Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareKNOWLEDGE ATTITUDE AND PRACTICES TOWARDS PRINCIPLES OF RESEARCH AMONG MEDICAL POSTGRADUATES IN A TEACHING TERTIARY CARE CENTRE
English0106Madhavrao C.English Mythili Bai K.English Rema Menon N.English Sharath Babu K.English Prathab Asir A.EnglishAim and Objectives: To evaluate the KAP towards principles of research in medical postgraduates in a teaching tertiary care centre. Materials and Methods: After obtaining approval from the IHEC and valid informed consent, the participants were recruited into the study. The study included 26 medical postgraduates from different disciples and who were asked to fill the pre-validated structured questionnaire on principles of research. The study was conducted during the period of January 2014- March 2015. The collected data from questionnaire forms were entered into Microsoft office excel 2007 and was expressed in frequency and percentage. Results: It was observed that more than 50% of study participants were able to answer the correct response for questions on knowledge about the principles of research. Majority of the study participants [88.46%] were able to mark the correct response for the definition of research. The study also showed that attitude towards research among medical postgraduates was positive with 92.31% were opined to have or undergo seminars/ workshops/CME to update their knowledge on principles of research periodically. However the practice towards principle of research seems to be not satisfactory. It was noticed that only 7.69% of study participants had experience in sending the manuscript for publication in peer reviewed journals. Conclusion: There was good knowledge and positive attitude, with poor practices towards principles of research among medical postgraduates.
EnglishKAP, Research, Postgraduates, Medical, Tertiary care centreINTRODUCTION
Training in health research area constitutes a very essential part of medical education.1 It is essential to attract the students’ interest towards research, so that in future the good quality of research can be conducted to improve the medical health care system existing in the nation as well as in the world. Knowledge on principles of research is important for health care professionals, so that they can conduct well planned and high quality of research which directly or indirectly contributes for advancement of medical health care system.2 It has been observed, the conflicting and inconsistent reports from different parts of world on Knowledge, Attitude and Practices [KAP] towards research among various health care professionals.3 The adherence to International Conference on Harmonization [ICH] standard guidelines on Good Clinical Practice [GCP] in research varies among countries4 and it is highly essential to understand the awareness about basic principles of GCP while conducting the research and hence its implementation for high quality data generation and applying it to the whole population.
Knowledge, Attitude and Practices [KAP] towards principles of research is an important issue as:
1. KAP towards research varies from place to place and from country to country
2. Knowledge on Research principles is not up to the mark among health care professionals in all over the world2
3. There is an indeed to understand the awareness about research principles specially among students, interns and postgraduates as it marks the best physician cum researcher in future5
It is essential to understand the KAP towards research principles among medical postgraduates to address the issues if any, so that the in future necessary steps will be taken to tackle these problems. Hence this study was planned to evaluate the knowledge, attitude and practices towards principles of research among medical postgraduates in a teaching tertiary care centre.
MATERIALS AND METHODS
Study design: Cross sectional survey Study setting: Sree Mookambika Institute of Medical Sciences [SMIMS], Kulasekharam [Kanyakumari District], Tamil Nadu [India] Study participants: Medical postgraduates Total participants: 26 Time period: January 2014- March 2015
Procedure After obtaining the approval from the Institutional Review Board [IRB], the participants were recruited into the study. The informed consent was obtained from all the participants of the study before enrolling them into the study. All the national as well as international principles of ethics were followed while carrying out this research. The modified self structured, pre-validated questionnaire1,3,4,6-10 on knowledge, attitude and practices towards principles of research was distributed to medical postgraduates and they were asked to return it after complete filling of these questionnaire forms. Total twenty six medical postgraduates [n =26] participated in this study and who formed the sample size of the study.
Statistical analysis The collected data was entered into the Microsoft Office Excel 2007 software and was tabulated in percentage and frequency.
Results This study included twenty six postgraduates from different disciplines of medicine, who formed the sample size of the study [n= 26]. The knowledge, attitude and practices regarding the principles of research among medical postgraduates is displayed in Table 1, 2 and 3 respectively. The majority of study participants opined to do research work on clinical trials in future as displayed in Figure 1. The various obstacles in doing the research work among medical postgraduates is displayed in Figure 2.
DISCUSSION This study was a questionnaire based survey which included medical postgraduates from different disciples in a teaching tertiary care centre of Sree Mookambika Institute of Medical Sciences [SMIMS], Tamil Nadu [India]. SMIMS was affiliated to the Tamil Nadu Dr. M.G.R Medical University, India. In our study it was confirmed that, medical postgraduates had good knowledge about the principles of research, as more than 50% of correct responses was given, for all the questions based on knowledge of principles of research. This could be due to the fact that, Tamil Nadu Dr. M.G.R Medical University enforces the postgraduates to attend the research methodology workshop conducted under its umbrella. Our study findings were similar to the study carried by Pawar et al.9 at Department of Pharmacology, Seth GS Medical College, Mumbai [India] to evaluate the awareness about medical research among resident doctors in tertiary care hospital, which included 100 participants.
The above study concluded that 58% of residents had the knowledge about the research hypothesis concept, 76% agreed to have adequate training in research, 98% were aware of obtaining the consent in case of human related research, 4% published the research work in various journals, 50% were engaged in carrying out research other than their dissertation work, 88% opined to carry out research in their future professional period and 28% had presentations at various conferences. In our study, majority of study participants [73.08%] had strong opinion that, research in their specialty encourages and improves the knowledge in their discipline with better patient care. More than 65% of medical postgraduates had keen interest in carrying out research projects in future mainly in clinical trials.
The study also found that half of the medical postgraduates were willing to review the articles in journals as reviewer during their lifetime. It seems that, medical postgraduates had positive attitude towards the principles of research in medical field. Our study findings were similar to the study7 which was done to evaluate the KAP of resident trainees towards health research at Aga Khan University [Pakistan]. The above study was a cross sectional survey in tertiary care hospital setting through the questionnaire. The study showed that resident trainees participated in basic science research [26.9%], in clinical research [59.6%] and in both basic and clinical research [13.5%].
The study also showed that 47.1% of participants had planned to carry out research in the future. Our study also highlighted various points as, more than 90% of study participants were not confident of designing the study for their own research work, only 7.69% had experience in submitting the manuscript to the various journals. It was also found that, more than half of the study participants had opined as ‘lack of time’ as the main obstacle preventing doing research. Other obstacles preventing doing research among medical postgraduates in decreasing order were, personal commitments like family problems, marriage etc, lack of mentors/assistants, lack of research curriculum and lack of interest. However in our study it was noticed that, more than 60% of medical postgraduates had experience in presenting the research work in the form of poster in various conferences.
It was also observed that, all the medical postgraduates in this study were involved in research projects as Principal Investigator [PI], this could be because of the fact that, for the partial fulfillment of either Doctor of Medicine [M.D] or Master of Surgery [M.S] courses, one has to carry the research project and need to submit the same in the form of dissertation to the medical university as per the norms of Medical Council of India [MCI].11,12
Our study also showed that only less than 4% of medical postgraduates were carrying the research work as Co-investigator [CI]. The above fact could be because of the lack of time as opined by the study participants, as the MD/MS courses are only limited to the three years, in which one has to complete their dissertation work along with other academic activities as directed by the university and MCI.11,12 As in this study, the practices of medical postgraduates towards principles of research looks somewhat unsatisfactory, but it can be well improved by motivation, interventional education strategies, providing the research atmosphere and amendment of regulations as prescribed by the university guidelines/MCI from time to time.
The various pitfalls of our study include, as it was a questionnaire based survey, there is tendency to have recall bias from the study subjects. The study data was also limited to a single centre from the southern part of Tamil Nadu, India, hence the findings can’t be made generalized. It need to have further larger data from other centers before it can be made generalized.
CONCLUSION Our study concluded that there was good knowledge and attitude but with poor practices towards principles of research among medical postgraduates.
ACKNOWLEDGEMENT Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=345http://ijcrr.com/article_html.php?did=3451. Khan H, Khawaja MR, Waheed A, Rauf MA, Fatmi Z. Knowledge and attitudes about health research amongst a group of Pakistani medical students. Bio Med Central Med Educ 2006;6(54):1-7.
2. Gore AD, Kadam YR, Chavan PV, Dhumale GB. Application of biostatistics in research by teaching faculty and final year postgraduate students in colleges of modern medicine: A crosssectional study. Int J Appl Basic Med Res 2012;2:11-6.
3. Leahy N, Sheps J, Tracy CS, Nie JX, Moineddin R, Upshur REG. Family physicians’ attitudes toward education in research skills during residency. Can Fam Physician 2008;54:413-4.e1-5.
4. Sumi E, Murayama T, Yokode M. A survey of attitudes toward clinical research among physicians at Kyoto University Hospital. Bio Med Central Med Educ 2009;9(75):1-7.
5. Zambudio AR, Gascón FS, Moro LG, Fernández MG. Research training during medical residency (MIR). Satisfaction questionnaire. Rev Esp Enferm Dig 2004;96:695-704.
6. Khan N, Mumtaz Y. Attitude of teaching faculty towards statistics at a medical university in Karachi, Pakistan. J Ayub Med Coll Abbottabad 2009;21:166-71.
7. Khan H, Khan S, Iqbal A. Knowledge, attitudes and practices around health research: the perspective of physicians-in-training in Pakistan. Bio Med Central Med Educ 2009;9(46):1-8.
8. West CP, Ficalora RD. Clinician Attitudes Toward Biostatistics. Mayo Clin Proc 2007;82:939-43.
9. Pawar DB, Gawde SR, Marathe PA. Awareness about medical research among resident doctors in a tertiary care hospital: A cross-sectional survey. Perspectives Clin Res 2012;3:57-61.
10. Ganguly NK. Ethical Guidelines for Biomedical Research on Human Participants. 1st ed. New Delhi: Indian Council of Medical Research; 2006. p. 1-107.
11. M.D./M.S. Regulations April 2015 onwards. The Tamil Nadu Dr. M.G.R Medical University [Online]. 2015 February 24 [cited 2015 February 24]; Available from: URL:http://www.web. tnmgrmu.ac.in/index.php/syllabus-and-regulations/192-navigation-block-1/syllabus-and-regulations/629
12. Medical Council of India Salient Features of Postgraduate Medical Education Regulations, 2000. [Online]. 2015 January 19 [cited 2015 January 19]; Available from: URL:http://www. mciindia.org/RulesandRegulations/PGMedicalEducationRegulations2000.aspx
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareINFLUENCE OF SMOKING CESSATION ON PERIODONTAL HEALTH: A STRATEGIC REVIEW
English0713Megha VargheseEnglish Hima S. LohiEnglish Shyamala Devi M. P.English Anila S.EnglishSmoking is one of the major risk factor in the development and progression of periodontal disease. Recent evidences supports that smoking may also interact with other factors including genetics and diabetes potentiating periodontal breakdown. Hence quitting smoking is absolutely essential for the prevention of diseases, health enhancement and improving the healing potential before beginning treatments of diseases, including periodontitis. This literature review aims to give an insight about the influence of smoking cessation on oral micro flora, gingival blood flow, gingival crevicular fluid, plasma constituents, enzyme activity, immunologic function, bone loss and healing potential. Periodontal disease progression and its response to periodontal therapy and the success rate involved in implant placement subsequent to quitting the habit of smoking is also discussed in this review
EnglishBone loss, Periodontium, Smoking cessation, Wound healingINTRODUCTION
"Giving up smoking is the easiest thing in the world. I know because I’ve done it thousands of times"- Mark Twain. Tobacco smoking is an addictive habit and has been practiced in one form or another since ancient times. Smoking harms virtually every organ in the body. Tobacco and various hallucinogenic drugs were smoked all over the Americas as early as 5000 BC in shamanistic rituals and originated in the Peruvian and Ecuadorian Andes. Many ancient civilizations, such as the Babylonians, Indians and Chinese, burnt incense as a part of religious rituals, as did the Israelites and the later Catholic and Orthodox Christian churches.1 One of the first published medical reports on the effects of tobacco appeared in 1859. It was based on a study of 68 patients in a hospital in Montpellier, France, who had cancer of lips, tongue, tonsils and other parts of the mouth. The authors noted that all of the patients used tobacco and that 66 of them smoked short-stemmed clay pipes. In the mid-1950s, the American Cancer Society and British Medical Research Council each conducted large scale epidemiological studies. Both groups independently reported that studies showed a higher death rate among cigarette smokers than nonsmokers.1 More than 40 years have passed since 1964 US Surgeon General Report linked cigarette smoking to lung cancer and cardiovascular disease. Since then, the list of smoking related health effects has grown and cigarette smoking is recognized as the leading preventable cause of death in the world. The following year federal legislation was passed requiring all cigarette packages to carry health hazards warning labels. Since the Surgeon General’s Report, the ADA has been in its opposition to use of any type of tobacco and has supported and promoted smoking cessation efforts by dentists since 1981.2 As a result of increased public awareness of the negative effects of smoking, the percentage of adult smokers in US has declined substantially over the past 20 years to approximately 21% in 2005. However smoking is on the rise in developing nations and on global level about 47% of the male adult population smokes. It is responsible for more than 5 million deaths each year and the death toll from tobacco is expected to climb to more 8 million people per year within next 25
years. It is estimated that eventually 50% of all smokers will be killed by direct or indirect effects of tobacco. As in 2002, some 1.22 billion people smoked. It was predicted that by 2010, 1.45 billion people will smoke and 1.5 to 1.9 billion by 2025.2 It has been estimated, there are 182 million (16.6%) smokers in India.3 Among tobacco users, 34% smoke Bidis, 31% are regular cigarette smokers, and 35% use smokeless tobacco.4 Bidis are chocolate, mint, or fruit flavoured tobacco cigarette hand-rolled in tendu or temburni leaf and are common throughout India and southeast Asia and are especially appealing to young smokers.
The prevalence of smoking among 13-15 year old school going students in India ranges from 19.7-34.5%, even the lowest was considerably higher than the global median of current cigarette smoking (13.9%).5 Many teenagers and younger children inaccurately believe that experimenting with smoking or even casual use will not lead to any serious dependency. In fact, the latest research shows that serious symptoms of addiction such as having strong urges to smoke, feeling anxious or irritable, or having unsuccessfully tried not to smoke can appear among youths within weeks or only days after occasional smoking first begins.6
The average smoker tries their first cigarette at age 12 and may be a regular smoker by age 14.7,8 Every day, more than 3,500 kids try their first cigarette and about 1,000 other kids under 18 years of age become new regular, daily smokers.9 Almost 90% of youths that smoke regularly report seriously strong cravings, and more than 70% of adolescent smokers have already tried and failed to quit smoking.10 For many years, smoking has been linked to lung disease, cancer, cardiovascular disease, and poor pregnancy outcomes, such as miscarriage and low birth weight. Over the past two decades, it has also been recognized that smoking is associated with periodontal disease. The fact that smoking is both a strong and a common risk factor highlights the significance of smoking cessation. This literature reviews the role of smoking cessation on periodontal health.
EFFECT OF SMOKING CESSATION ON ORAL FLORA
To gain insight into the influence of smoking on the micro flora, Michiya Kubota1 and Mariko Tanno-Nakanishi (2011) conducted a study on Japanese patients with periodontitis, and they observed a significant association between bleeding on probing and the detection of Campylobacter rectus, Prevotella intermedia, and smoking. Prevalence of Campylobacter rectus was higher in smokers than non-smokers. They concluded that the analysis of the subgingival microbial flora in smokers and non-smokers with chronic periodontitis suggests a relevant association between smoking and colonization by the specific periodontal pathogens including Campylobacter rectus.11
It is established that bacterial consortia within the subgingival microbiome play a critical role in the etiology of chronic periodontitis. Although tobacco smoking has been shown to preferentially enrich this microbiome for pathogenic species,12,13 it is not known if smoking cessation is capable of reversing this pathogenic colonization, since current evidence is based only on cross-sectional comparisons of former and current smokers.14,15 The subgingival microbiome is complex, with several uncultivated and as-yet-unrecognized members,16,17 and hence, cultivation-based approaches have not been able to comprehensively examine the effects of smoking cessation on this ecosystem. Suzanne L. Delima et al. longitudinally examined the effect of smoking cessation on the prevalence and levels of selected subgingival bacteria using molecular approaches for bacterial identification and enumeration. Subgingival plaque was collected from 22 smokers at the baseline and 12 months following periodontal nonsurgical management and smoking cessation counseling.
The prevalence and abundance of selected organisms were examined using nested PCR and multiplexed bead-based flow cytometry. Eleven subjects successfully quit smoking over 12 months (quitters), while 11 continued to smoke throughout (smokers). Smoking cessation led to a decrease in the prevalence of Porphyromonas endodontalis and Dialister pneumosintes at 12 months and in the levels of Parvimonas micra, Filifactor alocis, and Treponema denticola. Smoking cessation also led to an increase in the levels of Veillonella parvula. Following nonsurgical periodontal therapy and smoking cessation, the subgingival microbiome is recolonized by a greater number of health-associated species and there are a significantly lower prevalence and abundance of putative periodontal pathogens. The results from this study provide evidence that following nonsurgical therapy and smoking cessation, the subgingival microbiome undergoes a compositional shift resulting in colonization by health-associated species and a significantly lower prevalence and abundance of pathogens than those observed in smokers who receive nonsurgical therapy but continue to smoke. This shift toward a health-compatible profile may contribute to the clinical improvements in periodontal status associated with smoking cessation.
The results also indicate that there is very little alteration in the microbiome following periodontal therapy in continuous smokers, suggesting an urgent need for smoking cessation counseling in conjunction with active periodontal therapy.18 Fullmer S C investigated longitudinally, if smoking cessation altered the composition of the subgingival microbial community, by means of a quantitative, cultivation-independent assay for bacterial profiling. The microbial community in smokers was similar to baseline, while quitters demonstrated significantly divergent profiles. Changes in bacterial levels contributed to this shift. These findings reveal a critical role for smoking cessation in altering the subgingival biofilm and suggest a mechanism for improved periodontal health associated with smoking cessation.19
INFLUENCE OF SMOKING CESSATION ON GBF AND GCF
The gingival blood flow (GBF) and the gingival crevicular fluid (GCF) are well-known markers of gingival health and have been used in many studies (Persson et al. 1999, Meekin et al. 2000).20,21 Smoking has a long term chronic effect, impairing the vasculature of the periodontal tissues rather than a simple vasoconstrictive effect following a smoking episode. The suppressive effect on the vasculature can be observed through less gingival redness, lower bleeding on probing and fewer vessels visible clinically and histologically.
This also has relevance to the healing response with impairment of revascularization. Evaluation of the gingival blood flow in smokers and nonsmokers with periodontal disease before and after surgical periodontal treatment was performed. Gingival blood flow and gingival vascular conductance (VC) decreased significantly pre and post operatively in response to smoking. Cold pressor test evoked significant decrease in vascular conductance in smokers and blood pressure was significantly high in nonsmokers.22 McLaughlin W.S et al (1993) observed a strong evidence of an increase in GCF flow rate of short duration following smoking. This increase in GCF flow rate could be attributed to a reflex response to irritation or stimulation from tobacco smoke particles as observed by Pangborn and Sharon (1971) or a raised intra oral temperature.23 To determine the effect of smoking cessation on gingival blood flow (GBF) and gingival crevicular fluid (GCF), sixteen male smokers with no clinical signs of periodontal and systemic diseases, were recruited.
The experiment was performed before (baseline) and at 1, 3 and 5 days, and at 1, 2, 4 and 8 weeks after smoking cessation. The status of smoking and smoking cessation was verified by exhaled carbon monoxide (CO) concentration, and by serum nicotine and cotinine concentrations. A laser Doppler flowmeter was used to record relative blood flow continuously, on three gingival sites of the left maxillary central incisor. The GCF was collected at the mesio- and disto-labial aspects of the left maxillary central incisor and the volume was calculated by the Periotron 6000s system. The same measurements except for the GBF were performed on 11 non-smoking controls. The study reported eleven of 16 smokers successfully completed smoking cessation for 8 weeks. At 1 day after smoking cessation, there was a significantly lower CO concentration than at baseline.
Also, nicotine and cotinine concentrations mark edly decreased at the second measurement. The GBF rate of smokers was significantly higher at 3 days after smoking cessation compared to the baseline. While the GCF volume was significantly increased at 5 days after smoking cessation compared to the baseline, it was significantly lower than that of non-smokers until two weeks after smoking cessation. Hence the study concluded gingival microcirculation recovers to normal in the early stages of smoking cessation, which could activate the gingival tissues metabolism/remodeling, and contribute to periodontal health.24 A group of 27 subjects on a Quit-smoking programme were examined by Nair P et al, to determine the changes in gingival health over a 4-6-week period.
The bleeding on probing with a constant force probe increased from 16% of sites to 32% of sites, despite improvements in the subjects’ oral hygiene. Hence there was a two-fold increase in bleeding on probing after quitting smoking. This suggest that the interference of smoking with this property of the periodontal tissues is not due to a vasoconstrictive action (from nicotine), but a result of a more profound influence on the vasculature and cellular metabolism (Palmer et al. 1999, Meekin et al. 2000).20,25
INFLUENCE OF SMOKING CESSATION ON PLASMA CONSTITUENTS AND ENZYME ACTIVITY
In order to study effects of cigarette smoking and smoking cessation on plasma constituents and enzyme activities related to oxidative stress, 1255 smokers and 524 healthy non-smokers were investigated in terms of plasma levels of lipoperoxides (LPO), nitric oxide (NO), vitamin C (VC), vitamin E (VE) and beta-carotene (beta-CAR). Additionally, erythrocytes were examined to determine the level of LPO, the activities of superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GSH-Px). The results showed that, when compared with the average values of the nonsmoker group, the average plasma values of LPO, NO and the average erythrocyte value of LPO in the smoker group were significantly increased (P < 0. 001), while the average plasma values of VC, VE, beta-CAR, and the average erythrocyte activities of SOD, CAT, GSH-Px were significantly decreased (P < 0.001).
A linear regression and correlation analysis for 65 male smokers who were all 40 years old showed that with longer smoking duration and greater daily smoking quantity, the plasma values of LPO, NO and the erythrocyte value of LPO were elevated, while the plasma values of VC, VE, beta-CAR and erythrocyte values of SOD, CAT, GSH-Px were decreased. In a group of 73 smokers who stopped smoking completely for six months, the average plasma values of LPO, NO and the average erythrocyte value of LPO decreased, although they were still significantly higher than those in the matched non-smoker group (P < 0.05).
Additionally, the average plasma values of VC, VE, beta-CAR and the average erythrocyte values of SOD, CAT, GSH-Px increased, although they were still significantly lower than those in the matched non-smoker group. However, after smoking cessation for one year the above average values were not significantly different from those in the matched non-smoker group. This finding indicates that the markedly increased oxidative stress in smokers might gradually return to normal but only after a long period of smoking cessation. Hence in the bodies of smokers a series of free radical chain reactions were gravely aggravated, the dynamic balance between oxidation and antioxidation was seriously disrupted, and oxidative stress was clearly exacerbated, which is closely related to many disorders or diseases in smokers. The study underscored the need, urgency and importance of complete smoking cessation.26
SMOKING CESSATION AND IMMUNE FUNCTION Association between cigarette smoking and the depression of immune function were investigated by studies of 35 subjects before, and three months after, they had ceased to smoke cigarettes. The study included tests of natural killer cell (NK) activity against several target cells and the measurement of immunoglobulin levels in sera and saliva. Similar tests were conducted on 29 control subjects who continued to smoke. The result indicated a significant decrease in lymphocyte counts and a significant increase in NK activity against cultured melanoma cells in subjects who ceased smoking. Serum IgG and IgM levels rose significantly in those who ceased smoking cigarettes, but there was no change in IgA levels. Similar increases in immunoglobulin levels (IgA and IgG) in mucosal secretions (saliva) were noted after cessation of smoking.
The NK activity and immunoglobulin levels of smokers who continued to smoke did not show significant changes. These results were consistent with the reversal of changes in immune function associated with smoking.27 Meliska C J et al examined group of 28 healthy, white, male, light-to-moderate smokers, 21 to 35 years of age, who were offered a financial inducement to abstain from smoking for 31 days. A matched control group of 11 smokers were paid to continue smoking during the same period. Nonspecific parameters of immune system function were monitored before and at various times after smoking abstinence.
Abstinence increased natural killer cell cytotoxic activity but did not alter mitogen-induced T-lymphocyte proliferation as measured by responses to concanavalin A or phytohemagglutinin. Serum cortisol concentrations also decreased after smoking cessation; however, changes in immune function were not correlated with serum cortisol change, nor with indices of smoking such as plasma nicotine and cotinine levels. Responses to concanavalin A and phytohemagglutinin were positively correlated with change in self-reported alcohol ingestion during smoking abstinence. Hence the elevation in natural killer cell cytotoxic activity is detectable within one month of smoking cessation, even in light-to-moderate smokers.28
To determine the effectiveness of smoking cessation on natural killer (NK) activity of peripheral blood lymphocytes, Ioka A et al conducted a prospective study on 27 Japanese subjects who participated in a smoking cessation intervention program. Thirteen subjects ceased smoking (quitters), while 14 continued to smoke (cigarette smokers). NK activity before the intervention was correlated positively with age. NK activity remained almost constant among quitters, comparing the activity before and after the intervention, while it decreased among cigarette smokers although it was not statistically significant. In the subgroup analysis, NK activity increased among those aged less than 65 years, or urine cotinine levels over 800ng/ml before the intervention, especially among quitters.
This suggests that smoking cessation intervention programs might have been more effective for younger than elder subjects in consideration of NK activity.29 Effect of smoking cessation on the peripheral neutrophil mRNA expression levels for inflammatory cytokines, chemokine, growth factor and matrix metalloproteinase (MMP) were assessed. The status of smoking and smoking cessation was verified by exhaled carbon monoxide (CO) concentration and serum cotinine concentration. Neutrophils were isolated from each subjects’ peripheral blood, then the cell was stimulated with N-formylmethionyl-leucyl-phenylalanine (FMLP). The mRNA expression levels for interleukin (IL)-1b, IL-8, tumor necrosis factor (TNF)-a, vascular endothelial growth factor (VEGF) and MMP-8 were analyzed by semiquantitative reverse transcriptionpolymerase chain reactions. The same experiment was performed on 11 non-smoking controls. The inference of the study conveyed eleven of 16 smokers successfully completed smoking cessation for 8 weeks.
At one day after smoking cessation, there was a statistically significantly lower CO concentration than at baseline. Also, cotinine concentration markedly decreased at the second measurement, which was taken at one week. The MMP-8 mRNA levels were significantly increased at 8 weeks after smoking cessation compared with the baseline. Hence the study states that the neutrophil transcript levels in smokers were generally lower than those in non-smokers, which could be related to an impairment of neutrophils by smoking effects. The significant increase of MMP-8 mRNA levels were associated with the effects of smoking cessation, while recovery of the other mRNA levels seemed to require a bit longer period beyond 8 weeks after smoking cessation.30
EFFECT OF SMOKING CESSATION ON BONE LOSS
Tobacco produces a greater loss of alveolar bone height in smokers than in nonsmokers, even when the former maintain a good level of hygiene.31 This suggests that tobacco itself can directly produce periodontal bone loss, regardless of bacterial plaque levels, which are known to be the main etiological factors in the onset of periodontitis. The exact mechanisms by which tobacco exerts its influence on periodontal breakdown are not completely known. It is likely that smoking primarily has a systemic influence by altering the host response and/or by directly damaging the periodontal cells.32 Jansson L et al evaluated the influence of smoking on longitudinal marginal bone loss and tooth loss in a prospective study over 20years. In addition, the effect of cessation of smoking on bone loss and the interaction between smoking, plaque and marginal bone loss were evaluated. A total of 507 dentate individuals from an epidemiological study were examined in 1970 and 1990.
The clinical investigation included registration of number of remaining teeth and presence of plaque. The marginal bone level was determined by assessments on the proximal surfaces on the radiographs from 1970 and 1990. The marginal bone loss was defined as the difference in marginal bone level over 20years. The results conveyed that in 1970, 50.7%
of the subjects were smokers, while the corresponding relative frequency in 1990 had decreased to 31.0%. Smoking was significantly correlated to an increased marginal bone loss over 20years. Individuals who stopped smoking between 1970 and 1990 lost significantly less marginal bone during this period than those who declared that they smoked during the 20-year period.33
INFLUENCE OF SMOKING CESSATION ON WOUND HEALING
Smoking is a recognized risk factor for healing complications after surgery, but the pathophysiological mechanisms remain largely unknown. The direct cutaneous vasoconstrictive action of nicotine, the increased levels of fibrinogen, hemoglobin and blood viscosity, excessive levels of carboxyhemoglobin in blood, compromised polymorphonuclear neutrophil (PMN) leukocyte function, as well as increased platelet adhesiveness have all been hypothesized to be mechanisms by which smoking compromises wound healing.34,35 Sørensen LT studied the influence of smoking and nicotine on wound healing processes and to establish if smoking cessation and nicotine replacement therapy reverse the mechanisms involved. The study revealed smoking decreases tissue oxygenation and aerobe metabolism temporarily.
The inflammatory healing response is attenuated by a reduced inflammatory cell chemotactic responsiveness, migratory function, and oxidative bactericidal mechanisms. In addition, the release of proteolytic enzymes and inhibitors is imbalanced. The proliferative response is impaired by a reduced fibroblast migration and proliferation in addition to a downregulated collagen synthesis and deposition. Smoking cessation restores tissue oxygenation and metabolism rapidly. Inflammatory cell response is reversed in part within 4 weeks, whereas the proliferative response remains impaired. Nicotine does not affect tissue microenvironment, but appears to impair inflammation and stimulate proliferation. Hence the study highlights smoking has a transient effect on the tissue microenvironment and a prolonged effect on inflammatory and reparative cell functions leading to delayed healing and complications. Smoking cessation restores the tissue microenvironment rapidly and the inflammatory cellular functions within 4 weeks, but the proliferative response remain impaired. Nicotine and nicotine replacement drugs seem to attenuate inflammation and enhance proliferation but the effect appears to be marginal.36 Grossi S G et al. investigated the effect of cigarette smoking on 143 patients’ clinical and microbiological responses to mechanical therapy.
Treatment included four to six sessions of subgingival scaling and root planing and instruction in oral hygiene. Results indicate that current smokers have less healing and reduction in subgingival Bacteroides forsythus and Porphyromonas gingivalis after treatment compared to former and nonsmokers, suggesting that smoking impairs periodontal healing. As the healing and microbial response of former smokers is comparable to that of nonsmokers, smoking cessation may restore the normal periodontal healing response.37 In a systematic review conducted by T. Thomsen et al. conveyed patients scheduled to undergo surgery can benefit from intensive preoperative smoking cessation interventions lasting at least 4 weeks and including nicotine replacement therapy.
Benefit accrues not only in terms of postoperative recovery but also in long-term health. This is in accord with current Cochrane Review evidence.38 Moller A M et al. investigated the effect of preoperative smoking intervention on the frequency of postoperative complications. The overall complication rate was 18% in the smoking intervention group and 52% in controls. The most significant effects of intervention were seen for wound-related complications (5% vs 31% ), cardiovascular complications (0% vs 10%), and secondary surgery (4%vs 15%). Hence the inference gained from the study states that an effective smoking intervention programme 6-8 weeks before surgery reduces postoperative morbidity.39
INFLUENCE OF QUITTING SMOKING ON PERIODONTITIS
Although the detrimental effects of tobacco on the periodontal tissues have been reported extensively, little is known about the potential beneficial effect of smoking cessation on periodontal health. Tiago Fiorini conducted a systematic review to evaluate the effect of smoking cessation on periodontitis progression and response to periodontal therapy. One study reported that the progression of clinical attachment loss ≥3 mm during a 6-year period was approximately three times higher among smokers than quitters. Two studies (10 and 20 years of follow-up) observed a decrease in radiographic bone loss of ≈30% among quitters when com- pared with smokers. Among individuals receiving nonsurgical periodontal treatment, quitters were more likely to have periodontal probing depth reductions than non-quitters/ oscillators. No differences in clinical attachment loss were observed. Based on the limited available evidence, smoking cessation seems to have a positive influence on periodontitis occurrence and periodontal healing.40
The effects of smoking cessation on clinical and radiographic outcomes following non-surgical treatment in smokers with chronic periodontitis were longitudinally assessed. The study showed, after 12 months, of patients with complete data, 10 had continuously quit smoking (20% of the original population), 10 continued smoking and six were oscillators (those patients who quit and then relapsed). Analysis of probing depth reductions between baseline and month 12, however, and comparing quitters with the other two groups combined, demonstrated a significant difference in favor of quitters.
Furthermore, quitters were significantly more likely to demonstrate probing depth reductions than non-quitters and oscillators. Hence the study signifies smoking cessation has an additional beneficial effect in reducing probing depths following non-surgical treatment over a 12-month period.41 Success rates in quitting smoking following smoking cessation advice given as part of a periodontal treatment compared very favorably to national quit rates achieved in specialist smoking cessation clinics. The dental profession has a crucial role to play in smoking cessation counselling, particularly for patients with chronic periodontitis.42
SMOKING CESSATION AND IMPLANT SUCCESS RATE
Smoking has a strong influence on the complication rates of implants resulting in significantly more marginal bone loss after implant placement. It also increases the incidence of peri-implantitis and adversely affects the success of bone grafts.43 A smoking cessation protocol was put in place by Crawford A Bain and he found through his study that there was a statistically significant difference in the failure rates between those who continued to smoke and those who were on the protocol. Because all failures occurred prior to prosthetic loading, they were not likely to be a result of prosthodontic overload or other external factors.44
CONCLUSION
Smoking can induce cytotoxic effect on human gingival fibroblasts, which results in a decrease in their capacity for adhesion and proliferation.45 This could result in impaired maintenance, integrity and remodeling of oral connective tissue. Given the tenacity of smoking behavior, however, much work remains to be performed to determine the most effective and efficient cessation methods and a large scale, well designed epidemiologic and clinical studies are needed to explore the potential benefits and the challenges associated with smoking cessation programs in a dental setting.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=346http://ijcrr.com/article_html.php?did=3461. Usha Saha-Tobacco interventions and anesthesia- A review. Indian Journal of Anesthesia 2009; 53(5):618-627.
2. Georgia K. Johnson and Janet M. Guthmiller- The impact of cigarette smoking on periodontal disease and treatment. Periodontology 2000; 44, 2007, 178-194.
3. Sinha DN, Guptha PC, Pendnekar MS. Tobacco use among students in the eight north-eastern states of India. Indian J Cancer 2003; 2:43-59.
4. Preetha EC, Tobacco control in India. Indian J Dent Res 2007; 18(1):2-5.
5. Georgia KJ, Margaret H. Cigarette smoking and the periodontal patient. State of the Art Review. J Periodontol 2004; 75:196-209.
6. Russell MA, “The nicotine addiction trap: A 40 year sentence for cigarettes.” British Journal of Addiction Feb 1990 85(2):293-300.
7. DiFranza JR et al; "Tobacco Acquisition and cigarette Brand selection among youth" Tobacco control, 1994 3:334-38.
8. Hogan MJ, “Adolescent Medicine: Diagnosis and treatment of teen drug use”. The medical clinics of North America, 2000 84(4):927-66.
9. Substance Abuse and Mental Health Services Administration,(SAMSHA), HHS, results from the 2008 National Survey on Drug use and Health, NSDUH: Detailed tables http://www.oas.Samsha.gov/NSDUH/2K8NSDUH/Tabs/Sect Tabs10-11 pdf.
10. DiFranza et al "Measuring the loss of anatomy over nicotine use in adolescents: the DANDY (Development and Assessment of Nicotine Dependence in Youths) study" Archives of Pediatrics and Adolescent Medicine 2002, 156(4):397-403.
11. Michiya Kubota, Mariko Tanno-Nakanishi, Satoru Yamada, Katsuji Okuda, Kazuyuki Ishihara. Effect of smoking on subgingival microflora of patients with periodontitis in Japan. BMC Oral Health 2011, 11:1
12. van Winkelhoff, A. J., C. J. Bosch-Tijhof, E. G. Winkel, and W. A. van der Reijden. Smoking affects the subgingival microflora in periodontitis. J. Periodontol.2001 72: 666-671
13. Zambon, J. J., S. G. Grossi, E. E. Machtei, A. W. Ho, R. Dunford, and R. J. Genco. Cigarette smoking increases the risk for subgingival infection with periodontal pathogens. J. Periodontol. 1996; 67:1050-1054.
14. Haffajee, A. D., and S. S. Socransky. Relationship of cigarette smoking to the subgingival microbiota. J. Clin. Periodontol.2001; 28:377-388.
15. Stoltenberg, J. L., J. B. Osborn, B. L. Pihlstrom, M. C. Herzberg, D. M. Aeppli, L. F. Wolff, and G. E. Fischer. Association between cigarette smoking, bacterial pathogens, and periodontal status. J. Periodontol.1993; 64: 1225-1230.
16. Kumar, P. S., A. L. Griffen, M. L. Moeschberger, and E. J. Leys. Identification of candidate periodontal pathogens and beneficial species by quantitative 16S clonal analysis. J. Clin. Microbiol. 2005; 43: 3944-3955.
17. Paster, B. J., S. K. Boches, J. L. Galvin, R. E. Ericson, C. N. Lau, V. A. Levanos, A. Sahasrabudhe, and F. E. Dewhirst. Bacterial diversity in human subgingival plaque. J. Bacteriol. 200;1 183:3770-3783.
18. Suzanne L. Delima, Robert K. McBride, Philip M. Preshaw, Peter A. Heasman, and Purnima S. Kumar. Response of subgingival bacteria to smoking cessation. J Clin Microbiol 2010; 48: 2344-2349.
19. Fullmer S. C, Preshaw P M, Heasman P A, Kumar P S. Smoking cessation alters subgingival microbial recolonization. J Dent Res. 2009;88(6):524-8.
20. Meekin. T. N, Wilson R. F, Scott D. A, Ide M. and Palmer, R. M. Laser Doppler flowmeter measurement of relative gingival and forehead skin blood flow in light and heavy smokers during and after smoking. J Clin Periodontol 2000 27, 236–242.
21. Persson. L, Bergstrom. J, Gustafsson A., Asman B. Tobacco smoking and gingival neutrophil activity in young adults. J Clin Periodontol 1999 26, 9–13.
22. Antonios Mavropoulos, Pal Brodin, Cassioano Kuchenbecker Rosing, Anne Merete and Harald Aars Gingival blood flow in periodontitis patients before and after periodontal surgery assessed in smokers and nonsmokers. J Clin Periodontol 2007; 78; 1774-1782.
23. Mc Laughlin WS, Lovat FM, Macgregor IDM and Kelly PJ. The immediate effects of smoking on gingival flow. J Clin Periodontol 1993; 20; 448-451.
24. Morozumi T, Kubota T, Sato T, Okuda K, Yoshie H: Smoking cessation increases gingival blood flow and gingival crevicular fluid. J Clin Periodontol 2004; 31: 267-272.
25. Nair P, Sutherland G, Palmer RM, Wilson RF, Scott DA. Gingival bleeding on probing increases after quitting smoking. J Clin Periodontol 2003; 30: 435–437.
26. Zhou JF, Yan XF, Guo FZ, Sun NY, Qian ZJ, Ding DY. Effects of cigarette smoking and smoking cessation on plasma constituents and enzyme activities related to oxidative stress. Biomedical and Environmental Sciences : BES 2000; 13: 44-55.
27. Hersey P, Prendergast D, Edwards A. Effects of cigarette smoking on the immune system. Follow-up studies in normal subjects after cessation of smoking. Med J Aust. 1983 ;2: 425-9.
28. Meliska CJ, Stunkard ME, Gilbert DG, Jensen RA, Martinko JM. Immune function in cigarette smokers who quit smoking for 31 days. J Allergy Clin Immunol. 1995 95(4):901-10.
29. Ioka A1, Nakamura M, Shirokawa N, Kinoshita T, Masui S, Imai K, Nakachi K, Oshima A. Natural killer activity and its changes among participants in a smoking cessation intervention program--a prospective pilot study of 6 months’ duration. J Epidemiol. 2001 11(5):238-42.
30. Morozumi T, Kubota T, Sugita N, Itagaki M, Yoshie. Alterations of gene expression in human neutrophils induced by smoking cessation. J Clin Periodontol 2004; 31: 1110–1116.
31. Bergstrom J, Eliasson S. Cigarette smoking and alveolar bone height in subjects with a high standard of oral hygiene. J Clin Periodontol 1987;14:466-9.
32. Levin L, Schwartz-Arad D. The effects of cigarette smoking on dental implants and related surgery. Implant Dent 2005;14:357- 63.
33. Jansson L, Lavstedt S. Influence of smoking on marginal bone loss and tooth loss– a prospective study over 20years. J Clin Periodontol 2002; 29: 750–756.
34. Noble RC, Penny BB. Comparison of leukocyte count and function in smoking and non-smoking young men. Infect Immun 1975;12:550-5.
35. Lawrence WT, Murphy RC, Robson MC, Heggers JP. The detrimental effect of cigarette smoking on flap survival: An experimental study in the rat. Br J Plast Surg 1984;37:216-9.
36. Sørensen LT. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Ann Surg. 2012 6:1069-79.
37. Grossi S G, Zambon J, Machtei E E, Schifferle R, Andreana S, Genco R J, Cummins D, Harrap G. Effects of smoking and smoking cessation on healing after mechanical periodontal therapy. J Am Dent Assoc. 1997; 128(5):599-607.
38. T. Thomsen, H. Tønnesen and A. M. Møller. Effect of preoperative smoking cessation interventions on postoperative complications and smoking cessation. British Journal of Surgery 2009; 96: 451-461.
39. Møller AM, Villebro N, Pedersen T, Tønnesen H. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002 Jan 12;359(9301):114-7.
40. Tiago Fiorini, Marta Liliana Musskopf, Rui Vicente Oppermann, Cristiano Susin. Is There a Positive Effect of Smoking Cessation on Periodontal Health? A Systematic Review. J Periodontol 2014; 85(1): 83-91.
41. Preshaw P M, Heasman L, Stacey F, Steen N, McCracken GI, Heasman PA. The effect of quitting smoking on chronic periodontitis. J Clin Periodontol. 2005; 32(8): 869-79.
42. Nasry HA, Preshaw PM, Stacey F, Heasman L, Swan M, Heasman PA. Smoking cessation advice for patients with chronic periodontitis. Br Dent J. 2006 11;200(5):272-5.
43. Haas R, Haimbock W, Mailath G, Watzek G. The relationship of smoking on peri-implant tissue:a retrospective study. J Prosthet Dent 1996;76:592-6.
44. Crawford A Bain. Smoking and implant failure-benefits of smoking cessation protocol. Int J Oral Maxillofac Implants 1996;11:756-759.
45. Synder HB, Caughman G, Lewis J, Billman MA, Schuster G. Nicotine modulation of in vitro human gingival fibroblast γ1 integrin expression. J Periodontol 2002;73:505-10.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareCLIMATE JUSTICE,CLEAN ENERGY AND CARBON MARKET IN INDIA: A SUB-NATIONAL ANALYSIS
English1418Ashok Kumar SinghaEnglishPurpose: The purpose of this paper is to analyse the increasing attention of the public on issues relating to climate change and role of clean energy in containing the emission and ensuring equity and justice in the carbon market. Approach and Methodology: The key problem in analysing the issue of climate justice at the subnational level flows from the fact that, the inputs for generations in the state are given by nature be it hydro-power, wind or thermal. Even solar irradiation varies from state to state. Based on this factor endowment states convert this opportunity to have a certain kind of generation mix. Fewer still convert this clean energy generation to a carbon market opportunity. The paper analyses the generation mix of the states and their investment in converting them in to CDM opportunity in the interest of climate justice in moderating emission. Findings: It has been observed that the renewable energy generation is highly correlated with CDM project investment at the state level. Moreover states with higher thermal generation too do make effort to moderate emission by investing in CDM projects. Originality/Value: The paper hitherto ventures in to the uncharted area of the climate justice at the sub-national level within the boundary of a nation. So far the debates focussed on climate justice in the context of developing and developed nations. This paper tries to see what kind of incentive be there to develop a domestic carbon market in the interest of climate justice in the field of energy generation like it has been done in the context of energy efficiency.
EnglishEmission, Carbon market, Climate justiceINTRODUCTION
Energy is critical for a nation's development. The per capita energy consumption in India is 0.78 MWh as per International Energy Agency (IEA)energy outlook. Currently, India’s per capita energy consumption is one-third of the global average. About one in five of Indian population is living without electricity. Moreover the kind of life style maintained in rural India shows energy demand per capita in 2040 would still be about 40% below the world average. In addition energy intensity for India too have declined during 1990-2012. Overall the drop has been large for China, Russia and India than for the United States (US), the European Union (EU) or Japan1 . This clearly shows transition of India to commit to a low carbon path and the journey has already begun. In 1 https://www.iea.org/newsroomandevents/graphics/2014-08-19-energy-consumption-per-capita-and-energy-intensity.html accessed 30 Dec 2015 the climate justice view point one has to argue whether we keep countries in energy poverty while other countries keep occupying the carbon space without showing less ambition for emission cut.
This has been clearly observed from the intent of the developed countries like US, Japan, Australia in their Intended Nationally Determined Contribution (INDC) submissions. These countries have shown below par ambitions with scant attention to climate justice and equity. India in her Intended Nationally Determined Contribution aims at achieving a 30-40 percent share of renewables in the total energy mix by 2030. A large part of it is likely to come from the ambitious solar mission announced as part of National Action Plan on Climate Change (NAPCC). As per an analysis Indiahas to have an installed capacity of 175 gigawatts (GW) of renewable power capacity by 2022. The country also commits to reduce its emissions intensity per unit GDP by 33 to 35 percent below by 2030 from 2005 baseline year.
However, India has clearly made it conditional that it would do so with international assistance. In this context the role of carbon finance which is enshrined under the Kyoto protocol assumes lots of significance. The purpose of this paper is to analyse the increasing attention of the public on issues relating to climate change and role of clean energy in containing the emission and ensuring equity and justice in the carbon market at the state level in India.
CLIMATE JUSTICE FRAMEWORK IN RECENT LITERATURE
Climate justice dialogue has been in international climate change discourse for more than two decades. However, with the increased importance and public attention on vulnerability of earth due to climate change has raised the level of this debate.
Climate Justice Concept and its dilemma at the sub-national level
Under the United Nation Framework Convention on Climate Change, climate justice is embedded in the Common But Differential Responsibility (CBDR) principles. This is based on the premise of "Polluter pays". Considering the fact that global North (developed countries) industrialised earlier and faster enabled them to occupy large part of the carbon space and left little for the south remains a contentious issue. Most literature on equity and climate justice focusses on northsouth relations (Mathur et.al. 2014). However, the concept of climate justice has become a movement (Bond, 2013) as many in global north and south and both recognise the threat of climate change and need to advance this agenda. There is also strident appeal for paying the climate debts. While it is easier to negotiate climate justice issue from historical responsibility and burden sharing perspective among the countries, it is difficult to do that within the boundary of a country amongst various states.
The inputs for generations in the state are given by nature be it hydro-power, wind or thermal. Even solar irradiation varies from state to state. Based on this factor endowment principle, states convert this opportunity to have a certain kind of generation mix. Fewer still convert this clean energy generation to a carbon market opportunity. This paper tries to analyse this phenomenon and see whether a carbon market mechanism in the framework of climate justice feasible within a country considering the fact that there is very high stake and slow progress in these negotiations (Chatterton, 2013).
Kyoto protocol principles and climate justice
Kyoto protocol ratified by India draws heavily on climate justice agenda even though it accounts for only 12% of the global emission reduction. While many sceptics economically call Clean Development Mechanism (CDM) under the protocol asa zero sum game, it actually triggers reduction above the business-as-usual scenario in the developing countries. In some sense it tries to incentivise counties (developing countries) who have right to emit to not to do so and developed countries (polluters with historical responsibility) to pay for it. The key principles of United Nation Framework Convention on Climate Change (UNFCCC) (as per the Article 3 of the convention) is based on intra2 (current generation) and intergenerational (future generation) equity.
This include the following (a) Equity and Common but Differentiated Responsibilities and Respective Capabilities (b) Full Consideration for Developing Country Needs and Circumstances (c) Precautionary principle i.e. the lack of scientific certainty should not prevent Parties from taking cautionary measures if the likelihood of serious damage to the environment exists. (d) Right to Sustainable Development (e) Cooperate to Promote Supportive and Open Economic System (Oberthür, 1999). The backers of Kyoto protocol give credit to the flexibility and its market based approach and rigorous methodology. The detractors criticise the distributive and sometime opaque method of transfer of climate finance to genuine stakeholders. In this paper, discussion has been on the energy generation and opportunity in the states in India and how Carbon Market are related at the sub-national level.
MATERIAL AND METHODS
The generation data was collected form the states to understand the current generation mix. To ensure the boundary issue central utility share has been excluded and only state generation capacity has been included in computation. For the CDM project data, the UNEP CDP pipeline data was used. It is important to examine the fact that Clean Development Mechanism (CDM) projects are not always formulated based on generation type and depends on several factors and even several methodologies. For the analysis Hydro-power generation (HYGEN), Thermal Power generation (THGEN), Renewable Power Generation (RENGEN) and waste to energy projects (WGEN) projects were correlated with CDM projects (CDMPRO) in the states. Correlation procedure in STATA software was used for developing the correlation matrix.
RESULTS
The table 1 shows the generation mix in the states. Thecorrelation matrix in Table 2 shows how CDM projects (as in open database of UNEP) are distributed across the states. Table 3 shows how these are correlated with different types of generation in the states. Correlation matrix was generated using STATA software. It shows that the renewable generation (RENGEN) is highly correlated (0.937) with the number of registered CDM projects implying states with high renewable power investment trends are likely to have more CDM projects.
The interesting fact is that, the states with thermal energy investments too come second (0.772) in terms of the CDM project conversion. This points towards the emission moderation in these states from other kinds of energy efficiency projects or generally better investment climate for CDM. The relative higher correlation of waste generation (WGEN) and CDM projects (0.68) over hydro (HYGEN) projects (0.617) could be due to the higher profitability of waste management related CDM projects as compared to the hydro power generation projects. Apart from that the CDM Executive Board too have rejected many large hydro projects due to negative externalities related to displacements.
DISCUSSION
It is important to note that the states have their own state specific conditions (factor conditions) based on the resource endowment (i.e. coal baring states for thermal generation and states with higher amount of water and necessary gradient for hydro-power, etc.) for having a particular energy mix. Based on their exposure and ability the states would structure emission reduction projects and access carbon market. This study tries to identify where such correlation exists. Since equity and climate justice is the basis for carbon market, this study attempts to analyse whether such a principle is mirrored at the sub-national level.
As explained in the results areas with large quantity of number thermal power generation have too attempted to undertake emission reduction projects. This attempt mirrors equity and climate justice even though it may not be distributional (from high emission states to low emission states, but certainly such actions ensures emission reduction at aggregate level within country boundary or moderated emission within the state boundary than business as usual).
CONCLUSION
One of the critical pointers from this analysis is the fact that the states having higher number of renewableprojects are more likely to tap in to carbon market opportunity for the incentives that these projects provide in terms of Certified Emission Reduction (CER) revenue. In case of states where large number of thermal powerproject are there and they tap in to carbon market that is because of the disincentive that they foresee from the higher emission.
They do invest in CDM projects in anticipation of offsets or from the point of view of emission moderation not to be seen as fall guys. In many cases coal bearing states like Odisha, Chhatishgarh (where large number of thermal power projects are there) do create awareness for other industries to invest in CDM so that the carbon foot print of the state is reduced. This points to a scenario where domestic market may evolve if there is a good price clearing market for carbon credit. This would ensure some degree of climate justice both nationally and internationally.
ACKNOWLEDGEMENT
The author acknowledges Prof. N C Kar for his valuable suggestions and guidance. Author also acknowledges the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is 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=347http://ijcrr.com/article_html.php?did=3471. Bond, P. Politics of climate justice. Paralysis above, movement below. University of Kwa Zulu Natal Press, Cape Town2012.
2. Chatterton, P., Featherstone, D., and Routledge, P. Articulating climate justice in Copenhagen: Antagonism, the commons, and solidarity. Antipode 2013;45(3), 602-620.
3. Mathur, V. N., Afionis, S., Paavola, J., Dougill, A. J., and Stringer, L. C. Experiences of host communities with carbon market projects: Towards multi-level climate justice. Climate Policy 2014;14(1), 42-62.
4. Oberthür, S., and Ott, H. E. The Kyoto Protocol: international climate policy for the 21st century. Springer 1999.
5. Pandey, A., Basu, S., and Sarkar, R. India Infrastructure Report 2010: Infrastructure Development in a Law Carbon Economy. Oxford 2015.
6. Prouty, A. E. Clean Development Mechanism and Its Implications for Climate Justice, The. Colum. J. Envtl. L.2009; 34, 513.
7. Purohit, P., Michaelowa, A. CDM potential of SPV lighting systems in India. Mitigation and Adaptation Strategies for Global Change 2008;13(1), 23-46.
8. Rabe, B. G. Beyond Kyoto: Climate change policy in multilevel governance systems. Governance2007; 20(3), 423-444.
9. Rai, V., and Victor, D. G. Climate change and the energy challenge: a pragmatic approach for India. Economic and Political Weekly2009;44(31).
10. Singha, A. K., Nayak, S. K., Kar, N. C., Tripathy, S., Sahoo, B. K. Anticipating and Managing an Unwelcome Guest: Climate Smart Approach in Disaster Management. In Land and Disaster Management Strategies in Asia2015; Springer India. (pp. 155-168).
11. Singha, A. K., Majumdar, S., Saha, A., Hazra, S. Deconstructing Debate on the National Action Plan on Climate Change at the State Level: A Case Study of Meghalaya State, India. Governance Approaches to Mitigation of and Adaptation to Climate Change in Asia 2013;131.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareCLINICAL PRESENTATION, MANAGEMENT AND OUTCOME OF 100 CONSECUTIVE CASES OF CONGENITAL NASOLACRIMAL DUCT OBSTRUCTION SEEN IN A REGIONAL INSTITUTE OF OPHTHALMOLOGY
English1922Garima AgrawalEnglish Swati RavaniEnglishIntroduction:
2-6 % of full term newborn children manifest symptoms of congenital nasolacrimal duct obstruction. The most frequent presentation is tearing associated with mattering of the eyelashes and recurrent infection. We designed a study to document the clinical presentation, management and outcome of 100 consecutive cases of congenital nasolacrimal duct obstruction seen in a regional institute of ophthalmology. Aim: Clinical presentation, management and outcome of 100 consecutive cases of congenital nasolacrimal duct obstruction seen in a regional Institute of Ophthalmology. Material and Methods: 100 consecutive cases of congenital nasolacrimal duct obstruction, seen in our regional institute of ophthalmology were enrolled from June 2011 to June 2015. Patients of age less than 6 months were treated with massage four times a day and topical moxifloxacin 0.5% as and when discharge was seen. Probing was reserved for patients with acute infection or acute dacryocystitis in children aged 6 months to one year. Probing was the treatment of choice for children between one year and four years. Silicone intubation was done in patients who failed probing. Dacryocystorhinostomy was the procedure of choice for patients who failed probing or silicone intubation and as the primary procedure in children greater than four years. Observations and Results: Massage with topical antibiotics were given to all patients. Probing was done in 37 children. Repeat probing was required in nine children. Two out of these nine children required probing with silicone intubation with inferior turbinate in fracture. Four children were managed with dacryocystorhinostomy. The success rate of various procedures were 60% for conservative management, 70.3% for probing, 77.8% for repeat probing, 50% for probing with silicone intubation with inferior turbinate in fracture and 75% for dacryocystorhinostomy. Conclusion: Children with congenital nasolacrimal duct obstruction can be successfully managed with good outcomes.
EnglishCongenital nasolacrimal duct obstruction, Clinical presentation, Management and outcomeINTRODUCTION
30% infants have an obstructed nasolacrimal duct at birth. 1 Only 2-6% of full term newborn children manifest symptoms of congenital nasolacrimal duct obstruction. The most frequent presentation is tearing associated with mattering of the eyelashes and recurrent infection. The most common cause of obstruction is incomplete canalization of the nasolacrimal duct with a vestigial membrane at its distal end.1 Conservative management of the child with massage and topical antibiotics is recommended. More definitive treatment in the form of probing may be required for cases that fail to canalize or early in cases with recurrent infection, acute dacryocystitis or the presence of congenital dacrocystocele.1 We designed a study to document the clinical presentation, management and outcome of 100 consecutive cases of congenital nasolacrimal duct obstruction presenting to a regional Institute of ophthalmology.
AIM: Clinical presentation, management and outcome of 100 consecutive cases of congenital nasolacrimal duct obstruction seen in a regional Institute of Ophthalmology.
lMATERIAL AND METHODS: The study was carried out at our regional Institute of ophthalmology.100 consecutive cases of congenital nasolacrimal duct obstruction presenting to our Institute were enrolled. The study period was June 2011 to June 2015. The study was a prospective interventional study. Ethical approval was taken from the institutional review board. The diagnosis was made on the basis of clinical presentation of constant watering , mattering of eyelashes ,regurgitation of fluid , mucus or exudate on pressure over the lacrimal sac. Other causes of epiphora pertaining to the eyelids, ocular surface and congenital glaucoma were ruled out. Cases of punctal, canalicular or common canalicular block on probing were excluded from our study. The patients of age less than 6 months were treated with massage four times a day and topical moxifloxacin 0.5% as and when discharge was seen. Probing was reserved for patients with recurrent infection or acute dacryocystitis in children between 6 months to 1 year of age .
Probing was the treatment of choice for children between one year and four years. Informed consent was taken from the parents of the patient. Probing was performed under general anesthesia. Patients were followed at 1 week, 3 weeks, 3 months and 6 months after the procedure. Outcome was defined as resolution of symptoms and signs of nasolacrimal duct obstruction within 3 weeks of the procedure and continued remission for 6 months post procedure. Probing was done twice before the procedure was declared a failure. 2 Silicone intubation without intranasal fixation was done in patients who failed probing. The silicone tubes were kept in place for 6 weeks. Inferior turbinate in fracture was done in all cases of silicone intubation. In children greater than 4 years dacryocystorhinostomy was the treatment of choice. Dacryocystorhinostomy was also the procedure of choice in cases who failed probing/silicone intubation.
RESULTS AND OBSERVATIONS Table I shows the patient demographics. Majority of the patients were less than6 months of age (51 out of 100). 33 patients were between 6 months to 1 year. 13 cases were between one to four years of age. Only three patients presented after four years of age. Many patients were treated elsewhere initially and then referred to our regional institute of ophthalmology for management. Table II shows the clinical presentation of congenital nasolacrimal duct obstruction. Watering, regurgitation on pressure over the lacrimal sac, mattering of the eyelashes and increased tear lake were seen in all patients. Discharge at some point in the history of nasolacrimal duct obstruction was seen in 46 patients. 15 patients had acute dacryocystitis and 22 had persistent dacryocystitis. Recurrent conjunctivitis was seen in 35 patients. We did not come across a case of congenital dacryocystocele. Table III shows the management of congenital nasolacrimal duct obstruction.
The observed results were similar in both eyes in cases of bilateral affection and thus have not been presented separately. Massage with topical antibiotics were given to all patients. Probing was done in 37 children. This included those who presented after one year plus those who presented within one year but failed conservative management. Repeat probing was required in 9 children out of 37. Two out of these nine children required probing with silicone intubation with inferior turbinate in fracture. Three children who presented after four years of age were managed with dacryocystorhinostomy. One more child who failed probing with stenting was also managed with daryocystorhinostomy. Table IV shows the outcome of all procedures. Massage with topical antibiotics was successful in 60 out of 100 patients (60%). Probing was successful in 26 out of 37 children(70.3%). 9 children required repeat probing. Repeat probing was successful in 7 out of 9 children (77.8%). 2 children were subjected to probing with silicone intubation and inferior turbinate in fracture. It was successful in one child. Four children underwent dacryocystorhinostomy. It was successful in three children with only one child requiring a repeat procedure.
DISCUSSION In our institute probing was successful in 26 out of 37 children (70.3%) between one to four years of age. Repeat procedure was required in nine children. This resulted in resolution in 7 out of 9 children (77.8%). The overall success rate of probing in children between 1 to 4 years of age was 89.2%.These results are comparable with those in other studies. Hanover SG et al reported the outcome of probing for congenital nasolacrimal duct obstruction for children 2 years and older. 73.3% patients (44 of 60) had resolution after one attempt of probing. 16 patients needed a repeat procedure. Overall success rate was 80% (48 of 60). Factors predictive of poor prognosis were identified.2 MacEwena CJ et al reported that the use of nasal endoscope facilitated the success of probing in children with congenital epiphora.3
Maheshwari R reported the results of probing in children aged 13 months and above. The success rate in group 1 (13- 24 months ) was 88.1% and in group 2 (> 24 months) was 80.9%. 4 Deok Sun Cha et al reported that the success rate of initial probing in patients aged 6 – 71 months was 80%. The success rate of second probing was 61% for all patients. 5 The Paediatric Eye Disease Investigator Group concluded that probing is a successful primary treatment of nasolacrimal duct obstruction in about three/fourth cases in children aged 6 to < 36 months old.6 Kushner BJ reported the results of simple probing in children aged 18 months to 4 years. 70% children had a good outcome. 100% children with simple membrane at valve of Hasner had a good outcome. Only 36% of those with complicated obstruction had a good outcome. 7 Katowitz JA et al reported 97% success rate of initial probing in children under 13 months of age. Only 54.7 % success rate is reported in children over 13 months of age.
They concluded that initial probing should be done prior to 13 months of age depending on severity of symptoms and parent compliance with medical management. 8 Hirohiko K et al reported that congenital nasolacrimal duct obstruction in Japanese infants had a 82.9 % resolution rate with conservative management before the first year of age. 9 In our institute dacryocystorhinostomy was safe and successful in three out of four children with only one child requiring a repeat procedure. This result is comparable to that of other studies. Hakin K et al concluded that dacryocystorhinostomy in children in experienced hands is a safe procedure achieving relief of symptoms in most cases particularly in absence of canalicular disease. 10
CONCLUSION Children with congenital nasolacrimal duct obstruction can be successfully managed with good outcomes. Probing is the treatment of choice for children less than four years of age with great success rates. Children with persistent symptoms after four years of age plus those presenting after four years of age are best treated with dacryocystorhinostomy.
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=348http://ijcrr.com/article_html.php?did=3481. Yeatts RP. Lacrimal Drainage System Surgery.in Principles and Practice of Ophthalmology Albert DM,JakobiecFA ,Azar DT,Gragoudas ES. 2000 WB Saunders company USA Vol 4,chpt 268, pp3556-3558.
2. Hanover SG. Outcome of probing for congenital nasolacrimal duct obstruction in older children. Am J Ophthalmol ;130(1),2000 :42-48.
3. MacEwena CJ, Younga JDH, Barrasa CW, Ramb B, Whiteb PS. Value of nasal endoscopy and probing in the diagnosis and management of children with congenital epiphora. Br J Ophthalmol 2001; 85: 314-318.
4. Maheshwari R. Results of Probing for Congenital Nasolacrimal Duct Obstruction in Children Older than 13 Months of Age. Indian J Ophthalmol 2005;53:49-51.
5. Deok Sun Cha, Hwa Lee, Min Soo Park, Jong Mi Lee, Se Hyun Baek. Clinical outcomes of initial and repeated nasolacrimal duct office based probing for congenital nasolacrimal duct obstruction. Korean J Ophthalmol 2010; 24(5) :261-266.
6. Paediatric Eye Disease Investigator Group. Primary treatment of nasolacrimal duct obstruction with probing in children younger than 4 years. Ophthalmology 2008 ; 115(3) : 577-584.
7. Kushner BJ. The management of nasolacrimal duct obstruction in children between 18 months and 4 years old. J AAPOS 1998 ; 2(1) : 57-60.
8. Katowitz JA , Welsh MG. Timing of initial probing and irrigation in congenital nasolacrimal duct obstruction .Ophthalmology 1987; 94(6) : 698-705.
9. Hirohiko K, Yasuhiro T, Shinsuki f, Kunihiko S, Masayoshi I. The rate of symptomatic improvement of congenital nasolacrimal duct obstruction in Japanese infants treated with conservative management during the first year of age. Clin Ophthalmol 2008;2 (2) : 291-294.
10. Hakin K, Sullivan T, Sharma A, Welham R. Paediatric dacryocystorhinostomy. Australian and New Zealand Journal of Ophthalmology 1994 ; 22 :231-235.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareASSESSMENT OF BIOCHEMICAL RISK FACTORS OF CARDIO METABOLIC SYNDROME IN PATIENTS OF HYPOTHYROIDISM
English2328Meghana K. PadwalEnglish Bapu KambleEnglish Pinky SawlaniEnglish Rajani R. MelinkeriEnglishIntroduction: Hypothyroidism is the second most prevalent endocrinal disorder in India. Most of existing data supports that thyroid disease is associated with increased cardiovascular risk which is mainly attributed to hemodynamic alteration as well as to a high risk of atherosclerosis, dylipidemia and insulin resistance. Aim: To investigate relationship between thyroid function and biochemical risk factors of cardiovascular diseases. Material and Methods: The present study was a cross-sectional, prospective. The study population was comprised of a total of ninety (90) participants (30 new cases of overt hypothyroidism, 30 new cases of subclinical hypothyroidism and 30 age and gender matched controls). Estimation of serum Thyroid profile and Insulin (fT3 , fT4 and TSH) was done by CLIA while Glucose and Lipid profile were estimated by biochemistry autoanalyzer. Insulin Resistance was calculated by HOMA IR score. Statistical Analysis: Data obtained was statistically analyzed by using student “t” test. Results: We found statistically significant rise in the levels of serum cholesterol triglycerides VLDL and LDL in the cases of overt hypothyroidism than controls. HDL levels are low in overt hypothyroidism. We also found statistically significant rise in the levels of blood glucose, serum insulin and HOMA IR score in cases of overt hypothyroidism than controls. Conclusion: Overt Hypothyroidism is at the risk of developing cardiovascular diseases and type II DM.
EnglishHypothyroidism, Cardiovascular diseases, Type II DMINTRODUCTION
The thyroid gland synthesizes and releases two iodoamino acid hormones: 3,5,3’-triiodothyronine (T3 ) and 3,5,3’,5’ thyroxine (T4 ). Thyroxine (T4 ). More than 99% of the circulating T3 and T4 is protein bound. (1) The biologically active component of T4 and T3 in plasma is the free fraction (fT3 and fT4 respectively); that are not bound to proteins. Assay of free thyroid hormone levels is done routinely to avoid problems in interpretation of thyroid hormone levels caused by fluctuations in binding proteins.(2,3) Thyroid hormones may be considered the accelerator pedal of metabolism.(4,5,6) Thyroid disorders are among the commonest endocrine disorders worldwide. It has been estimated that about 42 million people in India suffer from thyroid diseases.(7) Hypothyroidism is the second most prevalent endocrinal disorder in India. ‘Hypothyroidism’ is the reduced production of thyroid hormone.(8) It is a clinical entity resulting from the deficiency of thyroid hormones or more rarely from its impaired activity at tissue levels.(9) Hypothyroidism is classified as Primary, Secondary and Tertiary by its association with the indicated organ dysfunction. (10) According to symptoms and clinical features; it is further sub classified into:
i. Subclinical Hypothyroidism (SCH): It is defined as biochemical evidence of thyroid hormone deficiency i.e. elevated serum Thyroid Stimulating Hormone (TSH) level with a normal serum free Thyroxine concentration(11) in patients who have few or no apparent clinical features of hypothyroidism. Subclinical hypothyroidism can progress to Overt Hypothyroidism.(12)
ii. Overt Hypothyroidism(OH): It is defined as an elevated serum Thyroid Stimulating Hormone (TSH) concentration and reduced free thyroid hormones with symptoms and clinical features of hypothyroidism. It is also referred as Clinical Hypothyroidism.(13) Most of existing data supports that thyroid disease is also associated with increased cardiovascular risk which is mainly attributed to hemodynamic alteration as well as to a high risk of atherosclerosis. (14-15) Dyslipidemia induces insulin resistance, oxidative stress, via vicious cycle. It has been also observed that Insulin resistance, hypertension, inflammation, oxidative stress and coagulation defect are also promoted by thyroid disease, independently of dyslipidemia.(15,16)
AIM AND OBJECTIVES: Assessment of biochemical risk factors of cardiovascular diseases in patients with hypothyroidism
MATERIAL AND METHODS: The present study was a cross-sectional, prospective study. It was conducted in the department of biochemistry; of university medical college with a tertiary care hospital. The duration was November 2011- June 2013.The study protocol was approved by Institutional Ethics Committee. The study group of a total of ninety (90) participants was divided into three groups:
1. Group A: Control- Euthyroid: Thirty (30) age and gender matched normal; healthy euthyroid individuals.
2. Group B: Subclinical hypothyroidism (SCH): Thirty (30) clinically diagnosed, new cases of subclinical hypothyroidism on the basis of clinical examination and their fT3, fT4 and TSH levels.
3. Group C: Overt hypothyroidism (OH): Thirty (30) clinically diagnosed, new cases of overt hypothyroidism on the basis of clinical examination and their fT3, fT4 and TSH levels.
Exclusion Criteria for cases and controls: Participants suffering from DM, CVDs, Renal, Liver diseases, Malignancy, other systemic disease that alters thyroid status or participants taking thyroid hormone supplementation, β-blockers, Multivitamins, Steroids, alcohol and smokers. All participants after their written informed consent underwent detailed physical and clinical examination.
Statistical Analysis: Microsoft Excel 2007 was used to calculate Z Test for finding the statistical significance between the means of Serum lipid profile, Blood glucose, Serum Insulin and HOMA-IR score in all the three groups.
DISCUSSION Table 1 A,B shows thyroid profile in groups. We observed that there was no statistically significant difference in the levels of fT3 and fT4 in subclinical hypothyroid group as compared with euthyroid group. However, the levels of TSH were significantly increased in subclinical hypothyroid group as compared with euthyroid group. Vanderpump MP et al. (1995)(24) and Surks MI et al. (2004)(25) stated that subclinical hypothyroidism is a state of biochemical hypothyroidism rather than clinical hypothyroidism. We noted that the levels of fT3 and fT4 had been significantly decreased while levels of TSH were significantly increased in subclinical and overt hypothyroid group as compared to euthyroid group.
Table 2 A,B shows the levels of Blood Glucose in all the groups. We found statistically highly significantly rise in Blood Glucose level in the overt hypothyroid group (115.36 ± 10.78) as compared with euthyroid (89.1 ±2.7) and subclinical hypothyroid (95.3 ±1.56). Table 3 A,B shows high levels of Serum Insulin in all the groups. We found that statistically significant rise in Serum Insulin overt hypothyroid group (36.67 ± 11.56) as compared with euthyroid (4.60 ±1.34) and subclinical hypothyroid (6.90 ±0.98). Table 4 A,B shows the levels HOMA-IR Score in all the groups. We found statistically highly significant rise in HOMA-IR Score in overt hypothyroid group (11.03 ±2.31) as compared with euthyroid (1.04 ± 0.98) and subclinical hypothyroid (2.02 ±0.86). Table 5 A,B shows the Lipid Profile in groups. We found significant dyslipidemia in overt hypothyroid group.
There was significant increase in Total Cholesterol (211.30 ±40.22), Triglyceride (155.30±96.39) LDL(170.9 ±33.37) and VLDL (31.00±19.22) levels as compared in subclinical hypothyroid group where it was Total Cholesterol (180.06±43.21), Triglycerides (133.64±79.60), LDL (154.22±40.48), VLDL (25.83±16.38) and in euthyroid group it was Total Cholesterol (170.11±40.26), Triglycerides (106.63±42.03), LDL (148.78 ±34.08), VLDL (21.32±8.40). There was also statistically significant decrease in HDL levels in overt hypothyroid group HDL (32.5±8.74) as compared with subclinical hypothyroid group (43.27±12.84) and euthyroid group (46.44 ± 12.11). We calculated the correlation of biochemical risk factors of cardiovascular diseases with TSH levels.
There is statistically significant positive correlation between TSH levels and BGL (r=0.41, p=< 0.0001), Insulin (r=0.50 p=< 0.0001), HOMA- IR (r=0.51 p=< 0.0001),Total Cholesterol (r=0.39, p=0.0001),TG(r=0.20, p=0.04) levels. We also found statistically significant negative correlation between TSH levels and HDL levels. (r= - 0.33, p=< 0.001) However we could not find any significant correlation between TSH levels and LDL levels. (r=0.20, p =0.96). Therefore it can be clearly seen from our results that there is dyslipidemia and insulin resistance associated with overt hypothyroidism, however the same was not observed in subclinical hypothyroid group. The levels of TSH `showed a strong positive correlation with biochemical markers of cardiovascular diseases in our study.
Togini et al (26) observed increase in total cholesterol, LDL, TG levels and decrease in HDL levels in overt hypothyroid group. XuC et al(27) observed that even after adjusting the confounding factors such as age, sex, smoking status, fasting plasma glucose levels and thyroid hormones , a significant positive impact of TSH on the serum total cholesterol (TC) level was revealed ( r = 0.095, p = 0.035 ). Similarly Benetti-Pinto CL et al(28) also observed no change in BGL, Insulin, HOMA IR, cholesterol, TG, HDL levels in sub clinically hypothyroids females. However they reported significantly elevated LDL levels. Garduno-Garcia Jde J et al (29) concluded that though subclinical hypothyroidism was not associated with derangements in the markers of metabolic syndrome (as per National Cholesterol Education Programme ATP III Criteria).
Despite the low thyroid function in hypothyroidism can predispose to cardio- metabolic syndrome. Uzunlula et al (30) and Shantha et al (31) also could not found any significant difference in lipid profile in euthyroid and sub clinical hypothyroid patients. Purvi Purohit (32) noted increase in serum insulin level and HOMA-IR score in hypothyroidism as well as hyperthyroidism. However, increased TSH level were positively correlated with IR. Their study concluded that there was presence of triad of metabolic syndrome in hypothyroid subjects. (i.e hypertension, dyslipidemia increased fasting plasma glucose). Khan et al (33) reported significant correlation TG and HDL level with HOMA-IR values in human subjects with Insulin Resistance syndrome. Chen G et al(34) could not found difference in Glucose, insulin HOMA-IR level in hypothyroid patient compared to euthyroid patients.
Thyroid hormone increases LDL receptor expression, increases Cholesterol Ester Transport Protein (CETP) concentrations and increases hepatic lipase (HL) concentrations. Thyroid hormone also increases hepatic cholesterol synthesis by inducing hydroxyl methylglutaryl coenzyme A (HMG CoA) reductase and decreases intestinal cholesterol absorption(35, 36). Overall effect of this leads to increased cholesterol synthesis and decreased degradation.
It is known that T3 and insulin have synergetic role in Glucose homeostasis, since hormone possess similar action site in regulation of Glucose metabolism at both cellular and molecular level (37,38,39). It could therefore be hypothesized that reduced intracellular content of T3 could lead to impaired insulin stimulated Glucose disposal. Interestingly even subtle decreases in level of thyroid hormone within the pathological range have been shown to correlate inversely with HOMA-index. Insulin resistance and metabolic syndrome are important cardiovascular risk factor, even in non-diabetic individuals (40). It has been found that individuals with Insulin resistance and raised TSH have higher LDL concentration while in those with normal insulin sensitivity, TSH level do not affect LDL (41).
CONCLUSIONS
• Overt hypothyroidism is associated with significant dyslipidemia.
• There is no derangement in this biochemical risk factor of cardiovascular disease in subclinical hypothyroidism.
• Thyroid stimulating hormone (TSH) showed significant positive correlation with total cholesterol, triglyceride, BGL, Insulin and HOMA- IR score and negative correlation with HDL level. Therefore estimation of TSH level can serve as prognostic marker of future cardio-vascular risk.
Englishhttp://ijcrr.com/abstract.php?article_id=349http://ijcrr.com/article_html.php?did=3491. Harper’s Biochemistry (1998): Published by a Lange Medical Book. Thyroid Hormones. Ed. 25th : 561.
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8. Krysiak R, Okopien B, Herman ZS. Subclinical thyroid disorders. Pol MerkurLekarski. 2006; (21): 573-8.
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10. Kostoglou-Athanassiou I, Ntalles K. Hypothyroidism – new aspects of an old disease. HIPPOKRATIA. 2010; (14,2) : 82-87.
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25. Surks M.I., Ortiz, E., Daniels, G.H., Sawin, C.T., Col, N.F., Cobin, R.H.: Subclinical thyroid disease: Scientific review and guidelines for diagnosis and management. J. A. M. A. 2004; 291(2):228-238.
26. Tognini S, Polini A, Pasqualetti G, Ursino S, Caraccio N, Ferdeghini M, Monzani F.Age and gender substantially influence the relationship between thyroid status and the lipoprotein profile: results from a large cross-sectional study. Thyroid. 2012 Nov;22(11):1096-103.
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32. Purohit P, Mathur R Hypertension association with serum lipoproteins, insulin, insulin resistance and C-Peptide: unexplored forte of cardiovascular risk in hypothyroidism. N Am J Med Sci. 2013 Mar;5(3):195-201.
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36. Kuusi T, Taskinen MR, Nikkilä EA. Lipoproteins, lipolytic enzymes and hormonal status in hypothyroid women at different levels of substitution. J Clin Endocrinol Metab. 1988. 66:51–56.
37. Bakker SJ, terMaaten JC, Popp-Snijders C, Slaets JP, Heine RJ, Gans RO. The relationship between thyrotropin and low density lipoprotein cholesterol is modified by insulin sensitivity in healthy euthyroid subjects. J Clin Endocrinol Metab 2001;86:1206-1211.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareEVALUATION OF BLOOD COUNT AMONG BLOOD DONORS ATTENDING KOSTI TEACHING HOSPITAL BLOOD BANK, WHITE NILE STATE, SUDAN
English2932Ahmed M. ElnourEnglish Nada Y. AliEnglish Moataz M. AliEnglish Elsharif A. BazieEnglish Algily A. EdriesEnglish Hadeel A. AliEnglish Mohiera O. AtaalmnanEnglish Abozer Y. ElderderyEnglish Nawal E. OmerEnglishObjectives: Current study aimed to evaluate blood counts among blood donors attending Kosti hospital blood bank. Methodology: This cross sectional descriptive study was performed at the blood bank of Kosti teaching hospital during December 2014-Febrauray 2015 and aimed to determine the haematological parameters of blood donors. One hundred donors were chosen randomly to participate in this study. Venous blood (2.5ml) was obtained from each individual into an EDTA container. The full blood count (FBC) was done for each donor, using fully automated haematology analyzer (Sysmex). Peripheral blood film for morphology was done using Giemsa stain. Results: Results showed that haemoglobin concentration was normal in 55% of the donors, less than the normal in 43% and above the normal in 2% of studied group. RBCs were 70% normal, 4% lower than normal and 26% higher than normal. 78% of the donor showed WBC within normal range and the remaining 18% were lower than normal. Platelets counts in donors were 90% normal, 8% low and 2% high. The Haematocrit values were 87% normal, 7% low and 6% high. The MCV in donors was 74% normal and 26% low. MCH value was 2% normal, 97%low and 1%high. The MCHC was 3%normal and 93% low. Conclusion: There is considerable number of donors with haemoglobin concentrations lower than normal as well as lower red blood cells indices. Thus full blood count should be incorporated in evaluating blood donors to insure both good quality of blood and safety of the donors.
EnglishBlood donors, Red blood cells, Red blood cell indices, Platelets, White blood cellsINTRODUCTION
Blood transfusion is an essential part of modern medicine. While blood transfusion can be life-saving it is not without risk(1). Specific pathologies associated with transfusion include transfusion-related acute lung injury (TRALI), transfusion related immunomodulation (TRIM), circulatory overload, bacterial infections and haemolytic transfusion reactions are complications that can lead to deleterious outcomes(2). Additionally, there is a growing body of evidence indicating an association between transfusion, especially of aged/stored blood products, and increased levels of morbidity and mortality in patients(3). The primary goal of any blood transfusion is to provide the patient with donor red blood cells that optimally survive after transfusion and serve their function and to ensure that the patient actually benefits from the transfusion.
To achieve this goal, donor red cells that are compatible with those of the patient’s blood are selected for transfusion(4). Blood safety is a major concern all over the world. One of the most important steps used to ensure blood safety is blood donor selection(5-8). Blood donor eligibility is determined by medical interview, based on national guidelines for donor selection(9). Donor screening criteria are established to protect both donors and recipients(10). To ensure blood safety, safe donors need to be recruited and high-risk donors should be discouraged from donation(11). For people who are considering donating blood, a local blood bank can describe the criteria for being a blood donor(11). Criteria for selection of donor including: The donor age , Weight of the person, temperature and pulse could be normal, The systolic and diastolic blood pressures are within normal limits without medication, Hb is normal, free from acute respiratory diseases, cardiovascular disease, epilepsy and other Central Nerves System (CNS) disorders(12).
The blood donors must be free from any blood transfusion diseases that, can be determined by history and examination, pregnant and lactating women excluded because of high iron requirements(13). Flowing our visiting Kosti teaching hospital blood bank we observed that, blood donors haematological parameters not measure, ABO blood group and virus screening only laboratory investigation done. So, our current study aimed at to know if the donors haematological parameters within the normal range or not.
MATERIALS AND METHODS One hundred fit blood donors without any history of longterm medication use, illness, and accepted by the physician for donate blood were selected randomly from donors attending Kosti teaching hospital blood bank in White Nile State, Sudan to participate in the current study. Third of the blood donors were from Kosti town, the most blood donors donate before periods 6 month -2 years. Data collected by structural interviewing questionnaire. All participants were completed an individual informed consent form. 2.5 ml of blood was taken from each individual in a sterile and clean EDTA container. The full blood count (FBC) was done, using fully automated haematology analyzer (Sysmex). Peripheral blood film for morphology was done using Giemsa stain. The results were recorded in the master sheet and the information fed to the statistical software program SPSS (version 21), frequencies were calculated as descriptive in all the results.
RESULTS Our results showed that all participants were males because females not normally donated blood in Sudan(14). Age ranged from 20 to 54 years. The results were processed statistically by using SPSS (version-21). The results include the following: of the Hb concentrations measured in donors 55% were normal, (43%) less than normal and2% more than normal, as shown in Figure 1.Corresponding results for RBCs were 70% normal, 4% low and 26% high. WBCs in donors were 78% normal and 18%low. Platelets in donors were 90% normal, 8%lowand 2%high (See Figure 2). The RBCs indices were set out in Table 1 as following: the Haematocrit values were 87% normal, 7%lowand 6% high. The MCV in donors was 74% normal and 26% low. MCH value was 2% normal, 97% low and 1% high. The MCHC was 3% normal and 93% low.
DISCUSSION Blood safety is a major concern all over the world. One of the most important steps used to ensure blood safety is blood donor selection. The transfusion of blood and its components is therapeutic and always associated with some level of risk, which if not well-screened, could lead to several complications. Laboratory tests such as a complete blood count are performed to find out if the patient’s symptoms are likely to be relieved. The present study aims to know the haematological profile of screened blood donors attending Kosti teaching hospital, White Nile State, Sudan. Hundred blood donors who accepted by physician were randomly selected for the investigation of haematological parameters. After obtaining an informed consent, 2.5 ml venous blood was collected from the subjects and dispensed into EDTA anticoagulant bottles and mixed by gentle inversion. Complete blood count was determined by haematology autoanalyzer-Symex-Kx-21N, while a thin blood film was prepared for examination of blood cell morphology.
From the results of this study, the majority of blood donors (69%) were between 25 and 39 years of age and all donors were men because usually women do not donate blood in Sudan, this findings consistent with study in Khartoum blood bank, Sudan in 2011stated that the majority of blood donors (74%) were between 25 and 39 years of age and all of them were men(14). The present results revealed that, more than half (55%),(Figure 1) of the participants were in normal Hb concentration, this results were inconsistent with study done in Benin City hospital in Nigeria in 2012(15), reported that, the majority blood donation Hb concentration (Hb) of 91.2% (146/160) of the paid donor blood were ≥12 g/dl while 8.8% (14/160) were >12 g/dl. Concerning RBCs counts the present study showed that, the majority of the participants (70%) within the normal RBCs counts, while quarter of them (26%) showed increased in RBCs count, and only (4%) showed decreased RBCs counts (Figure 2).
On the other hand the majority (82%) of the TWBCs within the normal range and the remaining (18%) showed decreased in TWBCs (Figure 2). 90% of blood donors in this study showed normal PLTs count, 8% increased PLTs count and only 2% showed decreased in PLTs count (Figure 2). Regarding PCV the current study results showed that the majority participants (87%) within the normal reference, 7% of them the PCV was decreased and the rest 6% increased (Table2).In contrast study done in Kenya blood donors haemoglobin (Hb), red cell parameters (red cell count, haematocrit, MCV, MCH and MCHC), total and differential white blood cell (WBC) counts, and platelet counts in two donor populations concluded that, a significant number of Kenyan blood donors showed abnormal haematology profiles(16).
The present study showed that the three quarter (74%) of the blood donors within the normal MCV values and the remaining (26%) bellower the normal value (Table2), while the only of (2%) of the participants found within the normal range of MCH, (1%) higher than the normal range, and the majority(97%) were below than the normal value of MCH (Table 2), these findings were not in agreement with the study done in Suadia Arabia male donors regarding MCV values while consistent with the results concerning MCHthat, haematological parameters(MCV, MCH) were generally lower than reference values amongSuadia Arabia male donors(17).
The status of MCHC showed the almost same values of MCH the majority (93%) were lower than the normal range and only remaining 7% within the normal value (Table1). The present study disagree with the results reported in the previous study done in Nigeria stated that, the MCV of 43.1% (69/160) of paid donors were ≥75 fl while the MCH of 86.9% (139/160) of the paid donors was ≥27 pg and the majority of the test group had MCHC ≥30 g/dl(15). The current study showed that 98% of the RBCs morphology are normocytic normochromic picture (Table2) which not in agreement with the previous study done in which stated, a significant number of the paid donor population in Benin are anaemic (predominantly hypochromic microcytic anaemia)(15).Several studies also have reported anaemia in blood donors(18, 19),with higher frequencies in Africa than in Western countries(19, 20).
CONCLUSION There is considerable number of donors with haemoglobin concentrations lower than normal as well as lower red blood cells indices. Thus full blood count should be incorporated in evaluating blood donors to insure both good quality of blood and safety of the donors. Further studies are needed to strength this recommendation.
Englishhttp://ijcrr.com/abstract.php?article_id=350http://ijcrr.com/article_html.php?did=3501. Vamvakas EC BM. Transfusion-related mortality: the ongoing risks of allogeneic blood transfusion and the vailable strategies for their prevention. Blood. 2009;113(15):3406-17.
2. Tung JP, Fung YL, Nataatmadja M, Colebourne KI, Esmaeel HM, Wilson K, et al. A novel in vivo ovine model of transfusion-related acute lung injury (TRALI). Vox Sang. 2011 Feb;100(2):219-30.
3. Bhaskar B, Dulhunty J, Mullany DV, Fraser JF. Impact of blood product transfusion on short and long-term survival after cardiac surgery: more evidence. Ann Thorac Surg. 2012 Aug;94(2):460- 7.
4. Chapman JF, Elliott C, Knowles SM, Milkins CE, Poole GD. Guidelines for compatibility procedures in blood transfusion laboratories. Transfus Med. 2004 Feb;14(1):59-73.
5. Newman B. Blood donor suitability and allogeneic whole blood donation. Transfus Med Rev. 2001 Jul;15(3):234-44.
6. Eder A BC. Screening blood donors: Science, reason, and the donor history questionnaire. American Association of Blood Banks. 2007.
7. Cable R, Musavi F, Notari E, Zou S. Limited effectiveness of donor deferral registries for transfusion-transmitted disease markers. Transfusion. 2008 Jan;48(1):34-42.
8. Zou S, Musavi F, Notari EP, Rios JA, Trouern-Trend J, Fang CT. Donor deferral and resulting donor loss at the American Red Cross Blood Services, 2001 through 2006. Transfusion. 2008 Dec;48(12):2531-9.
9. Katz L, Strong DM, Tegtmeier G, Stramer S. Performance of an algorithm for the reentry of volunteer blood donors deferred due to false-positive test results for antibody to hepatitis B core antigen. Transfusion. 2008 Nov;48(11):2315-22.
10. Wu Y, Glynn SA, Schreiber GB, Wright DJ, Lo A, Murphy EL, et al. First-time blood donors: demographic trends. Transfusion. 2001 Mar;41(3):360-4.
11. Arslan O. Whole blood donor deferral rate and characteristics of the Turkish population. Transfus Med. 2007 Oct;17(5):379-83.
12. Rysgaard CD MC, Drees D. Positive hepatitis B surface antigen tests due to recent vaccination: a persistent problem. BMC ClinPathol. 2012:12-5.
13. Hoffbrand AV MP, Pettit LE, editor. Essential haematology. Fifth ed. London, UK: Blackwell; 2006.
14. Mahmoud OA GA, Metwally Del S, Elnour AM, Yousif GE Detection of occult hepatitis B virus infection among blood donors in Sudan. J Egypt Public Health Assoc. 2013;88(1):14-8.
15. Benedict N, Augustina AO, Nosakhare BG. Blood donation in Nigeria: standard of the donated blood. J Lab Physicians. 2012 Jul;4(2):94-7.
16. Rajab JA, Muchina WP, Orinda DA, Scott CS. Blood donor haematology parameters in two regions of Kenya. East Afr Med J. 2005 Mar;82(3):123-7.
17. Abdullah SM. The effect of repeated blood donations on the iron status of male Saudi blood donors. Blood Transfus. 2011 Apr;9(2):167-71.
18. Adediran IA, Fesogun RB, Oyekunle AA. Haematological parameters in prospective nigerian blood donors rejected on account of anaemia and/or microfilaria infestation. Niger J Med. 2005 Jan-Mar;14(1):45-50.
19. Tayou Tagny C, Monny Lobe M, Mbanya D. [Evaluation of two methods for haemoglobin measurement in Cameroonian blood donors]. Transfus Clin Biol. 2006 Dec;13(6):331-4.
20. Erhabor O, Ok O, Awah I, Uko KE, Charles AT. The prevalence of Plasmodia parasitaemia among donors in the Niger delta of Nigeria. Trop Doct. 2007 Jan;37(1):32-4.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareRELATIONSHIP BETWEEN CLINICALLY PALPABLE AXILLARY LYMPH NODE AND HISTOLOGICAL POSITIVITY FOR METASTASIS AND MANAGEMENT IN BREAST CANCER PATIENTS
English3335Deepak David S.English Sadhan Kumar CHEnglish T. Tirou AroulEnglish Robinson SmileEnglishAim: The aim of the present study was to find out the relationship between clinically palpable axillary lymph node and histological positivity for metastasis in patients with breast cancer. Method: This is a prospective study of 50 patients who underwent mastectomy with axillary clearance between august 2007 to august 2009 were evaluated. The clinically palpable lymph nodes, number of lymph node retrieved and histological positivity were studied. Results: Out of 50 patients, in 31(62%) patients axillary lymph node were palpable. The number of lymph nodes retrieved varied from 3-13. Among these patients with clinically palpable axillary lymph nodes, in 87% of patients these lymph nodes showed metastasis. Conclusion: Routine Axillary Lymph node dissection (ALND) in clinically node positive patients is useful for determining histological status and also as a therapeutic procedure.
EnglishAxillary lymph nodal status, Routine Axillary Lymph node dissectionINTRODUCTION
Many studies have proved that axillary lymph nodal status is the most important prognostic indicator in breast cancer and influences the treatment pattern. Axillary lymph node dissection offers excellent loco-regional control and improves overall survival1 . It has seen reported that 30 % of the patients with clinically palpable lymph node proved to be negative and 30 % of the patients with clinically negative have node involvement by histology on axillary dissection2 . Ultrasound guided fine needle aspiration or core needle biopsy has reported a positive result only in 40 percent of axillary node metastasis3 . Sentinel lymph node biopsy (SLNB) has become a routine during the last decade and the recent guidelines recommend removal of clinically palpable axillary lymph nodes irrespective of SLNB results 4 . In 50 breast cancer patients clinically palpable ipsilateral axillary lymph nodes were studied for histological positivity after mastectomy with level II axillary clearance.
Patients and Methods Between August 2007 to August 2009, 50 consecutive patients with breast cancer presented to medical college were included in this study. An informed consent was obtained from each patient and approval of the Ethics committee of this institute was obtained before starting this study. Clinical evaluation with detailed history and physical examination including primary tumour size and axillary nodal status were carried out. Modified radical mastectomy or total mastectomy with level II axillary dissection, were carried out and follow up based on this standard protocol. Parameter studies were histology of the primary, number of nodes retrieved and number of nodes showed metastasis. Statistical test included Pearson’s R test for number nodes retrieved and involved. Chi - square test for clinically palpable lymph nodes and histological positivity.
RESULTS Between August 2007 to August 2007, 50 patients presented with breast cancer and underwent surgery were analysed. The mean ages of the patients were 48 years (range 19- 85 years) and maximum occurrence was in the age group above 50 yrs (48 %). All the patients presented with lump in the breast and out of 50 patients in 32 (62 %) ipsilateral lymph nodes were clinically palpable and in 19 (38 %) not palpable. Modified radical mastectomy was performed in 35 (70%) and total mastectomy in 15 (30%) patients, and axillary clearance up to level II in all the patients. The number of lymph nodes retrieved varied from 3 to 13, 3 – 5 in 18(36%), 6-9 in 13 (26%) and > 10 in 19 (38%) patients. Histopathological examination showed infiltrating Ductal carcinoma in 46 (92 %) and intraductal carcinoma in 2 (4%), medullary in 1(2%), lobular in 1(2%). Table 1 compares the number of nodes retrieved with metastatic node and Pearson’s R test did not show any statistical significance. Among the clinically palpable axillary lymph node patients (31) in 27 (87%) patients the lymph nodes were histopathologically positive and in 4 (12.9 %) patients nodes were negative and these findings were statistically significant (p value 0.006). Table 2
DISCUSSION Axillary lymph node status is one of the most important prognostic factor and influences treatment policy in breast cancer. ALND offers excellent loco regional control and improves overall survival 1 . It has been reported that clinical examination of the axillary region is falsely positive in up to 30 percent of cases, and about 30 percent with clinically negative have node involvement on axillary dissection 2 . Node positivity is influenced by the number of nodes retrieved and this depends on the extent of axillary clearance, nodes exceeding ten to have a higher probability of metastasis 5 .In this study only in 38 percent of patients had ten or more retrieved, because our dissection is limited to level II only. Patients with palpable axillary nodes may elect to proceed to axillary clearance since the probability of axillary node involvement is high. The potential complications and the doubtful benefit of ALND have led to the methods of pre operative diagnosis of involvement of axillary nodes. Ultrasound guided fine needle aspiration or core needle biopsy of axillary node is positive only in 41 percent of patients 3 .
Sentinel lymph node biopsy (SLNB) is emerging as an alternative to diagnose axillary node metastasis and to avoid an ALND in node negative patients. Though early results are promising still this technique needs validation. In a recent study by Specht et al have questioned whether SLNB should be considered in breast cancer patients with palpable Axillary lymph node and inconclusive ultrasound guided FNAC or core needle biopsy 6 . According to Axelson et al, SLNB is acceptable in patients with T1-2 and clinically node negative breast cancer 7 . Lymen G.H. et al have recommended ALND in clinically palpable axillary lymph node irrespective of SLNB result and in SLNB positive patients to undergo minimum level II clearance 4 . Large primary tumours have higher rate of Axillary lymph node metastasis but lymphatic infiltration causes decreased identification rate and increased false negative rate in SLNB 8 . According to Parmar V et al axillary sampling is a better alternative to SNB in operable breast cancer 9 . Forrest has stated that axillary sampling helps to identify a node positive axillary region and to select patients for radiotherapy 10. A study on sampling of axillary lymph node in UK has shown that the higher lumber of nodes harvested, higher numbers of metastatic nodes identified. In this study median number of nodes retrieved were 8 (range 0-30) 11. Alternative to axillary sampling up to 30 nodes followed by radiotherapy, prophylactic axillary clearance is a better option for operable breast cancer with clinically palpable lymph nodes 12. In this study, significant number of nodes showed metastasis in clinically palpable axillary lymph nodes. According to Boon et al, in clinically palpable axillary node patients axillary dissection is of therapeutic value and has this advantage over radiotherapy 13. A Meta analysis of six trials including 3000 revealed a survival benefit of 5.4 percent who underwent prophylactic ALND 14.
CONCLUSION Axillary lymph node status remains as one of the most important prognostic factor and it is difficult to confirm metastasis in axillary lymph node irrespective of pre operative US guided FNAC or true cut biopsy or Sentinel lymph node biopsy. Present study has shown Routine Axillary Lymph node dissection (ALND) in clinically palpable axillary lymph node removal has therapeutic value and confirms metastasis and helps in further management. However, further study with larger number of patients is necessary to confirm.
ACKNOWLEDGEMENT: Authors duly thank the department of general surgery, Mahatma Gandhi Medical College and Research institute and Sri Balaji Vidyapeeth University, for permitting us to publish the dissertation as an article in IJCRR. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Conflict of interest: All authors declare that there is no conflict of interest.
Englishhttp://ijcrr.com/abstract.php?article_id=351http://ijcrr.com/article_html.php?did=3511. Beenken SW, Urist MM, Zhang Y, Desmond R, Krontiras H, Medina H, et al. Axillary lymph node status, but not tumour size, predicts loco-regional recurrence and overall survival after mastectomy for breast cancer Ann.Surg. 2003;237:732-8
2. Sacks NPM, Baum M: Primary management of carcinoma breast Lancet 1993; 342:1402-1408
3. Deurloo EE, Tanis PJ, Gilhuijs KG. Muller SH, Kröger R, Peterse JL, Rutgers EJ, et al. Reduction in the number of sentinel lymph node procedure by preoperative ultrasonography of the axilla in breast cancer, Eur J cancer 2003;39(8):1068-73.
4. Lyman G.H, Giuliano AE, Somerfield MR, Benson AB, Bodurka DC, Burstein HJ et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy is early-stage breast cancer J.Chin oncol 2005;23(30):7703-20.
5. Fisher B, Wolmark N, Bauer M et al, The accuracy of clinical nodal staging and of limited axillary dissection as a determinant of histologic nodal status in carcinoma of breast. Sur Gynaec OBst 1981; 152 (6):765-72.
6. Specht Mc, Fey JV, Borgen PL, Naik AM et al. Is the clinically positive axilla in breast cancer really a contra indication to sentinel lymph node biopsy? J. Am. Coll. Surg. 2005; 200(1):10-14.
7. Axelsion CK, Rank F, Blicher Toft M, Mouriden HT, Jenson MB, Impact of axillary dissection on staging and regional centre in breast tumours < 10mm –The Danish breast cancer Cooperative Group (DBCG) Rigshsontalet, Copenhagen, Denmark Acta Oncol 2000;39:283-9.
8. Samphao S, Eremin JM, El-Sheemy M. Rodier JF, Velten M, Wilt M et al. Management of the axilla in women with breast cancer, current clinical practice and a new selective targeted approach. Ann Surg. Onco 2008; 15 (5):1282-96.
9. Parmar V, Badwe R, Tuttra I, Chinoy R, Hawaldav R. Sentinel node biopsy in operable breast cancer. Ind J Surg. 2003; 65:361- 365.
10. Forrest AP, Everington D, Mc Donald CC, Steele RJ, Chetty U, Steward HJ, The Edinburgh randomized trial of axillary sampling or clearness after mastectomy, Br. J. Surg. 1995;82:1504- 8.
11. Kutiyanawala MA, Sayed M, Scotter A, Windle R, Rew D. Staging the axilla in breast cancer and audit of lymph node retrieval in an UK regional centre. EUR J Surg Oncol 1998;24:280-2
12. NIH consensus conference. Treatment of early stage breast cancer. JAMA ; 1991:265(3):391-5
13. Boon, Owen U, Richard T, John B. Frequency and predictors of axillary lymph node metastasis in invasive breast cancer. ANZJ Surg. 2001; 71:723-728.
14. Orr R K, The impact of prophylactic axillary node dissection on breast cancer survival – a Bayesian Meta analysis. Ann Surg. Oncol 1999; 6(1):109-16.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareEFFECTS OF AMBIENT AIR POLLUTION ON RESPIRATORY HEALTH OF CHILDREN: FINDINGS FROM A CROSS-SECTIONAL STUDY IN CHANDRAPUR, MAHARASHTRA, INDIA
English3645Uddhao GawandeEnglish Suhas KadamEnglish Abhijit KhanvilkarEnglish Gurudatt PotdarEnglish Hrushikesh SalvitthalEnglishBackground: Outdoor air pollution and continuous exposure to ambient air pollutants like particulate matter are among the leading contributors to adverse respiratory health outcomes all over the world. This association between air pollution and the impairment of respiratory functions is evident from number of epidemiological studies. Health risk from particulate pollution is especially high for some risk groups such as children and elderly persons, and those with diseases of lungs. However, there are still many issues to be clarified before we know the real causal relationship between air pollution and health effects. Specific air pollutants have not been identified as causes of health effects. This specific study has been conducted with an objective to evaluate the effects of ambient air pollution on respiratory symptoms and diseases of children, in Chandrapur district of Maharashtra state in India. Methods: Comparative cross-sectional quantitative study was undertaken in the Chandrapur district with two geographical locations – study and control between August-November 2013. The data included primary data collection from school children to assess the lung function among children, flow meters were used and readings were recorded.2000 school children were selected in this study. Epidemiological information was collected from them by administering structured tool (2000) and Peak Expiratory Flow Rate was measured through use of Flow Meter (2000).Data was analysed using frequency tables, crosstab analysis and chi-square test to show significance. Results: Statistically significant difference is observed in prevalence of dry cough, night cough and sneezing symptoms between study and control groups. Statistically significant difference is observed in prevalence of dry cough, night cough and sneezing between less than or equal to 5 km (5 km) distance from the industry. Within study group rhinitis showed statistically significant difference for distance less than 5Km and more than 5Km between home and industry by chi square test. Conclusion: There is a significant effect of ambient air pollution on respiratory symptoms of school-aged students with high prevalence of the symptoms in the study area which is the industrial area than the control area. Presence of multiple industries in or near the village is more harmful than the single industry. Additionally, it also shows that the presence of steel, cement and paper industry in or near a village has caused more ill-effects as compared to coal and thermal industry.
EnglishAir pollution, Respiratory health, Disease, School children, Chandrapur, Maharashtra, IndiaINTRODUCTION
Ambient air pollution is one of the leading contributors to adverse respiratory health outcomes in industrial areas all over world and children are more susceptible to this pollution than the adults. The special vulnerability of children to air pollution exposure is related to several differences between children and the adults. The children are highly sensitive to the adverse effects of air pollution due to their rapidly growing lungs, incomplete immune and metabolic functions, patterns of ventilation and high levels of outdoor activity. (1) A large body of evidence from the Children’s Health Study (CHS) has documented that exposures to both regional ambient air and traffic-related pollutants are associated with increased asthma prevalence, new-onset asthma, risk of bronchitis and wheezing, deficits of lung function growth, and airway inflammation. The high levels of air pollution bring many challenges to public health.
To further ameliorate adverse health effects attributable to air pollution, many more toxic pollutants may require regulation and control of industrial emission sources may need to be strengthened. Individual interventions based on personal susceptibility may be needed to protect children’s health while control measures are being implemented. (2)Health risk from particulate pollution is especially high for some susceptible groups such as the children and the elderly persons, and those with diseases of the heart and lungs. (3) The study area, Chandrapur is a district in the north-eastern part of Maharashtra has large natural deposits of coal, limestone, high grade iron-ore, bauxite and chromite which have triggered the growth of industries in the district by the Maharashtra Industrial Developmental Corporation (MIDC).
There has been a tremendous growth in the number of coal, cement and steel industries in Chandrapur over the years which have contributed to the growing economy of the district and the state.(4,5)There are a total of 6000 small and big scale industries in Chandrapur. Chandrapur city is also called as City of Black Gold because of the large number of coal industries in and around the city. There are a total of 35 coal mines (out of which 7 are in the city), mostly open cast in the city and surrounding areas, over half a dozen coal washeries, one large paper mill, sponge iron units and several cement industries. The Chandrapur Super Thermal Power Station (CSTPS) is one of the biggest thermal power stations in Asia, which is currently generating 2340 MW of electricity.(6) Industrialization of such a scale has been responsible for very high levels of ambient air pollution in Chandrapur District.
According to the Ministry of Environment and Forests (MoEF), Chandrapur is the most polluted city in Maharashtra and the 4th most polluted industrial cluster in India among the 88 key industrial clusters.(7) In terms of Respirable Suspended Particulate Matter (RSPM) pollution, Chandrapur is the most polluted city in India. The ambient levels of SO2 in Chandrapur are the third highest in India, and the National Aeronautics and Space Administration (NASA) has already warned of acid rains in Chandrapur in the future.(8)Apart from its harmful effects on vegetation and water quality, high levels of air pollutants emitted from the industries have a significant effect on human health, not only among people working in these industries but also among people living in the vicinity of these industries.(9)High levels of PM10, SO2 and NOx have been associated with adverse respiratory health particularly those associated with airways diseases such as COPD and asthma, and cardiovascular health such as ischemic heart disease, hypertension, systemic inflammation and diabetes mellitus (DM).(10)
According to the Central Pollution Control Board (CPCB), levels of air pollution in Chandrapur district are in the critical zone raising serious concerns of adverse effects on human health. Several questions raised by Honourable Members of the Maharashtra Legislative Assembly during the legislative assembly meetings regarding concerns of worsening health of people living in Chandrapur due to industrial air pollution need to be addressed so that appropriate intervention strategies can be adopted and implemented in the future. Therefore, government decided to do a cross-sectional study to assess the health effects of ambient air pollution on the local residents of Chandrapur.
This study was commissioned by State Health Systems Resource Centre (SHSRC), Pune jointly with Prognosis Management and Research Consultants, Pune. This study tried to give the current health status children regards respiratory and cardio-vascular system. It also has compared it between the industrial and non-industrial areas of Chandrapur district. Further the results are compared with results of neighbouring district (Nagpur) and India as well.
Objectives: This study of assessing health effects was focussed with following objectives – • To determine the effects of ambient air pollutants on respiratory health of children in Chandrapur • To determine prevalence of respiratory symptoms and diseases (Asthma, LRTI/ Pneumonia etc.) among children studying in schools in Chandrapur Study Design / Methodology: Comparative cross-sectional quantitative study was undertaken in the district with two geographical locations – study and control between August-November 2013. The study is jointly done by State Health Systems Resource Centre, (SHSRC) Pune and Prognosis Management and Research Consultants, Pune in the select blocks of the Chandrapur District (Ballarpur, Chandrapur, Korapana and Rajura). Study location was in the vicinity of industry and control location was more than 25 km from any of the industries. Quantitative data included primary data collection from school children to assess the lung function among children, flow meters were used and readings were recorded. The laboratory of the district hospital was used for testing. The informed consent was given by the parents through principal of the school.
Sampling: Five private and five government schools were randomly selected from study area and same number from control area. From each school, fifty students each of standard 2 and standard 8 were randomly selected. Simple random sampling was used to select the blocks, locations and schools from the study locations. Industrial (study) and non-industrial (control) areas were selected as explained: One Factory each from power plant, coal mines, cement, paper and steel industry was first identified on the basis of maximal population density within radius of 40 km from the factory in Chandrapur district. The selected regions were then subdivided into radius of 1-5 km, 5-10 km, 10-20 km, 20-30 km, 30-40 km and >40 km =was included in non-industrial area. Based on this criterion, the sample was divided in eleven villages in study area and three villages in control area. Also, these locations were confirmed on consultation with local health functionaries during meeting held before commencement of field work in Chandrapur. The summary below provides at a glance industrial blocks (areas) and village wise distribution of industries:
Huge amount of dust or particulate matter is generated in cleaning and milling sections in a rice mill.(13)However there is no mechanism to measure the amount of emitted particulate matter. Additionally the MPCB pollution monitoring site is not established at Mul block. Therefore effect of the air pollution caused due to rice mills on the health of people in this block cannot be measured. Sample Size: The sample size was determined for school children upon considering lowest prevalence of respiratory disease. Asthma being the lowest prevalent respiratory disease its respective prevalence value for children was taken as ‘P’ in sample size calculation. This also meant coverage of larger population and other diseases. Sample for children: Prevalence of asthma for this age group is 4.5% as per the ISAAC study. This is taken as p in the sample size formula.
Interviews and diagnostics of target population: We have selected 2000 school children. Epidemiological information was collected from them by administering structured tool (2000) and Peak Expiratory Flow Rate was measured through use of Flow Meter (2000). Human Resources: Appropriate human resources were deployed for implementing the study. These included public health specialists, clinical specialists, air pollution specialist, social scientists, and auxiliary nurse midwives.
Data collection Training of all the data collectors was conducted prior to commencement of data collection. Data was collected in the following manner: School children’s epidemiological data- A structured questionnaire was filled by a group of social scientists, by asking questions to students. Students were asked questions regarding their demographic details, clinical manifestations that is number of illness episodes in last one year, presence of illness at the time of study and presence of respiratory illness. Height and weight of students was measured.
Teachers’ help was taken for the questions such as attendance or performance of child. School children’s diagnostics- Flowmetries were conducted usingRMS Helios flowmeters by social scientists. Each child was given instructions on how to perform the flowmetry before the test. The test was carried out in standing position. Every child was asked to perform the test five times and the best reading was recorded. Data Entry and Analysis: Collected data was entered using epi-info software and then was exported to SPSS for statistical analysis. Appropriate statistical tools and tests were used to compare the results. The analysis included descriptive statistics, inferential statistics and application of Test of Significance.
RESULTS Finding of school children epidemiological data: School children in the age group 6-7 years and 13-14 years were selected with the purpose of observing effects of ambient air pollution at different age groups.
Clinical manifestation: Following tables present clinical manifestations amongst school children from study and control areas and also the association of clinical manifestations amongst school children from study with respect to distance of their home from nearest industry.
Table 1 shows that, more than 70% of children from both, study and control sites had an episode of illness 2-4 times in last 1 year. Also, more than 10% of children from both sites have more than 4 episodes of illness in last 1 year. Wheeze, productive cough, night cough and breathlessness are the indicative symptoms for asthma and COPD. Hence, these symptoms were asked along with other respiratory symptoms such as dry cough, sore throat etc. Following table 2 presents the presence of respiratory symptoms in study and control area as well as with respect to distance of home from nearest industry.
Presence of respiratory symptoms: Table 2 shows that, close to 30% of children had dry cough in study area, the percentage of which in control area was 21.3% Equal proportion (7.8%) of children in study and control area experienced productive cough in last 1 year. More than 22% of children in study area had night cough in last 1 year, as compared to 13.6 % children in control area more children in study area (17.8%) experienced continuous sneezing as compared to the children in control area (10.2%). More children in study area (6.8%) had sore throat as compared to the children in control area (3.3%).
More children in study area (6.1%) had presence of wheeze as compared to the children in control area (4.4%). More children in study area (6.7%) had chest pain as compared to the children in control area (3.3%)... More children in study area (3.2%) experienced breathlessness as compared to the children in control area (1.7%). More children in study area(2%) had asthma as compared to the children in control area(1.2%). Barring a couple of cases in control areas tuberculosis was not evident. Pneumonia was very low. Only one student in study area had pneumonia in last year. More than 30% of students residing less than 5 kms from the industry experienced dry cough as compared to students
staying at a distance of more than 5 kms from an industry (19.5%). Amongst the students who experienced productive cough higher percentage (8.7%) were staying at less than 5 kms distance from nearest industry. More number of students were staying at less than 5 kms distance from nearest industry experienced night cough (23.6%) as compared to those students staying at a distance of more than 5 kms from industry (15.1%). Amongst the students who had continuous sneezing, more (19.7%) were staying at less than 5 kms distance from nearest industry. Amongst the students who experienced wheeze, maximum (6.8%) were staying at less than 5 kms distance from nearest industry. Amongst the students who had chest pain, higher proportion(7.5%) of these students were staying at less than 5 kms distance from nearest industry. Amongst the students who experienced sore throat maximum (7.5%) were staying at less than 5 kms distance from nearest industry.. , all the students who experienced breathlessness were staying at less than 5 kms distance from nearest industry. Amongst the students who had asthma, maximum were staying at less than 5 kms distance from nearest industry.
Statistically significant difference is observed in prevalence of following symptoms between study and control groups: • Dry Cough: 29.5% in Study and 21.3% in Control, p=0.000 Significant by Chi Square test • Night Cough: 22.3% in Study and 13.6% in Control, p=0.000 Significant by Chi Square test • Sneezing: 17.8% in Study and 10.2% in Control, p=0.000 Significant by Chi Square test Statistically significant difference is observed in prevalence of following symptoms between 5km distance • Dry Cough: 31.4% in 5 km, p=0.003 Significant by Chi Square test • Night Cough: 23.6% in 5 km, p=0.018 Significant by Chi Square test • Sneezing: 19.1% in 5 km, p=0.011 Significant by Chi Square test .
Village wise prevalence of symptoms The respiratory symptoms reported by school children in the study area were also assessed with respect to presence of industry in or near village.
From table 3, it can be seen that the prevalence of respiratory symptoms is higher in villages with multiple industries as compared to the villages with single industry. However in case of village having cement industry, the prevalence is higher irrespective of number of industries present in or near the village.
Finding of school children diagnostic test: Peak Expiratory flow rate(PEFR) was assessed with the help of flow meter in all school children in study and control area. (14) The percentage deviation of the recorded PEFR from expected PEFR was analysed with respect to study and control area. Table 4 present PEFR results amongst school children from study and control areas.
About 58.9 % students from study area had not acceptable PEFR% whereas 57.5% students from control area had not acceptable PEFR%. There is no significant difference observed in PEFR% result between Study and Control group (p-value by Chi-square= 0.130). This implies the lung function of children in these two areas is comparable.
PEFR results amongst school children from study area: Table 5 shows that, more than 80% students from study area having not acceptable PEFR% had more illness episodes.
alone and that the effects of air pollution on health needed to be ascertained further. In July 2001, the Bharatiya Adimjati Sevak Sangh along with the Collectors office in Chandrapur conducted a health survey of 3000 people from 5 study villages (villages in the vicinity of industries) and 2 control villages in Chandrapur(villages away from the industries). This study which was funded by the coal mine company (Western Coal Fields Limited) and executed by GMC Chandrapur and GMC Nagpur reported no significant variation between control and target population.(21)
CONCLUSION Exposure to a mixture of air pollutants associated with adverse respiratory health of the children living in the industrial areas of the district. Clinical manifestations: Presence of multiple industries in or near the village is more harmful than the single industry. Additionally, it also shows that the presence of steel, cement and paper industry in or near a village has caused more illeffects as compared to coal and thermal industry. School children: Statistically significant difference is observed in prevalence of following symptoms between study and control groups: • Dry Cough: 29.5% in Study and 21.3% in Control, p=0.000 Significant by Chi Square test • Night Cough: 22.3% in Study and 13.6% in Control, p=0.000 Significant by Chi Square test • Sneezing: 17.8% in Study and 10.2% in Control, p=0.000 Significant by Chi Square test Statistically significant difference is observed in prevalence of following symptoms between 5km distance • Dry Cough: 31.4% in 5 km, p=0.003 Significant by Chi Square test • Night Cough: 23.6% in 5 km, p=0.018 Significant by Chi Square test • Sneezing: 19.1% in 5 km, p=0.011 Significant by Chi Square test Within study group, following symptoms showed statistically significant difference for distance less than 5Km and more than 5Km between home and industry. • Rhinitis: 30.2% in less than 5Km and 13.4% in more than 5Km, p=0.004 Significant by Chi Square test.
Recommendations
1. Students under this study should be taken as cohort and periodically monitored over next 3 years to observe and record any deterioration in health and associated illness and performance at school
2. Strengthening of source emission monitoring is necessary.
3. Strengthening of air quality monitoring network- Levels of PM2.5, CO and CO2 gases should also be recorded along with the presently monitored SO2, NOx and RSPM as these gases are also equally harmful to health.
4. Proper mechanism for enforcement and compliance of regulations related to pollution should be built.
5. Bypass road should be built for truck transport, and also the transport of industrial products should be done in closed trucks.
6. Sentinel Surveillance Centres should be established by Public Health Department wherein, the equipment’s like Spirometer and Flow-meter used for the current study should be part of these Sentinel Centres. The Centres will act as Centres of Excellence. The role of these Sentinel Centres is proposed below.
Sentinel Surveillance Centres The foremost need of the hour is to establish Sentinel Surveillance Centres at the public health facilities where the MPCB monitoring sites are located i.e. Chandrapur SRO, Chandrapur MIDC, Tadali MIDC, Ghuggus, Ballarshahand Rajura. Thus, Centres should be established at following facilities- 1.General Hospital, Chandrapur, 2.Primary Health Centre, Durgapur, 3. Primary Health Centre, Tadali, 4. Primary Health Centre, Ghuggus, 5. Rural Hospital, Ballarshah and 6. Rural Hospital, Rajura. These Centresshall work as “Centre of Excellence” in the district. These Centres should impart promotive, preventive and curative services.
1. Target population: Population in the catchment area of 6 health facilities should be the target population. Cases identified in the study for respiratory symptom and diseases and cardio-vascular symptoms and diseases should be treated and followed up in these centres.
2. Local NGOs: Local NGOs should be involved in the activity and their help/ support should be taken for following up the cases.
3. Awareness creation and prevention measures: This centre should bring all 5 stakeholders together; namely: Public Health Department, MPCB, NGOs, Industries and Community. Every stakeholder will be enrolled in awareness activities. Community will be made aware about early signs of these symptoms and will be encouraged to take treatment on time.
4. Clinical Role: These Centres should provide treatment to all the cases that come with respiratory symptoms and diseases. I.e. dry cough, night cough, productive cough, sore throat, wheeze, sneezing like symptoms should be treated and monitored as they are precursors to the respiratory diseases Asthma and COPD. Similar, Cardiovascular symptoms and diseases will be treated and monitored here. I.e. hypertension, chest pain will
be treated and monitored as they are precursors to the cardiovascular diseases. Other diseases or symptoms which should be monitored are ophthalmic problems (redness of eyes, eye infections) and skin problems (itching, eczema). Regular supply of medicines for all these symptoms and diseases should be ensured. These centres should also maintain case-wise record of all these diseases and should make its use for planning and further improving health status. Moreover, these Centres should function as observation and monitoring mechanism for the health outcome of the people residing in the vicinity of industries with respect to changes in air pollution levels.
Although the association with known air pollutants is suggestive, a cross-sectional study cannot confirm a causal relationship and further studies are needed to determine the exposure-effect relationship between individualized air pollution exposure and various adverse respiratory effects. The sample from the current study should be taken as cohort for continued observation and monitoring; along with the cases of possible ill-effects of air pollution detected in all health facilities, including government hospitals and industry-run hospitals in the vicinity of industrial areas. Regular health check-up of these cases should be done in conjunction with pulmonary function tests, ECGs and blood tests if required.
Specific functions should include:
1. Capacity building of Doctors and paramedics • For detection of illnesses/diseases due to air pollution. For monitoring and reporting certain parameters and illnesses related to air pollution, For preventive measures to be taken by the people for these effects Process of reporting cases showing effects of air pollution
2. Follow up of participants in the study, showing unfavourable health effects of air pollution as well as cases reported by the health facilities in the nearby areas
3. Periodic check-up and investigations of this cohort for the effects of air pollution
4. Advice promotive and preventive measures through awareness such as use of cloth around mouth and nose, nutrition and hygiene, conversion of coal-chulhas to non-coal chulhas to patients showing pre-disease condition or minimal effects
Source of Funding: Please mention source of funding for this work (if any) – nil
Conflict of interest: Please declare conflict of interest (if any) – nil
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=352http://ijcrr.com/article_html.php?did=3521. Gilliland FD, McConnell R, Peters J, Gong H. A theoretical basis for investigating ambient air pollution and children’s respiratory health. Environ Health Perspect [Internet]. 1999 Jun 1;107(Suppl 3):403-7. Available from: http://www.ehponline. org/ambra-doi-resolver/10.1289/ehp.99107s3403
2. Chen Z, Salam MT, Eckel SP, Breton C V, Gilliland FD. Chronic effects of air pollution on respiratory health in Southern California children: findings from the Southern California Children’s Health Study. J Thorac Dis. 2015;7(1):46-58.
3. Ulrich MMW, Alink GM, Kumarathasan P, Vincent R, Boere a JF, Cassee FR. Health effects and time course of particulate matter on the cardiopulmonary system in rats with lung inflammation. J Toxicol Environ Health A. 2002 Oct 12;65(20):1571-95.
4. Ministry of Micro S and ME. Brief Industrial Profile of Chandrapur District.
5. Western Coalfields Limited. An overview of industries in the state of Maharashtra.
6. Maharashtra Pollution Control Board. Environmental Status and Action Plan for Control of Pollution at Chandrapur [Internet]. Available from: http://mpcb.gov.in/images/pdf/action plan chandrapur1.pdf
7. The Times of India. Chanda fourth most polluted city in India. :1-2. Available from: http://timesofindia.indiatimes.com/city/nagpur/Chanda-fourth-most-polluted-city-in-India/articleshow/5392934.cmsreferral=PM
8. Central Pollution Control Board. Comprehensive Environmental Assessment of Industrial Clusters [Internet]. Central Pollution Control Board, Ministry of Environment and Forests; 2009. 1-28 p. Available from: http://cpcb.nic.in/divisionsofheadoffice/ess/NewItem_152_Final-Book_2.pdf
9. Maharashtra Pollution Control Board. CEPI Report. 2010.
10. Natural Resources Defense Council. Our children at risk. 1998;(June 1993):1-13.
11. Sharma AK, Siddiqui KA. Assessment of Air Quality for an Open Cast Coal Mining Area. Indian J Sci Res. 2010;1(2):47- 55.
12. Atimtay A, Chaudhary T. Air Pollution Due to Nox Emissions in an Iron-Steel Industry Region in South-Eastern Turkey and Emission Reduction Strategies. Middle East Tech Univ Environ Eng Dep 06531 Ankara [Internet]. Available from: http://www. umad.de/infos/cleanair13/pdf/full_152.pdf
13. Central Pollution Control Board. Comprehensive Industry Document on Pulse, Wheat, Rice Mills. 2008; (July):108. Available from: http://cpcb.nic.in/upload/NewItems/NewItem_132_ coind-pulsewheatricemills.pdf
14. Chowgule R V, Shetye VM, Parmar JR. Lung function tests in normal Indian children. Indian Pediatr. 1995; 32(2):185-91.
15. Jindal SK, Aggarwal AN, Gupta D, Agarwal R, Kumar R, Kaur T, et al. Indian Study on Epidemiology of Asthma, Respiratory Symptoms and Chronic Bronchitis in adults (INSEARCH). Int JTuberc Lung Dis [Internet]. 2012 Sep 1;16(9):1270-7. Available from: http://icmr.nic.in/final/INSEARCH_Full_Report.pdf
16. World Health Organization. Ambient (outdoor) air quality and health. 2014; 313:7. Available from: http://www.who.int/mediacentre/factsheets/fs313/en/#
18. Radomski A, Jurasz P, Alonso-Escolano D, Drews M, Morandi M, Malinski T, et al. Nanoparticle-induced platelet aggregation and vascular thrombosis. Br J Pharmacol [Internet]. 2005 Nov; 146(6):882-93. Available from: http://doi.wiley. Com/10.1038/sj.bjp.0706386
19. Seaton a, MacNee W, Donaldson K, Godden D. Particulate air pollution and acute health effects. Lancet [Internet]. 1995 Jan; 345(8943):176-8. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0140673695901736
20. Nemmar A, Hoylaerts MF, Hoet PHM, Nemery B. Possible mechanisms of the cardiovascular effects of inhaled particles: Systemic translocation and prothrombotic effects. Toxicology Letters [Internet]. 2004. p. 243-53. Available from: http://linkinghub.elsevier.com/retrieve/pii/S0378427403005034
21. Government of India. State of Environment Report [Internet]. 2009. Available from: http://www.moef.nic.in/downloads/home/home-SoE-Report-2009.pdf
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareEVALUATION OF SUPPORT SERVICES NEEDED FOR PEOPLE LIVING WITH HIV (PLWH) ATTENDING RETRO CLINIC, TERTIARY CARE HOSPITAL AND ART PLUS CENTER, KARNATAKA, INDIA
English4656Mohammad HaghighatpanahEnglish Ateendra JhaEnglish Jeni Mary JoyEnglish Rajesh RadhakrishnanEnglish Danturulu Muralidhar VarmaEnglishIntroduction: Human Immunodeficiency Virus (HIV) that reasons Acquired Immunodeficiency Syndrome (AIDS) has become one of the world’s most alarming health-related problem. In developing countries like India AIDS have not only impact on physical health but also have retarding impact on Social and Psychological status of patients. People living with HIV/AIDS(PLWHA) may lose career, income, and even friends and family members as significant resources of assistance and support. The quality and organization of medical care for HIV-infected patients in any setting inevitably reflect the functioning of the health services in general. Aim: To evaluate support services needed for people living with HIV(PLWH) using validate questionnaire. Methodology: Validated survey questionnaire was used to evaluate the support services needed for HIV positive patients at Retro Clinic at Kasturba Hospital, (RCKH) Manipal and ART Plus center Udupi( ARTPCU ). We used both qualitative and quantitative research methodologies, including questionnaires and interviews of 120 patients receiving ART. Result: A total of 120 HIV patients were enrolled in the study, we found that 102(85.0%) got tested for HIV on Doctor’s suggestion while 18(15%) got tested by their own will. In RCKH (87.0%) waiting time was about 30-60 minutes while in ARTPCU (92.4%) it was less than 30 minutes. Most of the patients at either of the centers received counseling (76.7%) and were satisfied (94.2%). Economic support was available in ARTPCU but not in RCKH. Majority (56.7%) of the patients were on HAART since 1-5 years while only four (3.3%) were under one year of HAART. 30(55.6%) and 23 (24.8%) patients from RCKH and ARTPCU center respectively had their performance capacity affected and most of them (86.8%) reported tiredness. Forgetfulness and stigma (44.4% each) and cost (1.9%) were the reasons for the dose skipped and therapy break. Conclusion: There was no significant difference in the patient satisfaction at both the centers. Services provided at both of the centers were comparatively same, except for the extra facility of comorbid treatment in RCKH and economic support, free drug distribution and consultation in ARTCU.
EnglishAcquired immunodeficiency syndrome, Human immunodeficiency virus, People living with HIV, ART plus centre, Patient servicesINTRODUCTION
Human Immunodeficiency Virus (HIV) that reasons Acquired Immunodeficiency Syndrome (AIDS) has become one of the world’s most alarming health-related problem. In developing countries like India AIDS have not only an impact on physical health but also have retarding impact on Social and Psychological status of patients. Social stigma will be experienced not just among the illiterates or poorly developed community however can also be found in welldeveloped and educated society. People living with HIV/ AIDS(PLWHA) may lose career, income, and even friends and family members as significant resources of assistance and support.
AIDs is hitting adults in their most economically productive years and removing the very people who could be responding to crisis. Through its impacts on the labor force, households and enterprises. One way in which HIV and AIDS affect the economic system is by decreasing the labor supply through increased death rate and illness. Among those who are able to work, productivity is likely to decline as a result of HIV-related illness. PLWHA encounter several challenges with regards to the medical management of their illness and social stigma and psychosocial issues that are associated with HIV infection. It is manifested in prejudice, discounting, discrediting and discrimination directed at people perceived to have HIV, along with the groups and communities to which they are associated.
With development of antiretroviral therapy (ART) and quality care that increases life expectancy in patients, improvement of the quality of life in PLWHA is important. Social support as an aspect of psychological adjustment can improve psychological and physical health outcomes, self-care behaviors, increasing motivation for treatment and also prevention of transmission of infection during HIV/AIDS disease. Prevention and care are now seen as interrelated. Since resources are always limited, especially in developing countries, strategies need to be developed to provide an acceptable standard of care at an affordable price. The quality and organization of medical care for HIV-infected patients in any setting inevitably reflect the functioning of the health services in general.
The epidemiologic characteristics of HIV infection vary according to geographic region and rely upon the mode of transmission, cultural factors and governmental prevention efforts and resources. The mortality rate related to HIV in Asia was estimated to be 2, 50,000 [2,10,000-2,90,000] in 2013.Most countries aspiring to expand treatment access, set themselves a goal of providing antiretroviral treatment to around 80 percent of those in need. With current global treatment coverage at 65 percent, this treatment target has not yet been met on a global scale.
Nevertheless, a number of countries have achieved or are near achieving universal access by 2015.1 In India National Aids Control Organisation (NACO) is the body responsible for formulating policy and implementing programs for the prevention and control of the HIV epidemic in India. Improved antiretroviral treatment access reduces AIDS mortality and lowers HIV incidence by reducing the viral load at the individual/community level.2
MATERIALS AND METHODS
Study was conducted in Retro clinic, Kasturba Hospital (RCKH) Manipal and ART Plus Center Udupi (ARTPCU). All HIV- infected outpatients of either sex who were on antiretroviral therapy and agreed for survey questionnaire interview were included. While HIV-infected patients with traditional or alternate medicines alone or HIV- infected patients who refused for a survey questionnaire interview were excluded from study. Total number to PLWH interviewed were 120, including 54 from RCKH and 66 ARTPCU.
The study was carried out as per the protocol approved by Institutional Review Board/Ethical Committee of each of the health facilities granted approval for the study. Based on the study criteria, the study procedures have been explained and informed consent was taken from the patients. Validated survey questionnaire was used to evaluate the support services needed for HIV positive patients at RCKH, Manipal and ARTPCU. We used both qualitative and quantitative research methodologies, including questionnaires and interviews of 120 patients receiving ART.
Demographic details, information on socio-demographic factors, psychological factors, social habits, time of diagnosis of HIV, health care system and healthcare professionalrelated factors, HAART-related factors, knowledge and belief related to HAART, and reasons for lack of adherence was documented. Although the survey questionnaire was printed in English and Kannada, the interview was conducted in English, Hindi or Kannada languages for convenience and understanding of the respondents. Agreed patients for survey questionnaire was interviewed and asked to recall and report their answers for support services needed for better HIV treatment and HIV care. Survey questionnaire consist of questions with single answer, or with multiple possible answers.
RESULT Socio-Demographic Characteristics A total of 120 HIV patients were enrolled in the study, out of which 54 were from RCKH and 66 from ARTPCU. Out of 54 RCKH patients, 20 (37%) were male and 34 (63%) were female while out of 66 patients from ARTPCU, 45 (68.2%) were male and 21 (31.8%) were female. Out of 120, majority (45%) were in the age group 39-48 years and (15.8%) were in the age group 49-58 years. Both in RCKH and ARTPCU, most of the patients were married, 83.3% (N=45) and 71.2% (N=47) respectively. Unemployed patients were more both in RCKH and ARTPCU, 61.1% (N=33) and 56.1% (N=37) respectively. From 120 patients, 110 (91.7%) were HAART experienced, which includes 50(92.6%) and 60 (90.9%)
study subject from RCKH and ARTPCU respectively. 93.4% of the total patients enrolled were literate, out of which most of the patients of RCKH had collage level education while ARTPCU had a higher number of patients with secondarylevel education. Socio-Demographic details of the patients are shown in the Table 1.
Disease And Health Related Services In disease and Health-related services out of 120 patients, 102(85.0%) got tested for HIV on Doctor’s suggestion while 18(15%) got tested by their own will. 108 patients got tested due to their illness out of which 53(98.1%) and 55(83.3%) patients were from RCKH and ARTPCU respectively. 63% of RCKH and 93.9% of ARTPCU and 37 % of RCKH and 6.1% of ARTPCU patients have good and fair physical health respectively as shown in the Table 2.
Experiences with Waiting Times and Consultation Related Services In RCKH (87.0%) waiting time was about 30-60 minutes while in ARTPCU (92.4%) it was less than 30 minutes. In ARTPCU there was no consultation charge while in RCKH patients were charged. 75.9% of RCKH patients reported consultation time more than 20 minutes while 90.9 % of ARTPCU patients reported 5- 20 minutes. Most of the patients (79.2%) did not like to make frequent visits for follow up. All the patients had privacy during discussion with doctor and Most of the patients at either of the centres received counseling (76.7%) and were satisfied (94.2%). The details are summarized in the Table 3.
Highly Active Anti-Retroviral Therapy (HAART) Related Services Majority (56.7%) of the patients were on HAART since 1 to 5 years while only four (3.3%) were under one year of HAART. Out of 120 patients, 98.1% of RCKH and 98.5% of ARTPCU patients got their antiretroviral prescription filled for one month. 75.9% of RCKH and all from ARTPCU centre did not know either they are on monotherapy or combination therapy. 86.7% of total patients from both the centres, reported improvement in their health after starting HAART. About 17.5% of the total subjects experienced the side effects of the antiretroviral treatment and managed the same by consulting their respective HIV doctors (Table 4).
Adherence and Support Related Services Out of 54 RCKH patients, 3 had a therapy break and 24 had skipped the dose. Forgetfulness and stigma (44.4% each) and cost (1.9%) were the reasons for the dose skipped and therapy break. Out of 66 ARTPCU patients, 6 had a therapy break and 31 had skipped the dose. Forgetfulness (40.9%), was the major reason for the dose skipped and tuberculosis (7.6%) was the reason for the break of therapy. All the patients of ARTPCU were satisfied with the services like admission, lab investigation and economic support while patients from RCKH reported some un-satisfaction. Economic support was available in ARTPCU but not in RCKH.(Table 5)
Work, Travel and Food Related Services 30(55.6%) and 23 (24.8%) patients from RCKH and ARTPCU respectively had their performance capacity affected and most of them (86.8%) reported tiredness. 80% of the total subjects participated had difficulty in keeping their HIV status confidential. Patients from both of the centres found it easy to get public transport to their HIV centres. Majority of the patients from RCKH and ARTPCU were 50-100 km and 10-49 km far from HIV centre respectively (Table 6).
Income and Cost Related Services 21 (38.9%) and 29 (43.9%) patients from RCKH and ARTPCU respectively, had salary as their main source of income. 84.6% of ARTPCU and all patients of RCKH had income per month up to Rs.10,000 and Rs.5000-20,000 or more respectively. 50 (92.6%) of RCKH patients spent more than Rs.2500 on the drugs and patients of ARTPCU had received the free drug.(Table 7)
Comparative Presentation of HIV Centers Patients with higher level of education (Mean value:3.02) and higher income level (Mean value:3.09) selected RCKH to receive treatment and patient with a low income level mostly preferred to get treatment from ARTCU and HAART experienced patients were almost equally distributed in both centers as shown in Figure 1.
DISCUSSION Scaling up the access to antiretroviral treatment is not only desirable for individual patients with HIV and AIDS but also for consolidating the success of prevention and control programs in developing countries.3 Consequently expanding access to treatment has the potential to assist countries in achieving Millennium Development Goal (MDG) 6.4 This potential could be accentuated by providing quality antiretroviral treatment services in all health facilities (Government and Private Sector). The services provided to the PLWH include clinical care (treatment) and clinical support services (laboratory, pharmacy and counseling).
The choice of an HIV treatment depends on the factors such as respect to confidentiality, sensitivity toward patient needs, geographical closer, patient’s income and overall cost of the treatment. A total of 120 patients diagnosed with HIV were included in the study. In our study, RCKH showed female predominance and ARTPCU showed male predominance. Most of our patients were HAART experienced compared to naïve patients which was supported by similar study carried out by Osungbade KO. et al.3
Our experience of survey questionnaire for support services demonstrated literate patients took shorter time for giving their feedback compared to illiterate patients, the reason being illiterate patients require many explanations related to HIV disease and its management. While assessing disease and health survey questionnaire, we found that most of the patients were tested initially for HIV screening due to other illnesses as routine health check-up as per doctors’ advice. Our study results showed no significant difference at either of the centers for response regarding HIV disease, its treatment, transmission and prevention. These findings were in accordance with findings of Project Nasah, where they highlighted the importance of knowledge regarding a relationship to drug resistance and treatment failure.5
During the interview, we found that most of the HAART experienced patients reported good health condition after initiating HAART. We found that the patients of ARTPCU presented with HIV disease, mostly without comorbid conditions while RCKH patients presented with HIV disease mostly with comorbid conditions like mental disorders, cardiovascular disorders, and neurological diseases. This is because of the fact that most of the RCKH patients, preferred first to consult doctors for their comorbid conditions at Kasturba Hospital and if suspected for HIV, patients were asked for HIV screening, further confirmed for HIV positive, they would be directed to RCKH for their treatment. One of the limitation which we found for patients who were enrolled at both the centers was that they had no private insurance for PLWHA. These findings of our study, strongly support the need of health insurance.
Our findings are supported by the study done by Gupta I et al.6 Some standalone health insurance providers like Star Health and Allied Insurance offer such insurance.7,8 Related to medical consultation with a clinician, our survey revealed that in ARTCU waiting time was less than one hour but in case of RCKH, it was almost up to two hours. This may be because Kasturba Hospital is a tertiary care hospital so the doctors are involved in the ward rounds during morning hours. Privacy during discussion with doctor was maintained at either of the centers. In ARTCU doctors spent about 5 minutes to 20 minutes with patients while in case of RCKH this time varied from 10 to 20 minutes or more.
Majority of the patients did not prefer frequent visits to HIV Treatment Centre. The reason may be that HIV / AIDS has a social stigma so they prefer fewer visits to prevent the disclosure of their illness. In our study, Almost all the patient received the information regarding adherence to HAART, resistance and side effects of antiviral drug, CD4-T cell count, nutrition. Pregnancy associated information in HIV was also conveyed. This information encouraged the patients to hope for better quality of life. All the patients of ARTCU were satisfied with the other services like referral, medical checkups, lab investigations and economic support while we found some dissatisfaction for services in case of RCKH patients.
Our findings were in accordance to PLHIV satisfaction survey, Midline Assessment Report 2012 -13.9 There is no economic support for the patients of RCKH while ARTPCU patients received financial support every month at the rate of Rs.0.80 /- per kilometer for their travel fare. Only few patients opted to obtain drugs from community pharmacy. During the survey, we realized that patients did not prefer to get medication near their residency to maintain the confidentiality of their disease or sickness. Majority of the patients from either of the centers were HAART experienced (taking medication from about 1 to 10 years).
All patients got their HAART filled at the approved ART center and hospital pharmacy at ARTCU and RCKH respectively. Patients collected the drugs at a monthly basis. Few of RCKH patients were aware of the type of undergoing treatment (monotherapy / combination therapy). Majority of the patients did not experience side effects. Those who experienced side effects preferred to visit HIV doctors for their treatment. Most of the patients had no history of therapy break, but few were non adherent to the therapy. During the interview, we came to know that forgetfulness and stigma were the main reasons for the skipping of dose, while tuberculosis was the main reason for the therapy break. Study done by Fatiregun AA. et al also suggest the stigma and forgetfulness are the major reason for non-adherence to ART.10 Despite of social stigma and discrimination, patients had support from their family and friends. During the interview, a majority of (58.3%) reported that their daily duties were not affected by their illness which is supported by the report given by Blalock AC. et al which significantly showed higher incidence of overall quality of life among PLWH.11 Despite of awareness in society, still there is stigma of disease and discrimination with PLWH.
In our study, patients faced difficulties in keeping their illness confidential. Our findings were supported by the report given by Fatiregun AA. et al.10 In relation to the distance between home and HIV treatment centers(10 Km to 100 Km) most of the patients reported easy availability of public transport. Salary was the main source of income for the employed patients but the rest had economic support from their partner, family and friends. RCKH patients had good economic background while in ARTCU majority had an income maximum up to only Rs. 10,000 per month.
Patients of ARTCU got their drugs free of cost while RCKH had to pay Rs. 2000 to Rs. 2500 or more for one month treatment. Patients of RCKH reported economical difficulty in payments for medication for HIV/AIDS, other prescribed medications and Medical services while in ARTCU these were not applicable due to free availability of drugs and services. In the cross-sectional study done by Sangowawa A et al revealed that youth with HIV in Ibadan are experiencing various economic problems.12
CONCLUSION The study on the evaluation of the support services needed for patients living with HIV(PLWH) was done in RCKH and ARTCPU. In this study, overall satisfaction of patients at ARTCU and RCKH was same. Patients were aware regarding disease, its treatment and prevention at either of the centers. At ARTCU, patients got economical support as their travel fare while at RCKH patient reported economic difficulties. Patients at RCKH also got treatment for any comorbidity / other problems, but in ARTCU such as facilities were not available. Patients with higher level of education (Mean value:3.02) and higher income level (Mean value:3.09) selected RCKH to receive treatment and patient with low income level mostly preferred to get treatment from ARTCU. However, there was no significant difference in the patient satisfaction at both the centers. Services provided at both of the centers were comparatively same, except for the extra facility of comorbid treatment in RCKH and economic support, free drug distribution and consultation in ARTCU.
Competing Interests The authors declare no conflicts of interest.
ACKNOWLEDGMENTS The authors thank the staff of Department of Medicine, Kasturba Hospital, Manipal University Manipal College of pharmaceutical sciences, Manipal University for their assistance and cooperation during the study period.
Englishhttp://ijcrr.com/abstract.php?article_id=353http://ijcrr.com/article_html.php?did=3531. Organization WHO. Global update on HIV treatment 2013: results, impact and opportunities. 2013.; [Online] Available from: URL: www.who.int/iris/bitstream/10665/85326/1/97892415057 34_eng.pdf
2. NACO (2014) ‘Annual Report 2013-14’; [Online] Available from: URL: http://www.naco.gov.in/upload/2014%20mslns/ NACO_English%202013-14.pdf
3. Osungbade KO, Shaahu VN, Owoaje EE, Adedokun BO. Patients’ Satisfaction with Quality of Anti-Retroviral Services in Central Nigeria: Implications for Strengthening Private Health Services. Journal of Preventive Medicine. 2013;1(3):11-8.
4. United Nations Millennium Development Goals, retrieved 21 September 2013 [Online] Available from: URL: http://www. un.org/millenniumgoals/pdf/report-2013/mdg-report-2013- english.pdf
5. Project Nasah. HIV treatment information and other needs among African people with HIV resident in England. 2003.; [Online] Available from: URL: http://sigmaresearch.org.uk/ files/report2003a.pdf
6. Gupta I, Trivedi M. Willingness to pay for health insurance among HIV-positive patients in India. Appl Health Econ Health Policy. 2014 Dec;12(6):601-10 .
7. The Times of India. Coming soon: Life insurance policy for HIV/AIDS patients - The Times of India [Internet]. 2013 [cited 31 March 2015]. Available from: http://timesofindia.indiatimes. com/india/Coming-soon-Life-insurance-policy-for-HIV/AIDSpatients/articleshow/24558788.cms
8. Starhealth.in. Star NetPlus Insurance |HIV Positive Insurance | HIV Care Plan [Internet]. 2015 [cited 31 March 2015]. Available from: http://www.starhealth.in/starnetplus.php
9. PLHIV satisfaction survey, Midline Assessment Report 2012 -13 [Online] Available from: URL: http://gfatm.indiannursingcouncil.org/PLHIVsatisfactionSurvey 2013.pdf
10. Olowookere SA, Fatiregun AA, Akinyemi JO, Bamgboye AE, Osagbemi GK. Prevalence and determinants of nonadherence to highly active antiretroviral therapy among people living with HIV/AIDS in Ibadan, Nigeria. J Infect DevCtries. 2008 Oct 1;2(5):369-72.
11. Blalock AC, McDaniel JS, Farber EW. Effect of employment on quality of life and psychological functioning in patients with HIV/AIDS. Psychosomatics. 2002 Sep-Oct;43(5):400-4 .
12. Sangowawa A, Owoaje E. Experiences of discrimination among youth with HIV/AIDS in Ibadan, Nigeria. Journal of Public Health in Africa. 2012;3(1):10.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN-0001November30HealthcareCLIMATE CHANGE AND AGRICULTURE NEXUS IN SUB-SAHARAN AFRICA: THE AGONIZING REALITY FOR SMALLHOLDER FARMERS
English5764George Kanyama PhiiriEnglish Anthony EgeruEnglish Adipala EkwamuEnglishClimate change is one of the potent challenges facing smallholder farmers in sub-Saharan Africa in the recent past owing to the pattern and magnitude with which it presents the extreme events such as floods and drought. This review finds a general consensus that climate change is already happening in the region and the projections in the early, mid and end century all point to a much warmer future with highly variable rainfall across the region. These patterns in climate parameters is expected to trigger a negative trend in agricultural production for most food and cash crops in SSA. However, a few locations particularly the highland locations over eastern Africa will be expected to become more suitable for the production of some cereals such as maize leading to increased production. Overall, at present and in the future unless strategic interventions are judiciously implemented smallholder farmers in SSA produce below the optimal levels with considerable yield gaps in nearly all the cereals, legumes and tubers grown. Efforts to unlock the potential of smallholder farmers under the current and projected climate change situation ought to focus on strategic and systemic implementation of; options that yield multiple benefits such as climate smart agriculture, investing in capacity building at both technical and farmer level, creating multiple opportunities for investment capital including availing smallholders with credit as well as mobilizing private financing. Further, investing at the development of functional early and early warning systems, investing in agricultural value chains through a strategic focus on agribusinesses and gaining and strengthening political commitment through a focus on policy and governance in agricultural frameworks and processes. Finally, a no-one fit for all paradigm ought to be upheld at all time while dealing with smallholder farmers in SSA owing to the dynamic and complex farming systems under which they operate.
EnglishAdaptation, Capacity, Institutions, Resilience, RUFORUM, Yield gapINTRODUCTION
Sub-Saharan Africa is vulnerable to climate change for a couple of facts inherent in the region; high natural resource and agricultural dependence; poverty (58.9% living under multi-dimensional poverty (Alkire and Housseini, 2014); inadequate and ailing infrastructure; structural challenges at policy level (Ondige et al., 2013) and limited access and use of relevant and reliable agricultural inputs (Ringler et al., 2010). Understandablythe interaction of the multiple stresses create a higher susceptibility of the region to climate variability and change as well as constraining the region’s adaptive capacity (Connolly-Boutin and Smit, 2015). The impact of climate change on agriculture; food and livelihoods in SSA can no longer be under estimated.
This because there is a general agreement in the scientific community that temperatures have increased, and will further increase in the near term, mid and end century (O’Loughlin et al., 2014; Egeru et al., 2014). The SSA temperatures are expected to increase above the global average (Ringer et al., 2010) with varied performance in rainfall and seasons across the region (Shiferaw et al., 2014). For example, it is expected that rainfall will decrease in northern and southern Africa, increase over Ethiopian and East Africa highlands with increased frequency extreme events over the low lands (IPCC, 2007; Conway, 2009; Ringler et al., 2010). Temperature is particularly projected will increase leading to a level above tolerance range for most of the current crop varieties, cultivars and livestock species (Afenyo, 2015).
The debilitating impacts climate variability and change confers are wide ranging from perceived trigger of conflict (O’Loughlin et al., 2014) to production constraint among smallholder farmers in the region; these have become critical to decipher. Alterations in rainfall intensity (Songok et al., 2011), prevalence of extreme weather events including floods and droughts (Niang et al., 2014; Barasa et al., 2014; Egeru, 2014), spatial and temporal alterations is disease vectors and transmissions including trans-boundary livestock diseases (Chen et al., 2006), increased prevalence of heat events as well as escalation of desertification across the African continent (Reich et al., 2001) are all anticipated.
With a couple of these impacts occurring from time to time, smallholder farmers in Africa are already facing a series of robust negative impacts of climate variability and change on agriculture including among others; losses in crop and livestock productivity; leading to loss of major livelihood defenses and a cyclic poverty (AGRA, 2014). Further, climate projections for most of sub-Saharan Africa reveal potential negative impacts including among others; disruptions in the length of the growing season, constrictions in the livestock-crop suitable locations, potential decline in crop and other agricultural yields with some countries expected to experience up to 50% declines (Boko et al., 2007; Ringler et al., 2010), and changes in agro-biodiversity (Niang et al., 2014). Climate change is also expected to worsen the nutrition challenge in Africa with an additional 132 million people becoming undernourished by 2050 (AGRA, 2014).
Further, it’s been shown that an increase by 1.2 to 1.9 will make more of the continent’s population undernourished by 25% to 95% (central Africa +25%, East Africa +50%, Southern Africa +85% and West Africa +95%) (Munang and Andrews, 2014). Production risks and costs associated with climate change are similarly unceasing. A focused analysis of these risks and costs is pivotal in prioritizing effective investments that will assist adaptation to the espoused changes. Schlenker and Lobell (2010) have showed that changes in SSA's mean aggregate production for maize, sorghum, millet, groundnut, and cassava were likely to be -22, -17,-18, and -8% respectively. Such precise information is vital for decision making on allocation of scarce resources for adaptation relative to many other developmental needs.
However, precise information on climate change is particularly deficient in sub-Saharan Africa, more so, that which is relevant and applicable to smallholder farmers. Thus, farmer decisions often than not are based on past experiences yet the changes particularly occurring are laced with extreme whether that challenge the conventional practices of smallholder farmers. By all indications, climate change is seen as a real potent threat on Africa. All hope is not lost, because even amidst climate change Africa still has potential to feed itself but this requires getting the right mix of the agricultural value chain ‘cocktail’ in Africa right (Munang and Andrews, 2014).
Smallholder farmers and agricultural production in sub-Saharan Africa
Smallholder farmers are a vital artery of food security in subSaharan Africa. Over 80% of the farms in SSA are under smallholder ownership (about 50 million farms) and management and about 70% of whom are female farmers (AGRA, 2014; Schaffnit-Chatterjee, 2014).These farms however consist of small parcels and patches of land with constrained input resources. Subsequently, Africa’s smallholder farmers are often described as ‘resource poor’ (Mignouna et al., 2008). Whereas sub-Saharan Africa is generally ‘perceived’ to have fertile soils, the farming practices escalate the degradation of these soils through nutrient mining activities (Drechsel et al., 2001). Further, production gaps abound; the vertical yield is constrained.
Compared to other regions in world; sub-Saharan Africa's yield per hectare far lags behind in nearly every crop.For example, potatoes production is generally below 10 t/ha for most countries in eastern and central Africa. Even those that are above, their tuber yield riddles with inter-annual variability with an unceasing variability into 2020 (Figure 1 and 2). Further, the scenario from the cereal production is not any better; yields have generally remained stagnated at less than 25% of the potentially attainable yields with many parts of the region merely attaining 1.5 tha but marginal; Figure 3) compared to the potential that is greater than 5 t/ha (AGRA, 2013; Mutegi and Zingore, 2014).
The exception in the trap of stagnated growth in production is southern Africa that experienced a more than 350% increase in yields over a 50 year period (Ward et al., 2014). Thus, it is apparent that SSA is the only region that has failed to improve agricultural productivityfor a couple of reasons that are either directly or indirectly orchestrated including among others; under-investment, poor infrastructure, insecure land tenure, unfavourable price policies and weak institutions (Schaffnit-Chatterjee, 2014).
Smallholder agriculture in the face of climate change in sub-Saharan Africa
Many parts of sub-Saharan Africa are predisposed to climate variabilities and extreme events such as drought with devastating impacts. Regional analysis of extreme climate events particularly drought show an increased presence over the last 20 years with a shortened return period of eastern Africa(Williams and Funk, 2011; Shiferaw et al., 2014). Climate change is certainly making the prevalence of these extreme events over Africa more pronounced (Schmidhuber and Tubiello, 2007; Kahare, 2014). The impacts on crops will be devastating particularly that most of the crops in Africa are already grown close to their limits of thermal tolerance (Conway, 2009). It is also anticipated that a 10-40% risk of failed seasons during major cropping calendar is experience in SSA, climate change will likely make this situation worse (Figure 4;Shiferaw et al., 2014).
It is also expected that by 2025 the per capita water availability will be worsening with an increased water scarcity, stress and vulnerability. By the end of the century, grain crops (that constitute the major staples) will be most affected with up to 72% decline in wheat yields and up to 45% yield reductions in maize, rice and soybean (Figure 5; Adhikar et al., 2015). Smallholder farmers in SSA are also heavily reliant on autonomous adaptation (a reaction of farmers in response to a climate change event (Calzadilla et al., 2013).
A high certainty pertains that climate change, particularly increased temperatures, will negatively affect crop yields in sub-Saharan Africa (Ward et al., 2014). And, had temperatures to stay to the pre-1960 period, only then would a 32% yield gap increase have been possibly observed between SSA and other developing countries (Barrios et al., 2008).In Uganda, coffee production is being affected with further projections showing that the coffee production zones will significantly shrink (Nandozi et al., 2012). Overall, the damage of climate change will remain negative for most crops in SSA (Schlenker and Lobell, 2010).
However, all hope is not lost, some regions in SSA are projected will experience improved agricultural production. Calzadilla et al. (2013) show that in some areas of SSA agricultural production will increase by 25 per cent.This will be associated with expected increase in rainfall in some parts of eastern Africa including the Horn of Africa and central Africa (Collier et al., 2008). Further, within the region there are some islands of potential gains in production. For example maize yield is expected to increase in Kenya and Rwanda in 2030 and 2050 by 15% and 11% in 2030 and 18% and 15% by 2050 respectively.
The gains in Rwanda and Kenya are expected to arise from the beneficial effects of temperature increases that bring growing season temperatures close to optimum in the temperate/tropical highlands (Adhikar et al, 2015). Some 17 GCMs from the Comprehensive Climate Change Scenarios also show that millet will experience a slight increase e (Englishhttp://ijcrr.com/abstract.php?article_id=354http://ijcrr.com/article_html.php?did=3541. Adhikari, U., Nejadhashemi, A. P., and Woznicki, S. A. (2015). Climate change and eastern Africa: a review of impact on major crops. Food and Energy Security, 4(2), 110-132.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN2016January22HealthcareDELAYING POSTHARVEST RIPENING OF TOMATO (LYCOPERSICON ESCULENTUM MILL.) BY USING 2, 4-DICHLOROPHENOXY ACETIC ACID
English6573Duguma DibbisaEnglish Meseret C. EgiguEnglish Manikandan MuthuswamyEnglishThe aim of this study was to evaluate the roles of plant growth hormone (PGH); 2, 4-D to delay tomato fruit ripening under laboratory conditions so as to improve its shelf life and prevent its postharvest loss before reaching consumers. The experimental design was complete random design with three treatment levels of unripe healthy tomato immersed in (30, 50 and 100ppm) of 2, 4-D. The control fruits were immersed with distilled water. All treatments were done in three replications. Quality parameters that serve as indicators of ripening stages such as weight loss, pH, titratable acidity, total soluble solid, pigments (chlorophyll a, chlorophyll b and total chlorophyll), lycopene, total carotenoids, reducing and total sugars were measured over three weeks on weekly basis. Results showed that almost all measured parameters were significantly affected by the application of 2, 4-D; 2, 4-D was found to prevent quality deterioration and rapid ripening of tomato fruits. The effectiveness of PGH appeared to be high at their lower concentrations. Therefore, 2, 4-D may be useful at lower concentrations to delay ripening of tomato fruits and avoid rapid postharvest loss if applied on healthy unripe tomato fruits. However, their impact on other nutritional aspects and human health must be further investigated before application.
EnglishEthylene, Plant growth hormone, Postharvest treatment, Senescence, TomatoINTRODUCTION
Tomato (Lycopersicon esculentum Mill.) has become the most widely grown vegetable in the world being recognized as a reach source of vitamins and minerals. It is also among the most important vegetable crops in Ethiopia. The total production of this crop in the country has shown a marked increase since it became the most profitable crop providing a higher income for small to large scale farmers compared to other vegetable crops (Lemma et al., 1992). However, large portions of tomato it would be lost worldwide after harvest, the major of them are in sub-tropical countries (Javid, 2009). Tomato is one of the important fruit and vegetables highly cultivated in northern and central rift valley areas including Somali Regional States of the country. In recent years, commercial tomato production has significantly expanded since national agricultural strategies began favoring high value cash crops to enhance the need of Growth and Transformation Plan (GTP) of the country (Central Statistical Agency, 2011). The supreme important of tomato production in worldwide is; contributes versatile health benefits and the status of it as a functional food emphasize the need in the daily diet of all, because it is rich in minerals, essential amino acids, sugars, dietary fibers and it is considered to be fairly high in vitamins, vitamin C, flavonoid, lycopene and β-carotene with potential for better quality processing (Naika et al., 2005). To date there is no much information before on preventing postharvest losses of fruits and vegetables in Ethiopia. This study is therefore designed to delay post-harvest fruit ripening of tomato by plant growth regulator (2, 4-D) with different concentrations so as to reduce its loss after harvest until it reaches end users.
MATERIALS AND METHODS
Description of Experimental Site This study was conducted in April 2014 to June 2014. The experiment was carried out at Haramaya University Genetic and Molecular Biology and Microbiology Laboratories. Haramaya University is located at 515 km East of Addis Ababa, Ethiopia at an altitude of 2011 meters above sea level with 9.00 N latitude and 42.00 E longitude. The place has a mean maximum temperature of 25.50 C and mean minimum temperature of 12.260 C (Tekalign, 2005).
Experimental Materials Fruits of known tomato cultivars were obtained from local farmer’s field. The mature green (MG) and Breaker (BR) fruits were obtained and immediately transported in a polystyrene box to the genetic; molecular biology and microbiology laboratories of the university. Fruits were left for 22 hrs (after harvest) at room temperature in order to stabilize ethylene evolution caused by wounding.
Experimental Design and Treatments The experimental design was completely randomized design with three treatments in three replications. Of the collected tomato samples, 80 tomato of uniform size with no bruises or damage were selected for treatments with 30ppm, 50ppm and 100 ppm of 2, 4-D. Fruits were surface sterilized with sodium hypochlorite solution (500 ppm) for 10 minutes so as to reduce fungal infection and air-dried for approximately 15 minutes. After surface sterilization, fruit treatment was done by immersing eight tomato fruits per treatments in a jar containing equal volume of different concentrations of each solution for 15 minutes. The control one was immersed in distilled water in the same way. The fruits were then stored in a carton in laboratory at 13±2ºC. Thereafter, fruits were assessed for different quality parameters such as physiological weight loss, total soluble solids, titratable acidity, ascorbic acid, lycopene, total carotenoids, and chlorophylls, reducing sugars and total sugar every week for three weeks as follows.
Data Collection and Analysis Physiological Loss of Weight Weight loss was determined by using method indicated by Akbudak, (2007) by periodically (on 7th, 14th, and 21st days of storage) weighing tomato fruits by digital balance (Denver Instrument XL-1810). Percentage weight loss was calculated using the following formula.
Ascorbic Acid Analysis The ascorbic acid content was determined by the 2, 6- dichlorophenol indophenol methods A.O.A.C, (2000). An aliquot of 10 ml tomato juice extract was diluted to 50 ml with 3 percent metaphosphoric acid in a 50 ml volumetric flask. The aliquot was then centrifuged (Model, Z300, 580W, 3052 Nm, German) for 15 minutes and titrated with the standard dye to a pink end point (persisting for 15 second). The ascorbic acid content was calculated from the titration value, dye factor, dilution and volume of the sample.
pH, Titratable Acidity and Total Soluble Solid Measurements The digital pH meter (model–ME 962P, India) was used to determine the pH value of tomato fruit samples as per the method described by A.O.A.C, (2000) while the titratable acidity was determined by a standard titrimetric method. For the determination of titratable acidity, 20 grams of extracted tomato juice was mixed with 250ml of distilled water. In the presence of phenolphthalein as an indicator, the mixture was titrated by adding 0.1 N NaOH until the break of light pink colour (pH 8.2) was observed for 15 seconds. The volume of NaOH added to the solution was multiplied by the correction factor of 0.064 for the calculation of titratable acidity as percentage of citric acid.
Titratable acidity was expressed as percentage of citric acid (A.O.A.C, 2000). The total soluble solid content of the fruit was determined by using refractometer (Atago Co., Tokyo, Japan). For this, the homogenous sample was prepared by blending the tomato flesh in Kenwood blender, (Model, BC311 P.R.C. China). The sample was then thoroughly mixed and a few drops were taken on prism of refractometer and direct reading was taken by reading the scale and in expressed as ºBrix as described in (A.O.A.C, 2000).
Ethylene Production Determination Five fruits per treatment were sealed in a glass jar (225 ml) for 30 min. Thereafter, 1ml of the gas was withdrawn from the overhead space using a 1ml syringe. Ethylene concentration was determined using instrument called gas chromatograph (Model, CP, 9002, German) equipped with a flame ionization detector and a stainless column packed with activated alumina. The oven and detector temperatures were 80 and 120ºC respectively. Known concentration of pure ethylene was used to confirm the identity of ethylene in the sample and was expressed as µKgL-1h-1 (Arnold et al., 2005).
Determination of Chlorophylls, Lycopene and Total Carotenoids Determination was based on a Spectrophotometric analysis following the method developed by Nagata, (1992) for the simultaneous determination of chlorophylls and total carotenoids in tomato fruit. Sixteen millilitres of acetone–hexane (4:6) solvent was added to1g of tomato homogenates. For this, the homogenous sample was prepared by Kenwood blender, (Model, BC311 P.R.C. China). The homogenate was centrifuged at 5000 rpm using centrifuge (Model, Z300, 580W, 3052 Nm, German) for 10 minutes at 20°C. Then after an absorbance was measured at 663, 645, 505, 663.6, 646.6,470 and 453 nm in a Jenway model 6100 spectrophotometer. Lycopene, total carotenoids and chlorophyll contents were calculated according to the equations indicated below, and the final results were expressed as µg/g for chlorophylls and mg/g for antioxidants.
Sugar Analysis Reducing and total sugars were estimated by using the techniques of Seyoun, (2007). Liquidized fresh tomato (10g) was added to 15ml of 80 percent ethanol, mixed and heated in boiling water bath for sufficient time until the ethanol odor went off. After extraction, 1ml of saturated Pb (CH3 COO) 2 and 1.5ml of NaHPO4 were added and the contents were mixed by gentle shaking by vortex shaker. After filtration, the extract was made up to 50 ml with distilled water. An aliquot (1ml) extract was diluted to 25ml with 1ml copper reagent in a test tube and heated for 20 minutes in a boiling water bath. After heating, the contents were cooled under running tap water without shaking.
Arsenomolybdate colour reagent (1ml) was added, mixed, and made up to 10ml with distilled water and left for about 10 minutes to allow colour development. Thereafter, the absorbance was determined using spectrophotometer at 540 nm. For total sugar determination, sugar was first hydrolyzed with 1N HCI by heating at 70o C for 30 minutes. After hydrolysis, total sugar was determined following the same procedure employed for the reducing sugar. A blank was prepared using distilled water.
Data Analysis The data obtained from the study were analyzed using SAS 9.1.3 statistical software. Mean separation was performed by using least significance difference (LSD) at (P ≤ 0.05) level. The data were analyzed using Bartlett’s test.
RESULTS AND DISCUSSIONS
Effects on Physiological of Weight Loss
When measured after one week of storage, there was a significant difference observed between the different concentrations of 2, 4-D treated tomato fruits and their controls in weight loss. Among the different concentrations of 2, 4-D treated tomato fruits, lower weight loss were observed in 50ppm and 100ppm concentrations, whereas higher weight loss were observed in 30ppm concentration. Weight loss from control tomato fruits was significantly higher than both 2, 4-D treated tomato fruits (Figure 1). On the 14th days of storage, there was a significant difference between the difference concentrations in 2, 4-D treated tomato fruit and their control in weight loss. A comparison observed within their difference concentrations of by 2, 4-D treated tomato fruits at day 14th revealed the same trend with day seven treatments. However, the amount of weight loss in the control of tomato fruit was gradually increasing and it was significantly higher than of by 2, 4-D treated tomato fruits (Figure 1). Tomato fruits treated with by 2, 4-D showed reduction in weight loss significantly as compared to control group after 21st days of storage. There was a significant difference between the difference concentrations of 2, 4-D treated tomato fruit and their control in weight loss.
However, gradual weight losses of tomato fruits were observed in control group throughout the days of storage (Figure 1). The weight loss of tomatoes fruits may happen mainly due to transpiration and respiration Bhowmik, (1992). Respiration causes a weight reduction because a carbon atom is lost from the fruit each time as carbon-dioxide molecule was produced from an absorbed oxygen molecule and evolved into atmosphere Bhowmik, (1992). As compared to the control fruits, the less weight loss observed by 2, 4 -D treated tomato fruits accords with results of Lester, (1999) who reported that the application of calcium chloride to plums maintains membrane integrity and reduces weight losses in fruits and vegetables. The reduction in less weight loss of fruit and vegetable was due to their anti-senescent processes (Sudha et al., 2007).
Effects on pH Values On the 7th day of storage, there was insignificant difference between the different concentrations of 2, 4-D treated tomato fruits and their controls in pH values. However, the pH value in control tomato was significantly higher than that of both 2, 4-D treated fruits. The pH value did vary between the three different concentrations of 2, 4-D for tomato fruits treatments. Among the three different 2, 4-D concentrations, higher pH value was seen in 30ppm and the lower pH value was seen in 50ppm and 100ppm concentrations respectively (Figure 2).
On the 14th day of storage, there was a significant difference observed between the different concentrations of 2, 4-D treated tomato fruits in pH values. However, a significant different was observed between 2, 4-D treated fruits and their controls. Tomato fruits treated with the highest 2, 4-D concentrations had yield higher pH value than the lower. On the 21 days of storage, pH value showed decreased and the obtained results were statistically significant different (P≤ 0.05) (Figure 2). Generally, the pH values of tomato fruits treated by 2, 4-D was found to decrease and relatively to be lower than that of the controls group in all the days of storage. This study, therefore, showed that treatment of tomato fruits with 2, 4-D has significant effect on pH, and their effectiveness is in concentration dependent manner. The finding of this study is reliable with the findings of Andrea et al.,(1999) who reported that application of calcium chloride on apple fruits reduces the pH of fruits during their storage period.
Effects on Ascorbic Acid On the 7th day of storage, there was significant difference in ascorbic acid (AA) contents between tomato fruits treated with different concentrations of 2, 4-D and their control. Among the 2, 4-D treatments the lower value of ascorbic acid content was seen in 50ppm (9.66%) and 100ppm (7.96%) concentrations respectively and higher amount of ascorbic acid was found in 30ppm (11.90%). Ascorbic acid content was dramatically decreasing with increasing concentrations of 2, 4-D treated tomato fruit (Figure 1). The same trend was seen with the treatment at day 14th (Figure 1). On the 21st days of storage, there was a significant different has been seen between the concentrations differences in 2, 4-D treated tomato fruits and their control in ascorbic acid contents.
The content of AA was decreased during ripening stage but not as much as the control group. This decrease might be due to its antioxidant function when the ripening cells absorb high amount of oxygen; this was the result of an increase in respiration, which was the characteristic of climacteric fruits (with an autocatalytic synthesis of ethylene) (Macheix et al., 1990). The difference in the ascorbic acid levels among fruits in the different treatments could be due to the effects of respective treatments on ripening as described for other parameters in the earlier sections. In case of this study on 21st day fruits grouped under control were highly degraded while compared to the 2, 4-D treatments.
The result of this study is agreed with the report of ?16? and ?17? who indicated a decline in AA contents of tomato fruits during ripening. The slow degradation of ascorbic acid by 2, 4-D might be due to the lowering of respiration rate of fruits and vegetables or the conversion of ascorbic acid in to dehydro ascorbic acid content in the presence of enzyme ascorbinase as reported by (Sapers et al., 1990).
Effects on Total Soluble Solid On the first days of treatments, the total soluble solid (TSS) was observed statistically insignificant different between the different concentrations of 2, 4-D treated tomato fruit and their control group. Among the different concentrations of 2, 4-D the total soluble solids of the control tomato fruit was significantly higher than that of the other fruits hence PGH can effectively delay the ripening processes of tomato fruit during their storage period (Figure 2). The same was true day 14th storage of tomato fruits however the TSS value were increased when it was compared with day seven treatments (Figure 2). On the 21st days of storage period of tomato fruits, there was a significant different between the different concentrations by 2, 4-D treated tomato fruits and their control in TSS contents but it was declined. However, by 2, 4-D treated tomato fruits the observed values were statistically insignificant at (P≤0.05).
Changes in the TSS values of treated and untreated (control) tomato fruits during their post-harvest storage which was presented in (Figure 2) show that a control sample without treatment had significantly highest value in TSS (i.e. 7.73 ºBrix). In general, the TSS values of tomato fruit treated by 2, 4-D treatments were lower than that of control group.
The reduction in the TSS value by 2, 4-D treated tomato fruits were perhaps due to the effect of 2, 4-D which slowdown the respiration rate and metabolic activity of the treated fruits, hence it retarding or delaying the ripening progression Kader, (2002). In this regard the slower respiration rate of treated tomato fruits slows down the synthesis of ethylene and use of metabolites resulting in lower TSS value due to the slower change from carbohydrates to sugars.
Effects on Titratable Acidity There was highly significant (P ≤ 0.05) different in the content of titrable acidity of tomato fruits receiving vary concentrations of 2, 4-D throughout the storage period. In all storage days of the treatments, the amount of titratable acidity increased as ripening progressed. On the day 7th treatments by 2, 4-D the data obtained showed that no difference between the concentrations of 30pm and 50ppm. On the 14th and 21st day of storage period the TA contents of tomato fruits increased up to day 14th and then declined in day 21st.
Therefore, 2, 4-D treatments on tomato fruits showed effective in decreases of TA contents as compared to that of the fruits of control group hence it helps in delaying the ripening process (Figure 3). Generally, the retention of acidity by 2, 4-D treated fruits might be due to reduction in metabolic changes of organic acid into carbon dioxide (CO2 ) and water (H2 O).
These results are in agreement with those of Ibrahim (2005) who reported that higher retention of acidity of the calcium chloride treated apricot during its storage period. The current study in line with the work of (Cheour et al.,,1991) while reported the quantity of organic acids expressed as citric acid decreased in strawberry fruits treatment with calcium chloride (CaCl2 ) during storage.
Effects on Chlorophyll Pigments (Chl a, Chl b and Total Chlorophyll) Chlorophyll and its derivatives have important anti-carcinogenic properties which mean they have the ability to help prevent cancer by neutralising free radical oxidants in the human body. The result obtained from the present study shows a significant difference on chlorophyll a contents of tomato fruits treated by the different concentrations of 2, 4-D and their control at the first day of storage. For 2, 4-D treatments the low amount of chlorophyll a accumulation were recorded in 50ppm (0.045µg/g) and 100ppm (0.036µg/g) respectively and the high amount were documented in 30ppm (0.208µg/g).
The result also showed that as the concentration increases the amount of chlorophyll a content were decreased and vice versa (Figure 3). On the 7th days of storage, the degradation of chlorophyll a contents were increased throughout the experimentation of 2, 4-D treated tomato fruit and their control when compared with the day seven treatments. It was a highly significant difference at (P ≤ 0.05) between all the three difference concentrations of 2, 4-D treated tomato fruits. The higher chlorophyll a content was seen at the lower concentrations of 2, 4-D treated tomato fruits at 30ppm (0.208µg/g) (Figure 3). For the day 21st treatments, results were revealed the same trend with the day seven treatments. However, the degradation of Chlorophyll a pigments was increased with the addition of storage day (Figure 3).
On the 7th days of storage, there was highly significant difference has been observed in Chlorophyll b contents between the different concentrations of 2, 4-D treatments and their control. Among the difference concentrations of 2, 4-D, the higher amount of Chlorophyll b content was observed in lower concentration 30ppm (0.226µg/g) and lower amount was observed in the other (0.044µg/g) and 100ppm (0.113µg/g) concentrations respectively. For the day 14th treatments, the results were revealed the same trend with the day 7th treatments. However, at lower concentrations of 2, 4-D treated tomato fruit the chlorophyll b degradation was retained in contrast highly degraded at higher concentrations (Figure 4). On the twenty one days of storage, there was also highly significant variation obtained between all the treatments by 2, 4-D treated tomato fruits in chlorophyll b and their control.
The result was revealed the same trend with the day seven and fourteen treatments. However, the chlorophyll b degradation was found to be significantly increased in all treatments as compared to their control group (Figure 4). For total chlorophyll treatments at a day seven, there was significance different between the different concentrations of 2, 4-D treated tomato fruit and their control.
The Higher pigment content was found at the lower concentrations of 2, 4-D treated tomato fruit and low amount was found at higher concentrations of 2, 4-D treated tomato fruit. Hence at lower concentrations of the 2, 4-D treated fruit it can be retard the pigment degradation and have had an important implication for delaying post-harvest deteriorations of fruit and vegetable (Figure 4). On the14th days of storage, the total chlorophyll was gradually decreased as compared with at the seventh day treatments of 2, 4-D treated tomato fruits.
Among the difference concentrations of 2, 4-D treated tomato fruits, a varied amount of total chlorophyll was observed in varied concentrations. For 2, 4-D treatments, the high amount of total chlorophyll also retained at 50ppm (lower) concentrations (0.067µg/g) and highly degraded at higher concentrations with 2, 4-D treatments. For the 21st day treatments of storage, the same trend was seen with the day 7th and 14th (Figure 4).
Generally, the quantitative analysis of photosynthetic pigments indicates that, the more accumulation of pigments was observed in 2, 4-D treated fruits. In contrast, control fruit exhibit weaker stimulation on photosynthetic pigments accumulation. In all treatments of tomato fruits, the result showed statistically significant difference observed (P≤0.05). As the current study shows an application of 2, 4-D on tomato fruit simultaneously delayed the degradation of chlorophylls pigments (degreening) and delays the ripening process of tomato fruits.
Effects on Lycopene, Total Carotenoids and Sugar Contents On the 7th day of storage, significant variation was seen in lycopene pigment between the different concentrations of 2, 4-D treatments and their control. The amount of total carotenoid measured in control tomato fruits was significantly higher than that of 2, 4-D treated tomato fruits. The amount of reducing sugar was significantly higher in control tomato fruits than that of 2, 4-D treated tomato fruits, and significant different was observed between the different concentrations of 2, 4-D (Figure 6). On the 14st day of storage, significant difference was seen in lycopene pigment between the different concentrations of 2, 4-D treatments and their control.
The amount of total carotenoid measured in control tomato fruits was significantly higher than that of 2, 4-D treated tomato fruits. The amount of total carotenoid measured at the higher concentrations of 2, 4-D was significantly lower than the two lower concentrations. The amount of reducing sugar was significantly higher in control tomato fruits than that of 2, 4-D treated tomato fruits (Figure 6). On the 21st day of storage, significant difference was seen in lycopene pigment between the different concentrations of 2, 4-D treatments and their control.
The amount of total carotenoid measured in control tomato fruits was significantly higher than 2, 4-D treated ones. The amount of reducing sug ar was significantly higher in control tomato fruits than that of 2, 4-D treated tomato fruits (Figure 6). Lycopene and carotenoid are increase gradually with duration of storage Toor and Savage, (2006). Increased levels of lycopene in tomato during storage might be due to ripening advancements of tomato fruits and conversion of chloroplasts to chromoplasts. The increasing in redness of tomatoes during ripening is due to lycopene accumulation, in association with the internal membrane system Toor and Savage, (2006). In general, the increment of total carotenoid as well as reducing sugar contents of treated fruits by 2, 4-D showed that the tomato fruit tends to be ripening stages.
This is due to the breakdown of polysaccharides into water soluble sugar hence increases in the sugar accumulation content as (Neeta et al., 2010). On the 7th day of storage, significant difference was seen in reducing sugar between the different concentrations of 2, 4-D treatments and their control. The quantity of reducing sugar measured at the highest level of 2, 4-D concentrations was significantly higher than the two lower concentrations and significant difference was seen between the different concentrations of 2, 4-D treated tomato fruit. The amount of reducing sugar was significantly higher in control tomato fruits and the result showed significant difference (P≤0.05) between different concentrations of 2, 4-D (Figure 6).
For the day 14th treatments, result also showed significant difference in reducing sugar between the different concentrations of 2, 4-D treatments and their control. The amount of reducing sugar measured at the highest concentration of 2, 4-D was significantly higher than the two lower concentrations by 2, 4-D treatments (Figure 6). Statistically significant difference was observed in total sugar content of tomato fruits treated between the three concentrations of 2, 4-Dand control group on the 7th day of storage. However, high total sugar accumulation was observed at and 30ppm for 2, 4-D concentrations, and low total sugar accumulation was recorded for 2, 4-D at 100ppm, respectively (Figure 6).
On the14th day of storage, there was highly significant difference in total sugar between the different concentrations of 2, 4-D treated tomato fruits. The amount of total sugar contents was increased in 2, 4-D treated tomato fruits but, it was lesser than that of the control. The treatments of tomato fruit by 2, 4-D, the sugar analysis was found to be lower than that of the control group hence, 2, 4-D treatment of tomato fruits was delayed the ripened and deterioration and have had an important implication in postharvest managements (Figure 6). On the 21st days of storage the amount of total sugar contents was increased in control tomato fruits and less in 2, 4-D treatments.
There was highly significant variation observed between difference concentrations of the treated tomato fruits by 2, 4-D. The higher amount of total sugar content was observed for 2, 4-D 30ppm concentrations. In general, as concentration increases the amount of total sugar content was increased by 2, 4-D treated tomatoes. Starch is completely hydrolyzed into soluble sugar such as glucose; fructose and sucrose as ripening of tomato fruit was carried out throughout the storage. So, author report that the current study indicated that the treatment of 2, 4-D with varying concentrations delay the breakdown of polysaccharides into different sugar molecules hence, it delays the ripening process of tomato fruits.
Effects on Ethylene Production Treatment of tomato fruits with 2, 4-D significantly reduced ethylene production as compared to control throughout the storage periods (Figure 7). In control groups, ethylene concentration found to sharply increase with increasing of storage days. Though not as clear as in the case of control groups, increasing trend was also observed in ethylene concentration with increasing days of storage period in fruits treated with PGH. Generally, fruits treated with different concentration of 2, 4-D produced less ethylene. The result of this study is in line with the work of (Arnold et al., 2005) who reported that the ripening of climacteric fruits exposed to 0.07μLkg- 1 h-1 and 0.11 μLkg-1h-1 of 1-MCP delayed by at least 13 days after treatments.
CONCLUSIONS Depending on the data obtained from the study it may be concluded that postharvest application by 2, 4-D treatments is helpful to prevent rapid postharvest loss of tomato up to 21st day. Based on this finding, the following points are recommended:
I. Further research with different concentrations of the same hormones in sole and combinations must be carried out to come up with optimum concentrations that enhance shelf life of tomato fruits.
II. Stakeholders of the area need to be trained about the postharvest treatment and techniques to extending postharvest managements of fruit and vegetable crops.
ACKNOWLEDGEMENT The authors acknowledge Haramaya University and Ethiopian Ministry of education for financing this work. Authors also acknowledge the immense help received form the scholars whose articles are cited and including 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.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN2016January22HealthcareFOOD AVAILABILITY INFLUENCES THE SEASONALITY OF BIRD COMMUNITY IN TROPICAL FOREST, WESTERN GHATS
English7483T. NirmalaEnglishSeasonal changes of bird communities in relation with food availability were studied in the mixed dry deciduous forest (MDDF) of Western Ghats. Bird population was estimated using variable width line transect method. Vertical distribution of foliage was sampled in each transect. 51 species of plants comprising 255 individuals were marked for phenological studies. Sweep sampling, visual count, mechanical knock down, light trap, aerial trap and pitfall trap were used for the estimation of arthropods. Bird abundance was high during north-east monsoon and low during south-west monsoon. Total number of species during south-west monsoon was 90 (63%). The main winter visitors were Lesser Whitethroat, Dull Green Leaf-warbler, Blyth’s Reedwarbler and Brown Shrike. Species richness was higher during northeast monsoon. Bird Species diversity was found to be greater in MDDF. Winter visitors were high during northeast monsoon. Abundance of birds during different seasons was positively correlated with increasing winter visitor (r = 0.993, p = .001) and this community was largely dominated by insectivore guild. The abundance of arthropod influenced the bird species richness significantly and rainfall showed significant positive correlation with richness of birds. Insect and bird abundance showed significant positive correlation. Increase of Young and mature leaf had no significant correlation with bird abundance. There was a positive significant correlation between Foliage Height Diversity and Bird Species Diversity in all the seasons except summer proving “Higher foliage profile layers harbour more species”.Total abundance of birds was significantly correlated with total insect abundance.
EnglishINTRODUCTION
The community composition and densities of bird populations showed spatial and temporal variation due to food resource availability (Hilty 1980, Woinarski and Cullen 1984, Pyke 1985, Levey 1988, Innes 1989, Koen 1992 and Poulin et al. 1994). Besides, climatic factors were also found responsible for such variation in bird species composition (Price 1979, Vijayan 1984) along with time and space (Karr 1971, Greenberg 1981, Loiselle 1988, Blake and Loiselle, 1991). Seasonal variation in the abundance of a species is an adaptive phenomenon (Koen, 1992). The abundance and seasonal fluctuation of insects play a major role in determining the seasonality and biological cycle of the organisms, which are dependent on them for food as majority of the terrestrial birds, are insectivorous. The floral species diversity (Sparks and Parish 1995, Arun 2000), bird (Vijayan et al. 1999) and arthropod abundance (Gunnersson 1996, Arun 2000) influences bird seasonality. Seasonality of birds was scarcely documented in Western Ghats except (Jayson and Mathew 2000). Hence, an attempt was made during 1999-2001 in Anaikatty Hill to monitor the seasonal changes of bird community in the mixed dry deciduous forest (MDDF) with the following objective. • To identify the determinants of the seasonality of bird communities in Anaikatty.
METHODOLOGY Study area Anaikatti Hill (foothills of the Nilgiris in the Nilgiri Biosphere Reserve, Western Ghats), the mixed dry deciduous forest (MDDF) is situated between 760 39’ and 760 47’E and from 110 5’ to 110 31’N, at an elevation of about 610-1200m above MSL. The MDDF is dominated by plant species such as Acacia leucophloea, Ziziphus mauritiana, Chloroxylon swietenia, Albizia amara, Tamarindus indicus, Albizia lebbeck, Acacia polyacantha, Diospyros ferrea, Cassia fistula and Commiphora caudata. Major shrubs are Chromolaena odorata, Elaeodendron glaucum, Pavetta indica, Lantana camara, Randia dumetorum, Premna tomentosa, Flacourtia indica and Mundulea sericea. Opuntia dillenii and Euphorbia antiquorum are common Succulents.
Methods
Bird population was estimated using variable width line transect method following Bibby et al. (1993). A kilometer length of four permanent transects were laid and marked at every 10m distance. Census was carried-out thrice a month in each transect, early in the morning, half an hour after sunrise in all the seasons and time is limited to one hour. Species diversity and evenness, species richness and relative abundance were determined for each habitat. Foliage Height Diversity (FHD): Vertical distribution of foliage was sampled in each transect of 1 km following the method of MacArthur and Horn (1969) with very little modification as adopted by Daniels (1996) and Gokula (1998). At every 50-m interval, a circular plot of 15-m radius was established. The centre of the circle was considered as the centre point from where an addition of 12 points at every 5m interval on four cardinal directions was established. Ten such similar samples were repeated in all transects. A total of 520 points (10 plots in each transect and 13 points per plot) were made for the vegetation profile study.
From these measurements, the foliage height diversity (FHD) in each stratum was determined using Shannon’s index. Similarly bird species diversity (BSD) was also calculated at each vertical stratum and correlated with foliage height diversity. Plant phenology: Altogether, 51 species of plants comprising 255 individuals were marked for phenological studies. Thirtysix species were selected (plant species preferred by birds for food) and marked with aluminium tag and monitored once in a fortnight for their phenology for two years. The vegetative phase (young leaf and matured leaf=100%) and reproductive phase (buds, flowers, unripe and ripe fruits=100%) of the marked plants were estimated separately in percentages. The data were averaged for each species and given the phenological status during the study period. This data was used to compare frugivore and nectarivore abundance. Arthropod sampling methods: Six major sampling methods were used in the field for the regular sampling of insects, namely sweep sampling, visual count, mechanical knock down, light trap, aerial trap and pitfall trap following Southwood (1971) with slight modifications.
The arthropod collected by different sampling devices per fortnight were identified upto order following Imm’s classification (Richards and Davies 1977). Sweep sampling: The sweeps were done during the morning hours after 08.30 hour along a kilometre length of four transects (laid for bird census) in the mixed dry deciduous forest using sweep net. In total, two hundred and fifty sweeps were taken from each transect at every 100m distance The approximate area of coverage per sweep sampling was 1x10 m2 . Knock down: Mechanical knockdown was made using a bamboo pole and the insects were collected on a tray (1m x 1m). For uniformity, 10 beats were made as a standard for each sample to dislodge the insects. Ten such samples were collected from the fixed places (shrub) in each transect. Light trap: A fabricated light trap based on the design of Mathew (1990) was employed for the purpose of sampling the nocturnal insect abundance. The trap was operated only for an hour during the early night hours (19th hour) in each transect. Aerial trap: Plastic containers filled partly with water and preservative were hung in the canopy for two days (48 hours). 10 such traps per transect at every 100 m distance (60 traps/season) were used to collect aerial arthropods (Erwin T.L and Scott J.C,1980).
Pit-fall trap: Plastic containers filled partly with water and preserving solution were placed on the surface of the ground to get surface dwelling arthropods. 10 such traps were installed at every 100 m distance per transect (60 traps/season) (Erwin T.L and Scott J.C,1980). Visual count /Transect count: Various authors (Pollard 1977, Pollard and Yates 1993, Ishii 1993, Natuhara et al. 1996, Arun 2000) have tested the reliability of this method for estimating butterfly abundance. All the butterflies encountered within 10 x 5-m area were counted and recorded. The count was made in the morning hours (between 08.30 and 11.30 hour) at every 100 m distance along each transect. Abiotic factors, namely minimum temperature, maximum temperature, rainfall, number of rainy days, mean relative humidity and windspeed were obtained from the Meteorology Department, Chennai. Biotic factors affecting insect abundance such as phenology of plants and abundance of birds were monitored twice a month.
Data Analysis Four seasons noticed in Anaikatty were southwest monsoon (June-August), northeast monsoon (September-November),winter (December-February) and summer (March-May). Major statistical tests were employed in analysing the data using the statistical package SPSS (Norusis 1994) and SPDIVERS.BAS.
RESULT Seasonality of birds Bird abundance was high during north-east monsoon in MDDF and low during south-west monsoon (Figure 1). Total number of species during south-west monsoon shared by MDDF was 63%. The main winter visitors were Lesser Whitethroat, Dull Green Leaf-warbler, Blyth’s Reed-warbler and Brown Shrike. This was followed by the flocks of altitudinal migrants such as Black Bulbul, Grey-headed Myna, Rosy Pastor, and Blossom-headed Parakeet, and a few locally moving Grey Drongo and Verditor Flycatcher and the resident birds such as Red-whiskered Bulbul, Purple Sunbird, Loten’s Sunbird and Paradise Flycatcher which breed here during north-east monsoon.
Seasonality of birds based on migratory status The number of species increased consistently to reach the peak (90) during northeast monsoon and found lowest in summer (Table 1). The resident (with local movement) species were the highest during summer while winter visitors were high during northeast. No winter visitor was recorded during southwest monsoon 1 and 2. Total abundance of birds during different seasons was positively correlated with the increasing residents (r = 0.836, p < 0 .01, N = 8). The Common Iora was the most abundant species during southwest 1, Whitebrowed Bulbul was the first dominant species during northeast 1 and 2, summer 1 and 2 and southwest 2 and the Blyth’s Reed Warbler was the dominant species during winter 1 and 2. Abundance of birds during different seasons was positively correlated with increasing winter visitor (r = 0.993, p = .001) and resident with local movements (r = 0.862, p = 0.006).
Seasonality of bird abundance on feeding guild composition The avifauna was largely dominated by insectivore guild through out the study period followed by omnivore and frugivore. A definite seasonal pattern existed in all the six guilds (Figure 4). Insectivores occurred all through the seasons with the maximum during winter and minimum during northeast monsoon. Omnivores and carnivores were highly abundant during southwest monsoon and summer and lowest during winter. Frugivores were highly abundant during northeast monsoon and low during southwest monsoon.
On the contrary, granivores were abundant during southwest monsoon and lowest during northeast monsoon. Nectarivores were found low during winter and high during southwest monsoon. Variation in the total abundance of birds was correlated with the abundance of different guilds in various seasons. Nectarivores (r = 0.795, p = 0.018), insectivore (r = 0.726, p = 0.041) and frugivore (r = 0.952, p = 0.0001) showed significant positive correlation with the total abundance of birds while the other guilds such as granivore, carnivore and omnivore had no such significant correlation. Lepidoptera, Orthoptera and Diptera were significantly higher in the mixed dry deciduous forest during winter, whereas Hymenoptera was the highest during north-east monsoon and Hemiptera was high during summer (Figure 5). Legend: Figure 5. Seasonal fluctuation of arthropod abundances in the mixed dry deciduous forest during different seasons such as Southwestmonsoon (SWmonsoon), Northeast monsoon (NEmonsoon), Winter and Summer between 1999 – 2000 (1) and 2000-2001 (2).
Role of ecological factors on Arthropod Among the six abiotic factors namely minimum temperature, maximum temperature, rainfall, rainy days, mean relative humidity and windspeed, Only mean relative humidity showed significant positive correlation. The abundance of arthropod was influenced by the biotic factors such as plant species in fruit that showed significance positively with the abundance of insects (Table 2). Plant species in flower and phenology of young leaf showed significant negative correlation with the abundance of arthropod which depicts that when young leaves are more, arthropod are low and the vice versa. The effect comes after flushing of leaves and increase of arthropod occurred with a lag period after rain during north-east monsoon which might be the reason for their peak during winter. The abundance of arthropod influenced the bird species richness significantly (Table 2).
Bird and factors Role of abiotic factors on birds Among the six abiotic factors, maximum temperature, minimum temperature and windspeed showed significant negative correlation with both species abundance and richness (Table 3). Rainfall showed positive correlation with abundance of birds (r= 0.407, p= 0.048). Also rainfall showed significant positive correlation with richness of birds (r = 0.605, p = 0.002).
Bird and insect Bird and insect abundance fluctuated highly in Anaikatty hills (Figure 6), 44% of the Anaikatty birds depend on the insects. Bivariate test of Pearson correlation coefficient was used to test the relation between bird and insect abundance. They showed significant positive correlation (r = 0.438, P = 0.032) suggesting that insect abundance positively influenced the abundance of birds. Insectivore bird species with insects showed positive correlation with total insect abundance (r= 0.851, p = 0.0001). Each insectivore bird species was correlated with each insect order and the results are given in Appendix 1.
Bird and vegetation Increase of fruiting plants also increased the abundance of birds (Table 3) as total abundance of birds correlated significantly with frugivores (r = 0.952, p = Englishhttp://ijcrr.com/abstract.php?article_id=356http://ijcrr.com/article_html.php?did=3561. Arun, P. R. (2000): Seasonal variations in the abundance of insect groups in a natural moist deciduous forest of Western Ghats. Ph. D. Thesis, Bharathiar University, Coimbatore.
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27. Mathew, G. (1990): Studies on the Lepidoptera fauna. In. Ecological studies and long-term monitoring of the biological processes in the Silent Valley National Park. Report submitted to Ministry of Environment, Govt. of India, Kerala forest Research Institute. pp. 239.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524182EnglishN2016January22HealthcareA COMPARITIVE STUDY BETWEEN VAGINAL HYSTERECTOMY AND LAPAROSCOPICALLY ASSISTED VAGINAL HYSTERECTOMY
English8490Kavitha G.English Renukadevi B.English Rathna RamamurthiEnglish Rajarajeshwari S.EnglishIntroduction: Hysterectomy is the second most common surgical procedure performed by an Obstetrician and gynecologist next to Cesarean section. It can be performed by various methods, depending upon the pathology in the uterus, size of the uterus and the skill of the surgeon. Though there are a lot of advances in laparoscopic surgeries, most of the senior gynecologists feel that the laparoscopic hysterectomy have to replace abdominal hysterectomies but not vaginal hysterectomy and when ever feasible vaginal hysterectomy should be the method of choice for most cases of benign gynecological disease requiring hysterectomy. Objectives: The objective of the study is to compare the surgical and immediate post operative outcome for vaginal hysterectomy (VH) with those of laparoscopic assisted vaginal hysterectomy (LAVH). Methodology: This was a retrospective comparative study conducted among 200 patients who underwent vaginal hysterectomy/ (VH) laparoscopic assisted vaginal hysterectomy (LAVH) for various indication in the department of obstetrics and gynecology of Velammal medical college hospital and research centre from august 2012 to august 2015 (over period of 3yrs). The data were collected from medical records of the patient. The patients were divided into two groups of 100 each. Patients who underwent vaginal hysterectomy were grouped as VH and patients who underwent laparoscopic assisted vaginal hysterectomy were grouped as LAVH. The data was collected in terms of age, parity, history of previous surgeries, indications for surgery, operative time, and blood loss during surgery, intra-operative complication, post-operative complication and duration of hospital stay. The results were statistically analyzed with SPSS 16.0 version. Results: The baseline characteristics of both groups were similar. The mean operative time for the VH group was 90 minutes and 148 minutes for LAVH group (p=0.00). The mean blood loss for VH group was 152ml and 66ml for LAVH group (p=0.00). The incidence of vault hematoma was significantly more in the VH group and paralytic ileus was significantly higher in LAVH group. There was no significant difference between both groups in the incidence of hemorrhage, visceral injury and post operative pyrexia. Conclusion: Vaginal hysterectomy should be the preferred route of hysterectomy for benign conditions of the uterus whenever feasible, as it is associated with shorter operative time and early disappearance of post-operative pain.
EnglishVaginal hysterectomy, Laparoscopic assisted vaginal hysterectomy, Operative time, Post-operative pyrexia, Vault- hematoma, Paralytic ileusINTRODUCTION
In a country like India, were resources are limited, women generally refuse medical management and conservative surgical management for most of the benign uterine pathology, so hysterectomy has become one of the most commonly performed gynecological operation. Up to 20% of women undergo hysterectomy by the age of 601. Most common reasons for performing hysterectomies are fibroid uterus, menstrual irregularities, endometrial hyperplasia, cervical dysplasia, genital malignancies, endometriosis, adenomyosis and genital prolapse.
Traditionally uterus has been removed by either the abdominal or vaginal route. Nowadays, we distinguish three different surgical approaches to hysterectomy: vaginal, abdominal, and laparoscopic. There is no universal agreement among gynecologist about the optimal route of hysterectomy for various uterine pathologies. Origin of Vaginal hysterectomy dates back to the ancient times. There is reference that vaginal hysterectomy was performed by Themison of Athens in 50 BC2 . The first authenticated vaginal hysterectomy was performed by the Italian anatomist Berengario da Carpi of bologna in 15073 .
The first planned vaginal hysterectomy for non prolapse uterus with entry into the peritoneal cavity was done for cervical cancer in 1822 by Santer of Baden3 . The most common cited contraindication to vaginal hysterectomy is uterine size, nulliparity and uterine descent, need for oophorectomy and previous abdominopelvic surgery and extrauterine disease. The first vaginal hysterectomy with laparoscopic assistance was described in 1984. The true role of laparoscopy in facilitating vaginal hysterectomy was to convert cases that could be done only by abdominal route to a laparoscopically assisted vaginal hysterectomy. Laparoscopic assistance during vaginal hysterectomy not only provides visualization of the real anatomic picture in the abdominal cavity, but allows the surgeon to perform correction of the associated pathology and some steps of the hysterectomy itself, thus reducing the operative risk of this, to a certain degree, ‘blind intervention. Kovac4 has described a scoring system which involves grading of uterus, length of infundibulopelvic ligament, presence of adnexal adhesion, status of cul-de-sac, and degree of endometriosis.
Patients with scores of 10 or less were considered as candidates for vaginal hysterectomy; those with 11- 19 were candidates for laparoscopic surgery to reduce their scores to less than 10. ACOG established some guidelines for the route of hysterectomy by staging that the choice depends on the patient’s anatomy, surgeons’ experience, and that vaginal hysterectomy is usually performed in women with mobile uterus not larger than 12 weeks gestation, especially if there is uterine descent. The purpose of this study was to compare laparoscopic assisted vaginal hysterectomy versus vaginal hysterectomy in terms of surgery time, total blood loss, post operative stay in hospital, intra operative and post operative complication.
MATERIAL AND METHODS This was a retrospective comparative study done among 200 women who underwent laparoscopic assisted vaginal hyster ectomy or vaginal hysterectomy for various indications in the department of obstetrics and gynecology of Velammal medical college hospital and research institute. The study was conducted over a period of 3yrs from August 2012 to August 2015.
Method of Collection of data The data of the patients were obtained from hospital medical records. The first 100 cases of laparoscopic assisted vaginal hysterectomy were compared with the cases of first 100 cases of vaginal hysterectomy among women who met the eligibility criteria, done during the study period. The patients were matched for pathological diagnosis, age, parity, size of uterus between laparoscopic assisted vaginal hysterectomy and vaginal hysterectomy group. Group VH was designated for patients who underwent vaginal hysterectomy and LAVH was designated for patients who underwent laparoscopic assisted vaginal hysterectomy. Medical records of the patients were reviewed; factors examined included demographic details, indication for surgery, and history of previous surgeries, intra operative details, post operative recovery and complication.
Inclusion Criteria Women who underwent vaginal hysterectomy or laparoscopic assisted vaginal hysterectomy for Fibroid uterus, Adenomyosis, AUB, Cervical dysplasia and Postmenopausal bleeding and with size of uterus measuring less than or equal to16 weeks size were included in the study.
Exclusion criteria Women who underwent vaginal hysterectomy or laparoscopic assisted vaginal hysterectomy for Malignancies of cervix, endometrium, ovary and size of uterus measuring more than from the study 16 weeks were excluded from the study.
Operative procedure A standardized procedure for vaginal hysterectomy was followed. The procedure started with a circumferential incision all along the uterine cervix, followed by anterior and posterior colpotomies. The cardinal and uterosacral ligaments were clamped, cut and ligated on both the sides. Then the bilateral uterine vessels were clamped, cut and ligated, followed by the clamping, cutting and ligation of cornual structures. Finally the vaginal cuff closure was done. Laparoscopic assisted vaginal hysterectomy were started by introducing a 10mm trocar and canula supraumbilically to hold the camera. Two 5mm trocar and canula were inserted into the lower abdomen. Bilateral round ligaments, the fallopian tubes and ovarian ligaments were electrocoagulated and cut. The vesicouterine fold of peritoneum was opened using monopolar hook and rest of the procedure were accom- plished by vaginal route.
At the end of procedure the peritoneal cavity was inspected laparoscopically for hemostasis. The size of the uterus was measured in weeks of pregnancy. The operative time was calculated from the first incision to end of wound closure. The blood loss was estimated by calculating the blood volume in the suction apparatus and by weighing the swabs. Major and minor intra operative complication and post operative complications like hemorrhage requiring transfusion or re-operation, visceral injury to bladder, bowel or ureter, conversion to laparotomy, fever ( >380 c in two consecutive occasions more than or equal to four hours apart after 24 hrs of surgery), paralytic ileus and vault hematoma. Day of disappearance of pain was the post operative day when the patient needed no analgesics.
The patients were discharged from the hospital when they were pain free, able to tolerate normal diet, apyrexic and ambulant. The collected data was analysed with SPSS 16.0 version. The descriptive statistics, frequency analysis, percentage analysis were used for categorical variables and the mean and standard deviation was used for continuous variables. To find the significant difference between the bivariate samples in Independent groups (VH and LAVH) unpaired sample t-test was used. To find the significance in categorical data ChiSquare test was used. In both the above statistical tools the probability value P0.05).
There was no significant difference in two groups in the distribution of previous LSCS cases (P >0.05).
Vault hematoma: 7 cases of vault hematoma were seen in VH group against 0 cases in LAVH group (P < 0.05)
Paralytic ileus: 8 cases of paralytic ileus in LAVH group against 0 cases in VH group (p< 0.05).
Wound infection: There were 2 cases of vault infection in VH group and 9 cases of port site infection in LAVH group (pEnglishhttp://ijcrr.com/abstract.php?article_id=357http://ijcrr.com/article_html.php?did=3571. Royal college of Obstetricians and Gynaecologists. National Evidence - based Clinical Guidelines. The management of menorrhagia in secondary care. London, Engl: RCOG Press, January 1999.
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