlich Isotherm model is the most appropriate for this study. Oguegbulu and Okumiahor (2013)
MATERIALS AND METHODS: The stem parts of Psidiumguajava (Guava), Perseagratissima (Avocado pear) and Margiferaindica (Mango) were harvested from Obelle village in Emoha Local Government Area of Rivers State in Nigeria. Each was chopped into chips, air dried for 28 days under the ambient laboratory temperatures. They were thereafter carbonized respectively using the Muffler furnace (Nabertherm, Germany)at 650o Cfor 30 minutes Fiyyaz et.al. (2000).
Each of the medicoal samples was collected, pulverized with mortar and pestle as well as sieved using mesh size number 250. The fine powdered samples so obtained were stored in air tight containers separately and labeled accordingly Ademiluyo et.al.(2009). The sieving process was also carried out for the commercial (standard) medical sample. The test samples were reactivated at a temperature of 100o C for 2 hrs prior to the experiments. This reactivation process helps to expel moisture and volatile oil impurities.Wikipedia. (2014). For the assessment of temperature effect, a 150 ml MB dyestuff solution was prepared with a concentration of 50mg/L and adsorbent dose of 2.0g/150ml.
This was prepared by dissolving 7.5mg of MB in 150ml of distilled water in a conical flask and adding the 2.0g of activated medical to each. The mixtures were stirred to propel percolation and then subjected to different experimental temperatures as; 25, 30, 37 and 45o C in a water bath. Samples were collected from the mixtures, filtered and absorbance determined at different time intervals (5, 10, 20, 30, 60 and 120 minutes), for the different temperatures. Graphs of the amount adsorbed per unit mass of adsorbent (mg/g) against time (minutes) were plotted for each of the temperatures for various activated medicoal samples.
Effect of pH on the adsorption of MB on the test samples was conducted by preparation of five solutions as above. 150ml with concentrations of 50mg/L by dissolving 7.5 mg MB in 150ml of distilled water and their initial pH determined using pH meter(Mettler Toledo, Germany). The pH thereafter was adjusted by using 0.05N HCL for acidity and 0.05N KOH for alkalinity to obtain pH of 2, 5, 7, 9 and 12. To each of the various mixtures was added 2.0g of the various test medicoal samples. These were properly shaken and maintained at room temperature for 2 hrs. Following this, the samples were collected, filtered, the absorbance measured and concentrations extrapolated. A graph of amount adsorbed per unit mass of adsorbent (mg/g) versus corresponding pH of solutions was plotted. Hema, Martin, (2009).
DISCUSSION Results of comparative temperature and pH effects on the adsorption isotherm of developed medicoal samples as shown in figures 1 to 5 above, were used in the evaluation ofthe adsorption profiles of all the test medicoal samples. The study was conducted under the same experimental conditions such as, the particle size of adsorbent; uniform contact time; temperatures and pH. The effect of initial pH and temperatures on the adsorption of methyleneblue, dye stuffon medical was assessed by this research. At pH 2, adsorption was minimal, but was enhanced with an increase in the initial pH of the M.B dye solution. The adsorption of this cationic dye on the adsorbent surface was proportionately influenced by the surface charges on the adsorbent-medicoal samples, and is a function of the pH of the solution.
The results showed further that the availability of the negatively charged ions at the adsorbent surface is necessary for the adsorption of the MB dye and such was observable at pH above2. Adsorption was almost unlikely at that pH of 2 since there is a net positive charge in the adsorption system due to the presence of H3 O+ . Thus as the pH increases, more negatively charged surfaces are available, thereby facilitating a greater methylene blue adsorption. It was observed that adsorption increases with increasing pH in the case of all charcoal samples. This may be due to the fact that they all basically hadthe same composition and were activated using same activation method.The acidic stomach environment,will impact positively charged groups in the adsorbent surfaces and is a major condition for adsorption of an acidic adsorbates such as toxins that should exist in their unionized form there in. The reverse occurs in the basic pH region of the small intestine where basic adsorbates would be adsorbed more. The result of investigation of temperature effect on adsorption of medicoal samples showed that the adsorption of MB by the samples increased with increase in temperature.
This increase in adsorption may be as a result of increase in mobility of the large dye ions with temperature. An increasing number of adsorbate may also acquire sufficient energy to undergo an interaction with the active sides at the surface. Additionally, an increase in temperature may produce a swelling effect within the structure of the activated medicoal, thereby enabling large dye molecules to penetrate with ease and faster.. This temperature effect can as well be extrapolated to the human body environment of about 37o C as a useful phenomenon for maximal activity of medical in treatment. Thus in the case of pyrexia due to poisoning, the adsorption action of activated charcoal may be slightly enhanced which is a desirable effect for the poison victim.
CONCLUSION The adsorption Isotherm has highlighted the individual sample of Perseagratissima as ranking equally with the commercially available standard sample. It can then be established that the adsorption of MB on the various medicoal samples increased with an increase in both pH and temperature.
ACKNOWLEDGEMENT The authors are thankful to the entire staff members of Laboratories of Pharmaceutical and Medicinal Chemistry as well as Pharmacognosy and Physiotherapy Departments of University of Port Harcourt, Rivers State, Nigeria, for their co-operation during this research work. Much gratitude also should go to the Laboratory staff of National Agency for Food and Drug Administration and Control (NAFDAC), Port Harcourt Nigeria for their highly valued technical support in the realization of this research.
Englishhttp://ijcrr.com/abstract.php?article_id=309http://ijcrr.com/article_html.php?did=3091. Abrowski, A. D. (2005). Adsorption- from theory to practice, Advanced colloid interface science;pg 135 – 224.
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9. Oguegbulu EN and Nwoke EA.(2015).Physicochemical and Spectroscopic Evaluation of Adsorption Potentials of Activated charcoal from stem parts of Mangiferaindica, Perseagratissima and Psidiumguajava for Pharmaceutical medicine. Novo Journal of Medical and Biological Sciences.Vol.4(2).2015.1-9.
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13. Zhu, J., Gao, J., Li, Y., Sun, T., Wu, S., (2012). In Preparation of Activated Carbons for SO2 Adsorption by CO2 and steam activation. J Twain Inst Chem Eng; 43(1): 112-119.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcareBIOCHEMICAL ASSESSMENT OF HOMOCYSTEINE AND LIPID PROFILE IN PEDIATRIC STROKE: AN EGYPTIAN STUDY
English2229Tahia H. SaleemEnglish Mohammed H. HassanEnglish Ahmed El-Abd AhmedEnglish Abdallah M. A.A. El-EbidiEnglish Heba M. QubaisyEnglish Omayma A. HasanEnglishIntroduction: Stroke and cerebrovascular disorders are already amongst the top 10 causes of childhood death. Patients with homocysteinemia may present with vascular thrombotic events, with or without the traditional risk factors for a stroke. Objectives: The aim of this study was to measure plasma homocysteine levels and lipid profile (serum cholesterol, triglycerides, HDL and calculation of LDL) in pediatric patients with ischemic or hemorrhagic stroke. Assess the role of homocysteinemia as an associated risk factor in pediatric ischemic stroke. Correlate the results with the clinical data of the patients. Materials and Methods: Across-sectional case control study was carried out on 60 pediatric patients, divided into two groups: group A contained 30 pediatric patients with ischemic stroke and group B contained 30 pediatric patients with hemorrhagic stroke, they were recruited from outpatient clinics or admitted to PICU (pediatric intensive care unit) in Assiut university children hospital and Qena university hospital, Upper Egypt, after approval of the university hospital ethical committee. The control group “group C” contained 30 healthy age and sex matched subjects. Biochemical assay of plasma homocysteine and lipid profile among the previously mentioned groups were done. Results: The plasma homocysteine level showed statistically significantly higher levels among group A when compared with group B and group C (P-Value 0.0001). There was no significant difference in plasma homocysteine among group B when compared with group C (P-Value 0.9). Regarding the lipid profile assay in the studied groups, serum triglyceride level, cholesterol and low density lipoprotein (LDL) were significantly high among group A in comparison with group B and group C (P-ValueEnglishHomocysteine, Lipid profile, Pediatric stroke, Egyptian studyINTRODUCTION Stroke and cerebrovascular disorders are already amongst the top 10 causes of childhood death 1 . Considering the onset of impairment during childhood and the effect on quality of life for the child and family, the economic and emotional costs to society are amplified 2. There are two main types of stroke. Ischemic strokes are caused by a blockage in the blood supply to the brain. Hemorrhagic strokes occur when blood leaks from a burst blood vessel into the brain3 . The majority of signs and symptoms of stroke are nonspecific, and can be easily attributed to other causes. One way to avoid delays or misdiagnoses would be to identify risk factors for stroke that would prompt more aggressive and timely inves tigation. Multiple risk factors are often present in as many as 25% of children with stroke, which means further investigations are warranted even when one risk factor has been identified 4. Homocysteine (Hcy) is a sulfur containing amino acid. Hcy is formed through demethylation of methionine, which donates a methyl group in many biochemical reactions. It is metabolized through two enzymatic pathways; trans-sulfuration and remethylation, but not in all tissues. Vitamin B6 is important in Hcy trans-sulfuration, whereas folate and vitamin B12 play significant role in Hcy re-methylation5 .
Patients with homocysteinemia could be presented with vascular thrombotic events, in presence or absence of the traditional risk factors for the occurrence of a stroke. This group of patients may already have a history of strokes and myocardial infarctions in the third or fourth decade of life 6 . From a pathophysiologic point of view, homocysteinaemia is associated with atherogenesis and increased thrombogenicity 7 . Transient and chronic endoplasmic reticulum (ER) stress elicited by homocysteine has been shown to adversely affect several cellular functions involved in the development and progression of atherosclerosis, including lipid dysregulation, programmed cell death and inflammation8 . Both in animal models and humans, homocysteinaemia is characterized by platelet aggregation and formation of thrombi rich in platelets at the sites of injured endothelium. The increased risk of vascular thrombosis may be derived from the vascular oxidative injury and the modification of physiological antithrombotic mechanisms7 .
MATERIALS AND METHODS Study design: This study is across-sectional case control study and it was carried out on 60 children with CNS stroke (38 males and 22 females). This is in addition to 30 apparently healthy age and sex matched children. The study was carried out during the period from May 2014 to July 2015.Prior to initiation of the study; every subject was informed about the aim of the study and gave a written consent. They were recruited from outpatient clinics or admitted to PICU (Pediatric intensive care unit) in Assiut university children hospital and Qena university hospital, Upper Egypt, after approval of the university hospital ethical committee and according to the inclusion criteria that x old who presented with clinical history and signs suggestive of stroke and documented by brain C.T or M.R.I, the clinical signs included (neurological deficit e.g. hemiparesis, seizures, ataxia or altered levels of consciousness, manifestations of increased intracranial tension e.g. headache, projectile vomiting and blurred vision, signs of meningeal irritation e.g. neck rigidity, spinal rigidity, photophobia, headache, and positive Kernig’s sign and Brudzinski’s sign, cranial nerve affection e.g. ptosis (cranial nerve III affection), facial palsy(cranial nerve VII affection), or bulbar palsy (cranial nerve IX, X, XI, XII affection).The study was carried out during the period from May 2014 to July 2015. Prior to initiation of the study; every subject was informed about the aim of the study and gave a written consent.
Data collections: History taking for all included pediatric patients, including: Personal history/ Family History: age, sex, residence, history of consanguineous marriage among the patients’ parents. History of associated risk factors e.g. infection, diabetes mellitus, rheumatic heart disease, receiving certain drugs e.g. anticoagulant therapy, history of recurrence (recurrent stroke), history of having any metabolic disorders or collagen disease, epilepsy, history suggestive of disseminated intravascular coagulation “DIC”, history of vaso-occlussive crisis. Family history of early coronary heart disease. Thorough Clinical examination for: vital signs. Anthropometric measurement. Skin examination: purpuric eruptions, echemotic patches or abnormal rash. Cardiac examination: murmurs, arrhythmias, cardiomegaly. Neurological examination: level of consciousness assessed by Glasco coma scale (GCS), motor and sensory system examination, and cranial nerves examination. Radiological evaluation including Computed tomography (CT) was done to every patient.
Methodology: Two milliliters venous blood was drawn which were divided into: 1 ml on EDTA for assay of plasma homocysteine, 1 ml on plain tube for lipid profile assay, among the previously mentioned groups. Samples were centrifuged at 2000 rpm for 10 minutes. Serum and plasma were transferred into 1 ml cryotubes and stored at -20 0C for later analysis. Plasma homocysteine levels were measured according to the manufacture protocol using an enzyme-linked immune-sorbent (ELISA) assay kit, provided by Chongqing Biospes Co., Ltd. Paradise Walk, Jiangbei District, Chongqing, 400020, China. Standard curve for homocysteine was done (Figure 1). Serum lipids (HDL, triglycerides and total cholesterol) were measured according to the manufacture protocol using a spectrophotometric assay kit provided by BIOLABO SAS, Les Hautes Rives 02160, Maizy, France. The serum level of LDL cholesterol was determined by the Friedewald formula (9). Triglycerides
LDLc (mg/dl) = Total cholesterol - (------------------ + HDL).
Statistical analysis: Values are given as means ± SD, range, or as the number of patients and proportions. The chi square test was used to compare proportions. Correlation coefficients were used to describe associations between variables. P < 0.05 was considered significant. Analyses were performed using the SPSS software package (SPSS V 17 for Windows).
RESULTS Table 1 presents the demographic data of the studied cases: As regard sex, the ?/? ratio was 2:1 in group A, and 3:2 in group B. Age range for group A was 0.33-18 years (mean age 7.1±6.8 SD years), and for group B age range was 0.17-17 years (mean age 8.3±5.9 SD years). According to the age at presentation, we divided the patients included in the study into 4 groups. Regarding group A, the highest age groups were (above 12 years age group, and 1-Englishhttp://ijcrr.com/abstract.php?article_id=310http://ijcrr.com/article_html.php?did=3101. Neil F. Pediatric Stroke: Past, Present and Future. Advances in Pediatrics 2009; 56: 271–299.
2. Sharmini R. Arterial ischemic stroke in childhood. Pediatrics and Child Health 2014; 24:462-467.
3. Timothy J, Warren L and Mark T. Towards a consensus-based classification of childhood arterial ischemic stroke. Stroke 2012; 43:371-377.
4. Jonathan H, Daniel S. Pediatric stroke: a review. Emergency Medicine International 2011:1–10.
5. Djuric D, Jakovljevic V, Rasic-Markovic1 A, Djuric A, Stanojlovic O. Homocysteine, folic acid and coronary artery Disease: Possible Impact on Prognosis and Therapy. The Indian Journal of Chest Diseases and Allied Sciences 2008; 50: 39-48.
6. Richard E, Desviat L, Ugarte M, Pérez B. Oxidative stress and apoptosis in homocystinuria patients with genetic remethylation defects. J Cell Biochem 2013; 114(1):183-91.
7. Antoniades C, Alexios S. Antonopoulos, Dimitris T, Kyriakoula M, Christodoulos S. Homocysteine and coronary atherosclerosis: from folate fortification to the recent clinical trials. European Heart Journal 2009; 30: 6–15
8. Lawrence de Koning A, Geoff H, Richard C. Hyperhomocysteinemia and its role in the development of atherosclerosis. Clinical Biochemistry 2003; 36:441–431.
9. Friedewald W, Levy R, Fredrickson D. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin. Chem 1972; 18 (6): 499-502.
10. DeVeber G. In pursuit of evidence-based treatments for pediatric stroke: the UK and Chest guidelines. The Lancet Neurology 2005; 4(7):432–436.
11. Ogeng’o J, Olabu B, Mburu A, Sinkeet S. Pediatric stroke in an African country. Journal of pediatric neurosciences 2010; 5(1): 22-24.
12. Chung B, Wong V. Pediatric stroke among Hong Kong Chinese subjects. Pediatrics 2004;114(2): 206–212.
13. Salih M, Abdel-Gader A, Al-JarallahA. Infectious and inflammatory disorders of the circulatory system as risk factors for stroke in Saudi children. Saudi Medical Journal 2006; 27(1): 41–52.
14. Kalita J, Goyal G, Misra U. Experience of pediatric stroke from a tertiary medical center in North India. Journal of the neurological sciences 2013; 325(1): 67-73.
15. Saima B, Gilani S, Shah S, Siddiqui T: Childhood strokes: epidemiology, clinical features and risk factors. J Ayub Med Coll Abbottabad 2011; 23(2): 69-71.
16. Parakh M, Arora V, Khilery B. A Prospective Study Evaluating the Clinical Profile of Pediatric Stroke in Western Rajasthan. Journal of Neurological Disorders 2014; 2 (6) :1-4.
17. Vijaya B, Vennela D, Suma P. Study of homocysteine, lipoprotein (a) and lipid profile in ischemic stroke. Sch. J. App. Med. Sci. 2014; 2(4):1247-1250.
18. Ashjazadeh N, Fathi M, ShariatA. Evaluation of homocysteine level as a risk factor among patients with ischemic stroke and its subtypes. Iranian journal of medical sciences 2013; 38(3): 233-9.
19. Narang A, Verma I, Kaur S, Narang A, Gupta S, Avasthi G . Homocysteine- Risk factor for ischemic stroke?Indian J PhysiolPharmacol 2009; 53(1): 34-8.
20. García S, Concepción O, Carriera R, Zuaznábar M. Association between Blood Lipids and Types of Stroke. MEDICC Review 2008; 10(2): 27-32.
21. Xiao Y, Zhang Y, Lv X, et al. Relationship between lipid profiles and plasma total homocysteine, cysteine and the risk of coronary artery disease in coronary angiographic subjects. Lipids in Health and Disease 2011; 10(137): 1476-511.
22. Elshorbagy A, Nurk E, Gjesdal C, Tell G, Ueland P, Nygård O, Refsum H. Homocysteine, cysteine, and body composition in the HordalandHomocysteine Study: does cysteine link amino acid and lipid metabolism?.The American journal of clinical nutrition 2008; 88(3): 738-746.
23. El-Khairy L, Ueland P, Refsum H, Graham I, Vollset S . Plasma total cysteine as a risk factor for vascular disease The European Concerted Action Project. Circulation 2001; 103(21): 2544- 2549.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcareDEVELOPMENT OF DOUBLE LAYER KNITTED FABRIC FOR SPORTSWEAR USING TENCEL/POLYPROPYLENEFIBRES
English3034P. SakthiEnglish K. SangeethaEnglish M. BhuvaneshwariEnglishIn day to day life the requirement for the athletics and leisure wear are increasing to better their performance. The performance requirements of many sports goods often demand widely on different properties. Also the textile must fulfill the requirements such as fit, comfort, drape and easy movements of the consumers. The active sportswear fabrics has been developed in recent years and progressing towards high functions and to achieve comfort. The focus is to diversify the sportswear textiles in fibrous material and technology in manufacturing. The factors contributing for developing active sportswear fabrics are: polymer/fiber science, production and finishing techniques to obtain a sophisticated fiber, modified structure of yarns and fabrics. In this study, the sportswear are developed from polypropylene and tencel fibers by using a knitting technique, Ponte de roma structure (double layer knitted fabric by interlock structure) and analyzed for their various properties such as structural, mechanical and comfort properties of the knitted fabric samples.
EnglishFiber, Yarn, Fabric, Sportswear, Textile, Knit, Polypropylene and tencelINTRODUCTION
The people are paying more attention to sports activity and that the market for sportswear continues to expand. Developing sportswear solutions in this field are invaluable in order to produce an adequate response to these increasingly demanding expectations. Recently developed functional fibers, innovations in new structures and garments contribute substantially to the wearing comfort of these types of clothes. Nowadays, from very simple manmade fibers to much more complex fabric structures are effectively used in sportswear garments1 .
Sportswear requires some important functional and comfort properties such as optimum heat and moisture regulation, rapid moisture absorption and conveyance capacity, good air and water permeability, prevention of a long term feeling of dampness, low water absorption of the layer of clothing facing the skin, quick drying fabric to prevent catching cold, pleasant to skin, soft, non-abrasive and non-chafing, dimensionally stable even when wet, durable, lightweight, soft and pleasant touch, easy care, smart and functional design. All required properties are not possible to achieve for sportswear in a simple structure of any single fiber. The behavior of the fabric is mainly depending on its base fibers properties, fabric construction, weight or thickness of the material and presence of chemical treatments5 . The performance of layered fabrics in thermo-physiological regulation is better than single layer textile structure.
The most common strategy used to give high performance in synthetic fiber based active sportswear is to use a two layer fabric with a hydrophobic skin contact layer and a hydrophilic outer layer. In doing so, it takes away some of the body heat and keeps the body cool. On the inside, a synthetic material with good moisture transfer properties and good capillary action e.g. Polyester, Nylon, Acrylic or Polypropylene is used, whereas on the outside, a material with a good absorber of moisture, e.g. Cotton, Tencel, Wool, Viscose Rayon or their blends can be placed2 . In this study, the sportswear fabrics are developed from polypropylene; being used in sportswear have very low moisture absorbency, excellent moisture vapor permeability,
wicking capabilities and has the advantage of providing insulation when wet, and tencel fibers, deliver the hydrophilicity needed for transport of moisture through the fabric and for spreading across the outer surface3 .The double layer knitted fabric is developed with above said fibers by interlock structure using a knitting technique called Ponte de roma structure, a dense structure with stretching property is higher in lengthwise than in breadth wise, has advanced dimensional stability4 .Then the fabric is analyzed for their various properties such as structural, mechanical and comfort properties of the knitted fabric samples.
MATERIALS AND METHODS
Selection and Purchase of yarns a. Tencel: 100% Tencel yarn was selected for this study. The combed tencel yarn count with 40’s was purchased at the cost of Rs.325/- per kg from Cheran Spinners Pvt Ltd., Erode. b. Polypropylene: 100%polypropylene yarn of 120 Denier was selected and purchased at the cost of Rs.380/- per kg from Filatex India. Ltd, Dadra and Nagar Haveli. The yarn package is shown in figure 1.
Selection of fabric construction The technique of fabric construction selected for the study is knitting, as it is the most common fabric structure for base layer and possesses high stretch and recovery by providing greater freedom of movement, shape retention and tailored fit. Knitted fabrics also have relatively uneven surfaces (less direct contact with skin), which make the wearer feel more comfortable than smooth surfaced woven fabric of similar fiber compositions. a. Double layer knitted fabric The bi-layer weft knitted fabric with wicking fibers: polypropylene in their inner layer and tencel as outer layer, on circular double jersey knitting machine with interlock structure is prepared, which can able to transfer moisture from skin to the environment. Thus the bi-layer knitted fabric is prepared for the sportswear fabric as shown in the figure.
This fabric provides a comfortable environment for the wearer and consequently able to handle moisture vapor and sweat produced by the body during strenuous activity in sports to feel good. b. Selection of interlock structure- Ponte de roma Interlock fabric is double knit fabric is produced by the action of two needle by the interlinking of loops. The needles used were cylinder needle and dial needle. The interlock fabric is manufactured in various diameter and gauges. It depends upon end use of the fabric.
The fabric is a double knit, which means it is a double layer of fabric knitted with a 2 sets of needles on 2 needle beds most probably on a machine. As far as knits go, Ponte is a good fabric to start experimenting with. It is nice and stable, does not have a huge amount of stretch and won’t curl too much either when cut. The Knitting construction of Ponte de Roma was shown in Figure 2. c. Knitting machine details The weft circular knitting machine (type: rib machine) was chosen to knit the fabric. The main parameters of the machine are given below
Processing of fabrics The above knitted fabric is bleached using Hydrogen Peroxide (H2 O2 ) in a pressurized High Temperature (HT) apparatus at the temperatures of 110 - 130°C for 1 hour withSodium Hydroxide (NaOH) as a Stabilizer, Imerol blue liquid and Acetic acid. After bleaching, the fabric is rinsed in water for 3times. Recipe: Hydrogen Peroxide (H2 O2 ) : 3% Sodium Hydroxide (NaOH) : 1% Imerol blue liquid : 1.5% Acetic acid : 2.5% Time :1 hour Temperature : 110 - 130°C Material to liquor ratio : 1:3 pH Value : 4.5
Fabric testing The knitted fabric is tested for various properties such as, a. Structural Properties; b. Mechanical properties and c. Comfort properties. a. Structural tests The knitted fabric is tested for structural properties such as Course per inch, Wales Density, GSM, Loop length, Tightness Factor, Fabric Thickness and Dimensional Stability using the standard methods. b. Mechanical properties The knitted fabric is tested for mechanical properties such as Bursting strength, Abrasion resistance, Drapability and Pilling using the standard test methods and the results are obtained. c. Comfort properties The knitted fabric is tested for various comfort properties such as Wet ability – drop test, Wick ability, Water remind ratio, Water vapor permeability, Air permeability, Air resistance, Thermal conductivity, Thermal resistance and Stretch ability using the standard test methods and the results are obtained.
RESULT AND DISCUSSION Structural properties The structural properties for the samples is analyzed and given in the table.
CONCLUSION
Fiber qualities and fabric structure always influences the fabric quality. In this study, attempts were made to understand the characteristics required in fabrics used for sports and active apparel productions and other allied applications.
Here we studied about the various possibilities and methods of producing double layered knitted fabrics with different material combinations. And also we have developed the double layer knitted fabric by interlock structure called ponte de roma structure with Polypropylene yarn (inner layer) and Tencel yarn (outer layer) and analyzed to evaluate the structural, mechanical and comfort properties of the fabric samples. The test results gives indication that double layered knitted fabrics made of different combinations influences the mechanical and comfort properties and hence suitable attentions have to be paid while choosing combinations for functional active and sportswear fabrics productions. The fabric sample have more GSM and thickness because the denier of the Polypropylene yarn is about 120 D. By the study we can conclude that the fabric tencel- polypropylene is most suitable for active sportswear.
ACKNOWLEDGEMENT
The authors would like to acknowledge the staff, who help for this project. They would also like to acknowledge the industrial people for their kind support. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=311http://ijcrr.com/article_html.php?did=3111. Apurba Das, Ramasamy Alagirusamy and Pavan Kumar.(June 2011). Heat Transfer through Multilayer Clothing Assemblies: A Theoretical Prediction, Autex Research Journal, Vol.11 (2): Pp. 54-60.
2. Barnes J C and Holcombe B V. (1996). Textile Fiberusages for Sportswear, Textile Research Journal, Vol.79 (8):Pp.777-786.
3. Ziad Bayasi and Jack Zeng. (1993). Properties of Polypropylene Fiber Reinforced concrete.Materials Journal, Vol. 90 (6): Pp. 605-610.
4. Daiva Miku?ionience and Daiva Milašience. (2013).The influence of knitting structure on heating and cooling dynamic, Materials Science (Mediagotyra), Vol.19 (2): Pp.174-177.
5. David G Mehrtens and Kenneth C Mcalister (1962). Fiber Properties Responsible for Garment Comfort, Textile Research Journal,Vol.9:Pp. 628-665.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN-0001November30HealthcareHEALTH INSURANCE COVERAGE : A CROSS-SECTIONAL STUDY AMONG PATIENTS FOLLOWED AT THE DIABETES CENTRE OF ABIDJAN COTE D’IVOIRE (CADA)
English3539Kadidiatou Raissa KOUROUMAEnglish Apollinaire YAPIEnglishFelix Kouame ACKAEnglishObjective: This study aimed to evaluate the extent and types of health insurance coverage in a representative sample of adults with diabetes. Methods: This descriptive cross-sectional study was performed from May 6, 2015 till July 1, 2015 in the Diabetes Centre of Abidjan, with a sample of 500 diabetic patients followed for more than one year. Data was analyzed using SPSS version 18. Results: A total of 76.8% of all adults with diabetes had no form of health insurance. The main reason was the lack of financial resources (65.2%). Of the insured diabetic patients (23.2%), 51.7% were covered only by Civil Servants and State Workers of Côte d’Ivoire Fund, 20.7% had only a private for profit health insurance and 5.2% were covered through community based health insurance. Besides, 22.4% of responding patients had a private for-profit health insurance to supplement their Civil Servants and State Workers of Côte d’Ivoire Fund coverage. The fact to have a health insurance was influenced by age, gender, the level of education, employment sector and monthly income (pEnglishHealth insurance, Diabetes, Healthcare financing, Health system, Cote d’IvoireINTRODUCTION Health financing mechanism was developed to counteract the detrimental effects of user fees introduced in the 1980s, which now appears to inhibit heath care utilization, particularly for marginalized populations, and to sometimes lead to catastrophic health expenditures1 . In sub-Saharan Africa, the cost of health is often taken over by individuals; public contributions and health insurance companies hardly covering 10 to 15 % of the population2 . In Cote d’Ivoire, according to the World Health Organization’s Global Health Observatory, the total health spending was $172 per capita in 20133 . Of this, 69 % was paid out-ofpocket by households, while 27 % was funded by the government. In fact, in Côte d’Ivoire, household payments as a percentage of total health spending have long been among the highest in the West African Economic and Monetary Union (WAEMU)4 .
To improve healthcare utilization and to protect households against impoverishment from out-of-pocket expenditures, health insurance appears as a promising means, since it is attracting more and more attention in low and middle-income countries 5,6 In Cote d’Ivoire the main health insurance organizations are nonprofit groups including: Civil Servants and State Workers of Côte d’Ivoire Fund (MUGEFCI), National Social Security Fund for private sector employees (CNPS), Military Social Security Fund (Fonds de Prévoyance Militaire, FPM), National Police Social Security Fund (Fonds de Prévoyance de la Police Nationale, FPPN); Community-Based Health Insurance (CBHI)4 . Besides the nonprofit health insurance organizations, there are also private for-profit health insurance organizations (PPHI)4 . However, very few people (3-4% of the total population) in Côte d’Ivoire have health insurance7 .
The lack of health insurance coverage is often a barrier to receive routine, preventive medical care, yet these services are essential for people with diabetes who need regular checkups to monitor metabolic control, diabetes complications, and disease progression8 . Indeed, chronically ill patients such as diabetic patients often experience difficulty, paying for their medications9 . In Cote d’Ivoire where the prevalence of Diabetes is around 4.95% according to the International Federation of Diabetes (IFD), the cost of diabetes for the society in 2013 was around $162.4 compared to France where the cost was around $5,600.22 ; showing that an important part is supported by the patient.
Health insurance coverage is an important health policy issue in diabetes care, but very few studies in Cote d’Ivoire have examined the proportion of diabetic patients insured, the types of health insurance, or the reasons for not having health insurance among people with diabetes. Thus, in a context of progress towards Universal Health Coverage (UHC), this study aimed to explore theses issues among diabetic patients followed at the Diabetes Centre of Abidjan (CADA).
MATERIAL AND METHODS This is a descriptive cross-sectional study carried out in CADA, a healthcare service of the National Public Health Institute of Cote d’Ivoire. CADA is an outpatient clinic specialized in diabetes treatment, research, training and public awareness. The sample size was composed of 500 ambulatory diabetic patients followed regularly at CADA for more than one year, and chosen at random. Women with gestational diabetes were not included in the sample. Data was collected from May 6th 2015 until July 1st 2015, by the mean of a questionnaire with closed and opened questions.
The questionnaire was designed, based on a review of the literature and revised after a pilot testing with 30 diabetic patients. The first section of the questionnaire collected information about socioeconomic and demographic characteristics, information on medical history. The second section concerned health insurance status. If uninsured, diabetic patients should report reasons for not having health insurance. All the collected data were entered into SPSS 18.0. Descriptive statistics were used to describe the participant charac teristics, to show health insurance coverage, types of health insurance, and reasons for no health insurance coverage among uninsured people. Pearson’s chi-square was used to determine whether age, gender, level of education, monthly income, employment sector and complications of diabetes are related to health insurance status (p< 0.05 was considered as significant). The respondents signed the Informed Consent Form and their anonymity was preserved in the study. The study was approved by Research Ethics Committee and the National Public Health Institute of Cote d’Ivoire.
RESULTS Characteristics of the respondents (n=500) A total of 500 diabetic patients participated in this study; the characteristics of the responding patients are summarized in Table 1. The sample was in majority composed of women (57 %), and patients aged 60 and over (45.4%). Regarding economic characteristics of the patients, 59% worked in informal employment sector and 48% had a monthly income below the minimum inter professional guarantee salary wage (SMIG).
Health insurance status (n=500) The results showed that the majority of the diabetic patients (76.8%) had no health insurance. Chi-square of Pearson showed a highly significant correlation between gender, age, level of education, employment sector, monthly income and health insurance status; with p values less than 10-4. No difference (p=0.11) was found between those who had complications of diabetes and those who had not in terms of health insurance status (Table 2). Type of health insurance (n=116) Regarding the type of health insurance, the majority of the insured patients (51.7%) were covered only by MUGEFCI, 20.7% had only a PPHI and 5.2% were covered by CBHI.
In addition, 22.4% of responding patients also had PPHI to supplement their MUGEFCI coverage (Table 3) Reason for not having health insurance (n=384) Diabetic patients, who were not covered by health insurance, were asked about the reasons for not having health insurance. The results showed that the main reason was the lack of financial resources (65.2%), followed by the lack of confidence in health insurance systems (18.7%) and the lack of knowledge concerning the functioning of health insurance (16.1%). The uninsured diabetic patients turned to relatives to pay for the treatment in 54% of the cases or paid themselves in 46% of the cases.
DISCUSSION Health insurance coverage faces several challenges in Cote d’Ivoire notably the protection of people living with diabetes against the expenditures of medical care; this challenge remaining more important as regards indigent diabetic patients. Our findings showed that 76.8 % of diabetic patients followed at CADA had no form of health insurance and 23.2% was insured. These results are far from those obtained in a study performed in Burkina Faso in a sample of 388 diabetic patients, where only 1.5% of them had health insurance10. As regards the insured patients, 51.7% was covered by MUGEFCI.
Besides, 22.4% of the respondents stated to have PPHI to supplement their MUGEFCI coverage. This recourse to PPHI can be explained by the limits of government to finance care; it is also to be expected that demands unsatisfied in the public sector will be expressed as private payment, which might be more efficient than public mechanism11. Moreover, despite the implication of CBHI in the protection of poor household and workers of informal sectors against catastrophic expenditures12, only 5.2% was covered by CBHI. It is important for the Ivoirian government in a context of progress towards the UHC, to extend risk health coverage by the promotion of CBHI and sensitization of individual of working in the informal sector and living in rural area. Our study noticed that gender, age, level of education, employment sector and monthly income influenced health insurance status. Among the insurant diabetic patients, men, patients aged 40-59, patients with at least a secondary school level, diabetic patients working in formal employment sector and diabetic patients with a monthly income above 180000 FCFA ($300) are more numerous (pEnglishhttp://ijcrr.com/abstract.php?article_id=312http://ijcrr.com/article_html.php?did=3121. Mcintyre D, Thiede M, Dahlgren G, et al. What are the economic consequences for households of illness and of paying for health care in low-and middle-income country contexts?.Social science and medicine, 2006; 62(4):858-865.
2. International Diabetes Federation (IFD). IDF Diabetes Atlas, Sixth edition. Brussels, Belgium : International Diabetes Federation; 2013. Available from www.idf.org/sites:default/EN_6E_ Atlas_Full_0.pdf
3. World Health Organization Global Health Observatory. Available from http://www.who.int/countries/civ/en/
4. Juillet A, Konan C, Hatt L et al. Measuring and Monitoring Progress Toward Universal Health Coverage: A Case Study in Côte d’Ivoire. Bethesda, MD: Health Finance and Governance Project, Abt Associates.2014.
5. World health report 2010- Health systems financing: the path to universal coverage. Geneva: World Health Organization; 2010.
6. Spaan E, Mathijssen J, Tromp N et al. The impact of health insurance in Africa and Asia: a systematic review. Bull World Health Organ 2012;90:685–692A | doi:10.2471/BLT.12.102301
7. Institut National de la Statistique et ICF International. Enquête Démographique et de Santé et à Indicateurs Multiples de Côte d’Ivoire 2011-2012. Calverton, Maryland, USA: INS et ICF International 2012.
8. Casagrande SS, and Catherine CC. Health insurance coverage among people with and without diabetes in the US adult population. Diabetes care; 2012; 35(11): 2243-2249.
9. Piette JD, Wagner TH., Potter MB and Schillinger D. Health insurance status, cost-related medication underuse, and outcomes among diabetes patients in three systems of care. Medical care 2004;42(2):102-109.
10. Kyelem CG., Yaméogo TM., Ouédraogo MS et al. Caracté- ristiques thérapeutiques des diabétiques suivis au CHU de Bobo-Dioulasso, Burkina Faso. Health Sciences and Disease, 2014;15(2).
11. Pauly MV, Zweifel P, Sheffler RM et al. “Private health insurance in developing countries. Health Affairs, 2006; 25(2): 369- 379.
12. Jütting JP. “Do community-based health insurance schemes improve poor people’s access to health care? Evidence from rural Senegal. World development, 2004;(32)2: 273-288.
13. Dubois F. «Les déterminants de la participation aux mutuelles de santé: étude appliquée à la mutuelle Leeré Laafi Bolem de Zabré.» Mémoire de fin d’études, Université de Liège, DES en Gestion du Développement, 2002.
14. Harris MI. “Racial and ethnic differences in health insurance coverage for adults with diabetes. Diabetes Care, 1999; 22(10): 1679-1682.
15. DE Allegri M., Kouyante B., Becker H.et al. Understanding enrolment in community health insurance in sub-Saharan Africa: a population-based case-control study in rural Burkina Faso. Bulletin World Health Organisation, 2006;84(11): 852-858.
16. Durairaj V, D’Almeida S and Kirigia, J. Obstacles in the process of establishing a sustainable National Health Insurance Scheme: Insights from Ghana. Geneva, Switzerland: World Health Organization. 2010.
17. Kalenscher T. Attitude Toward Health Insurance in Developing Countries From a Decision-Making Perspective. Journal of Neuroscience, Psychology, and Economics, 2014; 7(3):174–193 http://dx.doi.org/10.1037/npe0000024
18. Ngassam E, Nguewa JL, Ongnessek S, et al. Coût de la prise en charge du diabète de type 2 à l’hôpital central de Yaoundé. Diabetes Metab 2012;38(Special issue 2):A105 [Abstract P318].
19. Betz Brown J, Gagliardino JJ and Ramaiya K. For International Diabetes Federation. Studies on the economic and social impact of diabetes in low- and middle-income countries. Presentation to IDF World Diabetes Congress. Montreal, October 2009. Available from http://www.idf.org/webdata/docs/WDC-PC-IDF%20Impact%20Studies.pdf
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcarePROPAGATION OF THE SHOCK WAVES IN THE EXPONENTIALLY DECREASING ATMOSPHERE
English4046Rajan SinghEnglish Mukesh ChandraEnglish Anand kumarEnglishThe purpose of the present paper is to study propagation of the shock waves and the flow parameters in the exponentially decreasing atmosphere. Plane shock waves as it propagates vertically upward in the static atmosphere of the earth are also studied. The variation of Mach number and the velocity of the shock waves are obtained analytically by using Whitham’s Rule. It is found that shock velocity increases as the shock wave propagates in the atmosphere with decreasing density normal to plane of the shock front
EnglishShock wave, Pressure, Density, Velocity, Mach number, Propagation, Adiabatic and isothermal atmosphere1. INTRODUCTION Bhatnagar and Sachdev [1] have obtained a relation between the density, pressure and Mach number by using Whitham’s Rule to the propagation of the shock waves in the nonhomogeneous medium. Kopal and Carrus [2], Hardy and Grover [3] have been studied the problem of propagation of the shock waves in a non-uniform medium with various density distributions and found the behavior of the fluid flow in the presence of the shock waves. Hayes [4] investigated the vorticity jump across a gas dynamics discontinuity by considering the radiative heat transfer into account and concluded that for an optically thin gas, vorticity is unaffected in pseudo-stationary flows. Kanwal [5, 6] employed the theory of generalized functions and differential geometry to study the propagation and deformation of wave front in stationary three dimensional gas flows.
With minor changes the experimental data for temperature distribution given by Mitra [8,9] has been used .So the aim of the present paper is to see how the shock velocity varies in the absence of any body force as the shock waves propagate in the atmosphere, in which the density is decreasing exponentially, Whitham’s Rule [10] is applied to find and approximate analytic relation for the Mach number and the shock velocity. In this paper, we have studied the problem of propagation of the shock waves in the earth’s atmosphere and also used the Whitham’s rule. The experimental data for temperature distribution given by Mitra [8] has been used for minor changes.
RESEARCH METHODOLOGY The following Research Methodology is adopted for the proposed Research paper: • Identification of the problem • Collection and study of related literature • Mathematical formulation of the problem • Analysis and numerical solution of the mathematical model • Interpretation of results • Conclusion.
2. FORMULATION OF THE PROBLEM Let us assume that a gaseous medium, in which the pressure, the temperature and the density vary along a fixed direction. Let us consider that the X -axis of the medium be taken along this direction and the distance measured along this axis be denoted by x. So that the thermo dynamical parameters. In the direction normal to the X -axis are constant. Let the pressure P0 the temperature T0 and the density p0 at a distance x measured from a fixed plane denoted by x = o and Ps , Ts and
CONCLUSION In this paper, if is very useful discussed the Plane shock waves as it propagates vertically upward in the static atmosphere of the earth studied. It is found that shock velocity increases as the shock wave propagates in the atmosphere with decreasing density normal to plane of the shock front.
ACKNOWLEDGEMENT Authors acknowledge the immense help received from the scholars whose articles are cited and included in the 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. Authors are grateful to IJCRR editorial board members and reviewers for their useful comments that lead the improvement of the manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=313http://ijcrr.com/article_html.php?did=3131. Bhatnagar, P.L., Sahdev, P.L., Nuovo Cimento, 44, (1966), pp. 5-15.
2. Carrus, P.A., Fox, P.A., Kopal, Z., Hoas, F. , Ap. J., (1951), pp.113.
3. Grover R. and Hardy, J.W., App. J. (1966), 143.193,496,48.
4. Hayes, W.O. The vorticity jump across a gas dynamics discontinuity. J. Fluid Mech, 2(1957), p.597-600.
5. Kanwal, R.P. Propagation of curved shocks in pseudo [1] stationary three dimensional gas flows. Illinois; J.Math, 2( 1958), p.129-136.
6. Kanwal, R.P. Flows behind shock waves in conducting gases, Proc. Roy. Soc., 257( 1960), p.263-268.
7. Kolobkov, N., Our Atmospherics Ocean Foreign Language Publishing, House Moscow,(1960), p.41.
8. Mitra, S. K.,Upper atmosphere, Asiatic Society, Calcutta (1952).
9. Mishra, R.S., Determination of jump conditions across a 3D shock in conducting fluids.
10. Whithan, G.B , On the propagation of the shock waves through regions of non-uniform area or Flow , J. Fluid, Mech (1956), p.337-360.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524186EnglishN2016March22HealthcareCHALLENGES IN THE MANAGEMENT OF SUBHEPATIC ACUTE APPENDICITIS IN THE EMERGENCY SETTING
English4752Bader Hamza ShirahEnglish Hamza Assad ShirahEnglish Wael Awad AlhaidariEnglish Omer Elhag AbdulbagiEnglishIntroduction: Subhepatic acute appendicitis is a very rare variety of appendicitis that has rarely been reported and is difficult to diagnose. In our study, we aim to evaluate the clinical, diagnostic, and surgical approach done to 43 patients in the emergency setting to overcome the challenge. Patients and Methods: A retrospective cohort database analysis of 43 patients who were proven to have had subhepatic appendicitiswas done. 32 were male, and 11 were female (age range, 14–23). All patients presented with an acute onset of the disease to the emergency department after regular working hours.Preoperative workup was the same to all patients (blood count, chemistry, chest and abdominal X-ray and ultrasound). All patients had emergency open appendectomy procedureand treated with cefazolin and metronidazole intravenously. Results: Preoperative proven diagnosis was achieved in 14 patients, and clinical suspicion dominated in 29 patients. The chief complaint was a sudden abdominal pain.Fever was reported in 43 patients, leukocytosis in 39 patients. Ultrasound detected 14 cases, suspected 9, and was inconclusive in 20 patients. 39 patients were treated through a laterally extended gridiron incision while 4 had a conversion to midline laparotomy. Postoperative morbidity and mortality rates were 0%. Conclusion: When subhepatic anatomical location of the appendix makes it difficult to diagnose acute appendicitis in the emergency setting, then a high level of clinical suspicion, prompt decision to operate, and skillful surgical approach could make a difference in the outcome of managing subhepatic acute appendicitis, and help to achieve zero postoperative morbidity and mortality.
EnglishAcute appendicitis, Subhepatic appendicitis, Open appendectomyINTRODUCTION Acute appendicitis is considered one of the most common abdominal emergencies, responsible for 1% of all surgical operations. As a result, appendectomy continues to be one of the commonest procedures in general surgery1 . The varying anatomical positions of the appendix are well established scientifically, which include a retrocecal position (65.28%), a pelvic (31%), a subcecal (2.26%), a preileal (1%) and a postileal (0.4%). The Subhepatic and lateral pouch are very rare variants. The subhepatic position of the appendix is the direct result of a developmental anomaly and was explained as a failure of descent of the caecum during the embryonic development2 . Diagnostic uncertainty due to the non-classical evolution of acute appendicitis may occur when the appendix is anatomically mal-located. At any age of presentation, variation in the location of the appendix due to adhesions or developmental anomalies could lead to a non-typical presentation, delays in the diagnosis and increased adverse outcomes3 .
In 1955, King described subhepatic appendicitis for the first time4 , but had rarely been reported since5 , with most cases being documented in case reports. Its incidence is 0.08% of all cases of appendicitis in one study from India6 . A research paper from Kenya reported 4.2% frequency of subhepatic appendix7 . A third paper reported 4% among Pakistani’s8 . Unfortunately, no statistical reports or papers were generated from Saudi Arabia. Subhepatic appendicitis usually presents with right upper abdominal pain. It is clinically indistinguishable from acute cholecystitis, and may mimic liver abscess, ureteric colic, or acute pyelonephritis. A delay in the diagnosis results in a ruptured appendix which is very rare9 . Preoperative diagnosis of subhepatic appendicitis is clinically difficultand usually diagnosed at laparoscopy for undiagnosed abdominal pain. Subhepatic appendicular abscess is the most common reported presentation. Abdomen ultrasound is usually used in suspected cases but computedtomography scan of the abdomen has been reported to be more sensitive in diagnosing acute appendicitis especially in young females.
In situations where abdominal computed tomography is inconclusive and clinical diagnosis of appendicitis is doubtful then diagnostic laparoscopy is recommended10. Magnetic resonance imaging was reported to be of value in visualizing the appendix in an atypical location. However, in the absence of the availability of emergency laparoscopic surgery or advanced imaging, the surgical management of these patients can be challenging. A delay in the diagnosis of subhepatic appendicitis may then lead to complications such as perforation and peritonitis11. In the emergency presentation where advanced diagnostic tools are not available, the clinical judgment and surgical experience should help in the early and safe management of subhepatic appendicitis. In our study, we aim to evaluate the clinical, diagnostic, and surgical approach done to 43 patients in the emergency setting to overcome the challenge.
MATERIALS AND METHODS A retrospective cohortdatabase analysis of themanagement method and outcome for patients who were confirmed to have had acute subhepatic appendicitis and subsequent open appendectomy as an emergency treatment in a public health general hospital in Medina, Saudi Arabia between January 2005 and December 2014 was done to evaluate the effectiveness of our response to patients with rare and abnormal position of the appendix among acute appendicitis patients presenting to our hospital emergency department which averages between 500-700 per year.
43 patients who were confirmed to have had open appendectomy for subhepatic acute appendicitis were included. All patients presented as an acute onset of the disease to the emergency department after regular working hours.Preoperative workup was the same to all patients (blood count, chemistry, abdominal X-ray and ultrasound). All patients had emergency open appendectomy procedure, and treated with cefazolin and metronidazole intravenously. Postoperative care was the same for all patients.
Retrospective database analysis was done concerning symptoms, duration of the disease, clinical presentation, laboratory and radiology investigations, the length of work up until decision to operate, operative method and findings, histopathology findings, and the outcome of treatment.All results were saved in a computerized database file for follow up and the statistical analysis was performed using the Statistical Package for Social Science (SPSS) program (Release 22).
RESULTS Between January 2005 and December 2014, the results of the 43 patients who were confirmed to have had open appendectomy for subhepatic acute appendicitis were analyzed. At the same period, the overall total number of patients treated in our hospital for various diseases was 79364 patients, and the total number of operated acute appendicitis cases in our hospital during the study period was 4279, while the number of operated subhepatic acute appendicitiscases was 43 patients.The incidence rate of subhepatic appendicitisamong all acute appendicitis in our hospital cases was 1 %. The incidence rate of subhepatic acute appendicitis in our hospital total Saudi Arabian population was 0.054 %.32(74.4%) patients were male and 11(25.6%) were female, ratio 2.9:1.
The age range was 14–23 years, (median = 18.5). All patients presented with a sudden acute onset of abdominal pain, 21(48.83%) had right iliac fossa pain, 17 (39.53%) had right middle abdominal pain, and 5 (11.62%) had right upper abdominal pain. The range of pain duration was 6-12hours before presentation (median = 9). Fever was reported by 36 (83.7%) patients, nausea by 39 (90.7%), vomiting by 26 (60.5%). (Figure 1) 41 (95.35%) reported first time attackwhile 2 (4.65%) reported similar attack within two weeks earlier treated conservatively. None of the patients had co-morbid diseases or previous surgery. Leukocytosis was reported in 39 (90.7%) patients.
The rest of laboratory values were normal. Chest and abdominal X-ray were normal in all patients. Ultrasound detected 14 (32.55%) cases in which thickened wall appendix with free fluid around it was the main comment reported, suspected 9 (20.93%) in which free subhepatic fluid was the main positive finding, and was inconclusive in 20 (46.5%) patients. Sensitivity of ultrasound = True positive rate (TPR) = Diseased with positive test/Alldiseased = 23/43 = 0.5348 x100 = 53.5 %. (Figure 2)
All patients were operated within 6 hours of presentation to the emergency departmentand treated with a single dose of cefazolin and metronidazole intravenously preoperatively. All patients had emergency open appendectomy procedure through grid iron right lower abdominal incision, 39 (90.7%) patients were managed through laterally extended gridiron incision while 4 (9.3%) had a conversion to midline laparotomy.No drains were used in any patient. The mean operative time was 105 ±5 minutes. (Figure 3) Postoperative care was the same to all patients.
All patients had 3 doses of cefazolin and metronidazole intravenously every 8 hours. Postoperative pain was managed similarly to other cases of appendectomy and laparotomy, and no significant difference was found in regard to laterally extended gridiron or converted laparotomy in our patients.No postoperative complications were recorded.The average hospital stay was 4-7 days (median = 5.5). Morbidity and mortality rates were 0%.Histopathology confirmed acutely inflamed appendix in all patients (100%). Negative appendectomy rate was 0%.
DISCUSSION Appendectomy remains the most frequently performed emergency abdominal surgical procedure. The reported lifetime risk of developing acute appendicitis in males and females is about 8.6% and 6.7% while the lifetime risk of having an appendectomy is 12% for men and 25% for women. The correct diagnosis of appendicitis is not straightforward in all cases. Approximately 20-33% of the patients suspected of having acute appendicitis present with atypical findings. The indication for surgical intervention is usually based on a combination of clinical and laboratory findings.
The significance of this diagnostic dilemma is the increased risk of developing a perforated appendicitis which could lead to an increased morbidity and a prolonged hospital stay. Logically, the most effective method to lower the rate of perforation is to adopt a lower threshold for the decision to take the patient to the operating room at the expense of increasing the negative appendectomy rate12. The clinical findings and experience remain of great significance in appendicitis diagnosis. When acute appendicitis appears with atypical presentations, it represents a clinical challenge. In such circumstances, laboratory and imaging investigation may be useful in establishing a correct diagnosis13. Subhepatic appendicitis is a rarely reported variant of a common surgical emergency that leads to delayed diagnosis and subjects to higher complication rates, including suppuration and perforation4 .
Appendicitis in unusual locations or situations always poses a diagnostic dilemma and surgery is never straightforward. Few reports in the literature described the surgical approach for these rare types of appendicitis.In the open technique, an extension of the incision would be required after finding that the appendix is in an abnormal position. Laparoscopy is reported to be of value in certain situations where doubt of the diagnosis is encountered. The location of the appendix could be visualized, and the other intraabdominal organs could be inspected6 . In the emergency sitting, where advanced diagnostic and operative modalities are not accessible, a high level of clinical suspicion contributes positively in the management of subhepatic acute appendicitis. And if combined with good surgeons experience in dealing with different and difficult presentations of acute appendicitis, could constitute a safe approachto subhepatic acute appendicitis patients, and effectively achieve a level of no postoperative morbidity and mortality.
The simple and easy to use emergency room ultrasound modality is helpful in bringing the clinical suspicion to high levels, either by accurately diagnosing the presence of subhepatic appendicitis, raising the probability by detecting signs of inflammation, or excluding other conditions that could mimic subhepatic appendicitis (acute cholecystitis,ureteric stones, or liver abscess). In our study, ultrasound detected 14 cases, suspected 9, and was inconclusive in 20 patients, but accurately excluded other conditions in all patients, especially acute calcular cholecystitis, which played an important role in the decision to operate. Recent studies have convincingly shown that ultrasound in experienced hands improve diagnostic accuracy14. Despite that all 43 patients presented to the emergency room at late day time (after regular working hours), all patient were operated within3 hours of emergency admission. The prompt decision to operate, even at night hours, contributed well to decrease the morbidity and mortality rates.
There was no perforation, no abscess formation, and no peritonitis, and thus 0% morbidity, and 0% mortality. In our emergency setting, laparoscopic instruments and technicians are not available after regular working hours according to the hospital’s policy. Therefore, all 43 patients had open appendectomy. The grid iron incision was favored due to the possibility of lateral extension. The appendix was not found in the normal position in all 43 patients. Lateral extension of the wound was done to all patients, and it successfully enabled visualization and resection of the subhepatic appendix in 39 patients (90.7%).
In 4 patients (9.3%), neither visualization nor resection were possible due to adhesions of the caecum to the lower liver edge, therefore, a midline laparotomy incision was done, followed by the release of ad-hesions, and appendectomy. The type and extent of incision did not adversely affect any patient in our study, except for the length and shape of the scar. In our study, 39 (90.7%) patients had high caecum and appendix fixed at the subhepatic level which could be considered as anatomical anomaly or congenital arrest of descend while in the other 4 (9.3%) patients, the caecum and appendix were loose, looping upward and attached by adhesions to the lower liver edge. In our study, we noticed that there was a delay in restoration of bowel motility postoperatively, 22 (51.2%) patients needed 48 hours to open their bowl and start an oral diet, and 21 (48.8%) patients required 72 hours to do so. We attributed that to the mobilization of the intestine during the search for the appendix, and to the adhesions found in the 4 laparotomy patients.
Fortunately, no bowel trauma was recorded. Careful and skillful approach to locate the subhepatic appendix is advised. Despite the difficulty in the diagnosis of subhepatic appendicitis, and the fact that in patients clinically diagnosed of acute appendicitis the reported overall negative appendectomy rate is about 15–20%; 10% in men and 25–45% in women of childbearing age15, in our study, histopathology confirmed the diagnosis of acutely inflamed appendix in all 43 patients. High clinical suspicion, and mild to moderate investigative probabilities in the management of subhepatic acute appendicitis should not be confronted by doubt or fear of negative appendectomy. Prompt decision to operate is a key stone in the successful management.
CONCLUSIONS We conclude that when subhepatic anatomical location of the appendix makes it difficult to diagnose acute appendicitis in the emergency setting, then a high level of clinical suspicion, prompt decision to operate, and skillful surgical approach could make a difference in the outcome of managing subhepatic acute appendicitis, and help to achieve zero postoperative morbidity and mortality.
Authors’ contributions All authors have contributed substantially to the paper. BHS wrote, edited the manuscript, and analyzed the clinical data. HAS conducted the clinical part of the study. WAA and OEA participated in the clinical part of the study and the data collection. All authors read and approved the final manuscript.
Competing interests The authors declare that they have no competing interests.
ACKNOWLEDGEMENT Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Ethical Clearance The study was approved by the quality control subcommittee for management guidelines and clinical pathway in Al Ansar general hospital. Informed Consent Not needed as it is a retrospective cohort database study. Source of Funding None received.
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