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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareA DETAILED STUDY OF ABSENCE OF EOSINOPHILIA IN PATIENTS WITH HOOKWORM INFECTION DIAGNOSED BY DOING UPPER GASTRO-INTESTINAL ENDOSCOPY
English0105Govindarajalu GanesanEnglishObjective: Many studies have shown the presence of eosinophilia in hookworm infection. But so far detailed study was not done to know about the absence of eosinophilia in hookworm infection. Hence a detailed study was done to know about the absence of eosinophilia in hookworm infection diagnosed by doing upper gastro-intestinal endoscopy in our institute.
Methods: A study of 1137 patients who had undergone upper gastro-intestinal endoscopy for a period of four years and eight months from May 2009 to December 2013 was carried out in our institute to know about the absence of eosinophilia in hookworm infection diagnosed by doing upper gastro-intestinal endoscopy in our institute.
Results: Out of these 1137 patients, 14 patients found to have hookworms in duodenum while doing upper gastro-intestinal endoscopy were taken into consideration for our study. Out of these14 patients with hookworms in duodenum, as many as 10 patients with hookworms in duodenum were found to have eosinophilia [71%]. But 4 patients with hookworms in duodenum di nt have any eosinophilia[29%]. Out of these 4 patients without eosinophilia with hookworm infection, 3 patients without eosinophilia
with hookworm infection had anaemia[75%].
Conclusion: Hence, eosinophilia can sometimes be absent in hookworm infection. But 3 out of 4 patients without eosinophilia with hookworm infection had anaemia in our study. Hence anaemia is an important indicator of hookworm infection which is not associated with eosinophilia.
EnglishAbsence of eosinophilia, Presence of anaemia, Hookworm infection, Upper gastro-intestinal endoscopyINTRODUCTION
Many studies have also shown the presence of eosinophilia in hookworm infection (1 to 14) . But so far detailed study was not done to know about the absence of eosinophilia in hookworm infection. Hence a detailed study was done to know about the absence of eosinophilia in hookworm infection diagnosed by doing upper gastro-intestinal endoscopy in our institute.
MATERIALS AND METHODS
This study was conducted in the department of general surgery, Aarupadai Veedu Medical College and Hospital, Puducherry. A study of 1137 patients who had undergone upper gastro-intestinal endoscopy for a period of four years and eight months from May 2009 to December 2013 was carried out in our institute. In each of these 1137 patients, the first and second part of duodenum were carefully examined to find out the presence of hookworms. In all the patients found to have hookworms in duodenum, investigations were done to know about the presence or absence of eosinophilia and anaemia. Anaemia is defined as haemoglobin < 12g/dl or 12g% in women (15 to 22) and haemoglobin < 13g/dl or13g% in men (21, 22). Mild anaemia is taken as haemoglobin 10to12g/dl or10to12 g%, moderate anaemia is taken as haemoglobin 7to10g/dl or 7to10 g% and severe anaemia is taken as haemoglobin or = 500 cells/cu.mm (24). Se vere eosinophilia or hypereosinophilia is defined as eosinophils>1000 cells/cu.mm (4). The results were found as given below.
RESULTS
1. Out of these 1137 patients, 14 patients found to have hookworms in duodenum while doing upper gastrointestinal endoscopy were taken into consideration for our study.
2. Out of these14 patients with hookworms in duodenum, as many as 10 patients with hookworms in duodenum were found to have eosinophilia[71%].
3. But 4 patients with hookworms in duodenum did not have any eosinophilia[29%].
4. Out of these 4 patients without eosinophilia with hookworm infection, 3 patients without eosinophilia with hookworm infection had anaemia[2 patients had mild anaemia and 1 patient had severe anaemia].
5. One patient without eosinophilia with hookworm infection also had absence of anaemia.
Hence the 4 patients without eosinophilia with hookworm infection can be divided into 3 groups as follows
a. Absence of both eosinophilia and anaemia in hookworm infection [1 patient].
b. Mild anaemia without eosinophilia with hookworm infection [2 patients]
c. Severe anaemia without eosinophilia with hookworm infection [1 patient]
DISCUSSION
a. Absence of both eosinophilia and anaemia in hookworm infection [1 patient].
1. One patient with hookworm infection neither had eosinophilia[absolute eosinophil count - 160cells/ cu.mm] nor had anaemia[haemoglobin -14g%] which is of extremely great significance.
2. This patient had adequate amount of haemoglobin indicating clearly that the patient was in the extremely early stage of hookworm infection.
3. Eosinophilia was probably not present since the patient was in such extremely early stage of hookworm infection.
4. Eosinophilia only peaks at 5to 9weeks after the onset of infection, a period that coincides with the appearance of adult hookworms in the intestine (10).
b. Mild anaemia without eosinophilia with hookworm infection [2 patients]
1. 2 patients without eosinophilia with hookworm infection had mild anaemia [1. haemoglobin 11.2g% , absolute eosinophil count - 396cells/cu.mm 2. haemoglobin 10g% , absolute eosinophil count - 364cells/ cu.mm].
2. The single hookworm in duodenum found in the patient with mild anaemia [haemoglobin 10 g%] without eosinophilia [absolute eosinophil count - 364cells/ cu.mm] is shown in Fig 1, 2. 3.
The hookworm in duodenum is identified by its bent head which looks like a hook (Fig1) and by its Sshaped appearance (25) (Fig1) .
c. Severe anaemia without eosinophilia with hookworm infection [1 patient]
1. Severe anaemia is due to significant loss of blood due to large number of hookworms and very heavy burden of hookworm infection and indicates severe hookworm infection.
2. Severe anaemia without eosinophilia with hookworm infection was present in one patient in our study [haemoglobin 2.1g%, absolute eosinophil count - 366 cells/cu.mm].
3. Hence even in patients with severe anaemia due to severe hookworm infection, eosinophilia need not be present.
4. Hence significant anaemia always occurs in severe hookworm infection, but eosinophilia can sometimes be absent even in severe hookworm infection.
5. Various other studies have also shown the presence of severe anaemia without eosinophilia in hookworm infection (25to29).
6. Multiple hookworms in duodenum without eosinophilia [absolute eosinophil count - 366cells/cu.mm] and with severe anaemia [haemoglobin 2.1 g%]indicating severe hookworm infection is shown in Fig 3.
CONCLUSION
1. 3 out of 4 patients without eosinophilia with hookworm infection in our study had anaemia. Of these 3 patients, 1 patient without eosinophilia had severe anaemia due to severe hookworm infection.
2. Hence significant anaemia always occurs in severe hookworm infection, but eosinophilia can sometimes be absent even in severe hookworm infection.
3. Hence upper gastro intestinal endoscopy should be done to confirm the presence of hookworms in all patients with anaemia even when there is no eosinophilia.
ACKNOWLEDGEMENT
The author sincerely thanks the staff nurse Nithya who was assisting the author while doing endoscopy and the staff nurses A.K. Selvi and Nithya for their immense help rendered to the author while conducting this work. The author 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. The author is extremely grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=414http://ijcrr.com/article_html.php?did=4141. Nutman TB, Ottesen EA, Ieng S, Samuels J, Kimball E, Lutkoski M, Zierdt WS, Gam A, Neva FA. Eosinophilia in Southeast Asian refugees: evaluation at a referral center. J Infect Dis. 1987 Feb;155(2):309-
2. Triteeraprapab S, Nuchprayoon I. Eosinophilia, anemia and parasitism in a rural region of northwest Thailand. Southeast Asian J Trop Med Public Health. 1998 Sep;29(3):584-90.
3. Lawn SD1, Grant AD, Wright SG Case reports: acute hookworm infection: an unusual cause of profuse watery diarrhoea in returned travellersTrans R Soc Trop Med Hyg. 2003 JulAug;97(4):414-5.
4. Heukelbach J, Poggensee G, Winter B, Wilcke T, Kerr-Pontes LR, Feldmeier H Leukocytosis and blood eosinophilia in a polyparasitised population in north-eastern Brazil. Trans R Soc Trop Med Hyg. 2006 Jan;100(1):32-40. Epub 2005 Sep 23.
5. Verboeket SO1, Van den Berk GE., Arends JE, van Dam AP, Peringa J, Jansen RR. Hookworm with hypereosinophilia: atypical presentation of a typical disease. J Travel Med. 2013 JulAug;20(4):265-7.
6. Kato T, Kamoi R, Iida M, Kihara T.Endoscopic diagnosis of hookworm disease of the duodenum J Clin Gastroenterol. 1997 Mar;24(2):100-102.
7. Anjum Saeed, Huma Arshad Cheema, Arshad Alvi, Hassan Suleman. Hookworm infestation in children presenting with malena -case seriesPak J Med Res Oct - Dec 2008;47(4) ):98- 100.
8. Wang CH, Lee SC, Huang SS, Chang LC. Hookworm infection in a healthy adult that manifested as severe eosinphilia and diarrhea. J Microbiol Immunol Infect. 2011 Dec;44(6):484-7. Epub 2011 May 23.
9. Yan SL, Chu YC. Hookworm infestation of the small intestine Endoscopy 2007; 39: E162±163.
10. Maxwell C, Hussain R, Nutman TB, Poindexter RW, Little MD, Schad GA, Ottesen EA. The clinical and immunologic responses of normal human volunteers to low dose hookworm (Necator americanus) infection. Am J Trop Med Hyg. 1987 Jul;37(1):126- 34.
11. Kucik CJ, Martin GL, Sortor BV. Common intestinal parasites. Am Fam Physician. 2004Mar 1;69(5) ):1161-8.
12. A Rodríguez, E Pozo, R Fernández, J Amo, T Nozal. Hookworm disease as a cause of iron deficiency anemia in the prison population Rev Esp Sanid Penit 2013; 15: 63-65.
13. Li ZS1, Liao Z, Ye P, Wu RP Dancing hookworm in the small bowel detected by capsule endoscopy: a synthesized video. Endoscopy. 2007 Feb;39 Suppl 1:E97. Epub 2007 Apr 18.
14. McSorley, H. J., and Loukas, A. The immunology of human hookworm infections. Parasite immunology, 2010;32(8), 549- 559.
15. Kabir, Y., Shahjalal, H. M., Saleh, F., and Obaid, W. Dietary pattern, nutritional status, anaemia and anaemia-related knowledge in urban adolescent college girls of Bangladesh. JPMA. The Journal of the Pakistan Medical Association, 2010; 60(8), 633.
16. Ahmed, F., Khan, M. R., Islam, M., Kabir, I., and Fuchs, G. J.. Anaemia and iron deficiency among adolescent schoolgirls in peri-urban Bangladesh. European journal of clinical nutrition, 2000 ;54(9), 678-683.
17. Ahmed F1, Khan MR, Karim R, Taj S, Hyderi T, Faruque MO, Margetts BM, Jackson AA. Serum retinol and biochemical measures of iron status in adolescent schoolgirls in urban Bangladesh. Eur J Clin Nutr. 1996 Jun;50(6):346-51.
18. Foo, L. H., Khor, G. L., Tee, E. S., and Prabakaran, D.. Iron status and dietary iron intake of adolescents from a rural community in Sabah, Malaysia. Asia Pacific journal of clinical nutrition, 2004 ;13(1), 48-55.
19. Chandyo, R. K., Strand, T. A., Ulvik, R. J., Adhikari, R. K., Ulak, M., Dixit, H., and Sommerfelt, H. Prevalence of iron deficiency and anemia among healthy women of reproductive age in Bhaktapur, Nepal. European journal of clinical nutrition, 2007;61(2), 262-269.
20. Sarita Modi, Bose Sukhwant, Study of iron status in female medical students, Indian Journal of Basic and Applied Medical Research; March 2013: Issue-6, Vol.-2, P. 518-526.
21. Sikosana, P. L., Bhebhe, S., and Katuli, S.. A prevalence survey of iron deficiency and iron deficiency anaemia in pregnant and lactating women, adult males and pre-school children in Zimbabwe. Central African Journal of Medicine, 1998;44(12), 297- 304.
22. WHO. Iron deficiency anaemia: assessment, prevention, and control. a guide for programme managers. Geneva, Switzerland: World Health Organization, 2001. (WHO/NHD/01.3.)
23. Hyder, S. M. Z., Persson, L. Å., Chowdhury, M., Lönnerdal, B. O., and Ekström, E. C.. Anaemia and iron deficiency during pregnancy in rural Bangladesh. Public health nutrition, 2004 ; 7(08), 1065-1070.
24. Meltzer E, Percik R, Shatzkes J, Sidi Y, Schwartz E. Eosinophilia among returning travelers: a practical approachAm J Trop Med Hyg. 2008 May;78(5):702-9.
25. Cedrón-Cheng H, Ortiz C .Hookworm Infestation Diagnosed by Capsule Endoscopy. J Gastroint Dig Syst 2011 S1:003. doi: 10.4172/2161-069X.S1-003.
26. Kuo YC, Chang CW, Chen CJ, Wang TE, Chang WH, Shih SC . Endoscopic Diagnosis of Hookworm Infection That Caused Anemia in an Elderly Person. International Journal of Gerontology. 2010 ; 4(4) : 199-201.
27. Kalli T1, Karamanolis G, Triantafyllou K Hookworm infection detected by capsule endoscopy in a young man with iron deficiency. Clin Gastroenterol Hepatol. 2011 Apr;9(4):e33
28. Chen JM1, Zhang XM, Wang LJ, Chen Y, Du Q, Cai JT. Overt gastrointestinal bleeding because of hookworm infection. Asian Pac J Trop Med. 2012 Apr;5(4):331-2.
29. Wu KL, Chuah SK, Hsu CC, Chiu KW, Chiu YC, Changchien CS. Endoscopic Diagnosis of Hookworm Disease of the Duodenum: A Case Report. J Intern Med Taiwan 2002;13:27-30.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareSTUDY OF CORONARY DOMINANCE IN THE POPULATION OF HYDERABAD KARNATAKA REGION
English0608Jaishree H.English Ashwini H.EnglishAim: To determine the dominance pattern of coronary artery in adult human hearts of Hyderabad Karnataka region.
Materials and Method: 76 human cadaveric hearts were studied and analyzed by dissection method to know the dominance pattern of coronary artery.
Result: Out of 76 heart specimens, Right dominance was found in 63 cases (83%), left dominance in 11 cases (14.5%) and co dominance in 2 cases (2.5%).
Conclusion: In our present study right coronary artery was dominant. Knowledge of dominant pattern is significant for determining the prognosis of coronary artery disease. Hence this study was done, which would be helpful to the physicians belonging to the Hyderabad Karnataka region.
EnglishCoronary dominance, Coronary artery disease, Posterior interventricular arteryINTRODUCTION
The term dominant coronary artery was coined by Schlesinger to indicate the areas of heart supplied by right and left coronary artery.1 The distribution of coronary arteries does not follow uniform pattern in all the hearts. The pattern of blood supply is classified into three type’s i.e. Balanced, right dominance and left dominance.2 The increasing use of diagnostic and therapeutic interventional procedures necessitates a sound and basic knowledge of the coronary artery pattern. Coronary artery anomalies are gaining consideration as a cause of coronary heart disease in the diagnosis workup.3 As Coronary artery disease is one of the most common heart diseases and also the major cause of death in developing countries, this study would be helpful to physicians, radiologists and surgeons of Hyderabad Karnataka region to understand the pattern of coronary arterial dominance.
MATERIALS AND METHOD
The sample size used for this study is 76 heart specimens. The specimen of adult human hearts used for this study were obtained from routine dissection conducted for undergraduate students from the Department of Anatomy, Bidar Institute of Medical Sciences, Bidar and also from other nearby medical colleges of Karnataka. By cutting the ribs and sternum the thoracic cavity is opened. The great vessels were ligated. The parietal pericardium is incised and heart along with great vessels is taken out of the pericardial cavity. Each specimen is thoroughly washed to free it from the blood clots. All specimens are preserved in 10% formalin solution. The specimens were labelled numerically. The origin of right coronary artery from the ascending aorta is identified. The right coronary artery lies in between right auricle and right side of pulmonary trunk. Then the right coronary artery is dissected along its course running in the right atrioventricular groove and traced on the posterior surface of heart running in the coronary sulcus towards the crux of heart and noted for origin of PIVA (posterior interventricular artery). On the anterior surface of the heart, Origin of the left coronary artery arising from the ascending aorta is identified i.e. between the left auricle and the left side of the pulmonary trunk. The LCA (left coronary artery) was traced until its division on the superior end of anterior interventricular groove which branched into LAD (left anterior descending) and LCX (left circumflex) artery. The LCX artery is dissected along its course on the posterior surface of the heart and noted for origin of PIVA. The PIVA running in the posterior interventricular sulcus is identified. The PIVA is dissected along its course upto the termination. The origin, course of PIVA is noted.
RESULTS
The present study is carried on 76 specimens of cadaveric hearts and observed for the dominance of coronary arteries. In our study, it is observed that out of 76 specimens studied, the PIVA originated from RCA (right coronary artery) in 63 (83%) cases, in 11 (14.5%) cases PIVA originated from LCA, in 2 (2.5%) cases PIVA originated from both RCA and LCA.
DISCUSSION
The incidence of left coronary arterial dominance in present study was 14.25% as compared to 18.5% reported by Hirak Das et al 9 , 11.5% by Vasudeva Reddy J et al 10, 10% by MA El Sayed 8 , 8% by Jose Roberto Ortale et al 7 . The variation in result could be due to racial and geographical variation. Keshav Kumarstudied the relation between coronary arterial pattern and coronary artery disease. He described about the types of dominant pattern. 1. Right coronary arterial dominance (83%) 2. Left coronary arterial dominance (16%) 3. Right coronary arterial great dominance (0.7%) 4. Coronary arterial no dominance (0.3%) There is increased incidence of coronary heart disease in the persons with left coronary arterial dominance and co dominance heart. In left coronary dominance and co dominance, the left coronary artery has to supply entire interventricular septum due to which the pulse pressure of blood rises more than 60mmHg in it producing atherosclerosis.11 Hirak das et alstudied coronary dominance in population of Assam in 70 hearts and found right dominance in 70%, left dominance in 18.75% and co-dominance in 11.43%.9 Dr Hussein Ali Fakhir et alstudied the coronary artery dominance by angiography and their relationship with coronary artery disease in 657 Iraqi patients consecutively suffering from coronary artery disease. The right coronary artery was dominant in 76.4%, left dominant in 12.6%, co dominant in 10% cases. No significant difference in type of coronary dominance in relation to sex and age. There was significant association between right dominant system and coronary artery disease especially 3 vessel disease and right coronary artery occlusion.4 J. Vasudeva Reddy et al studied the origin, branching pattern and termination of coronary arteries in population of Andhra Pradesh. He dissected 80 human heart specimens by using vascular corrosion technique. Out of 80 specimens dissected 69 were of right dominance, 9 specimens were of left dominance and 2 specimens were of co-dominance type of coronary circulation. Incidence of right coronary dominance is higher in males than females. Left predominance is higher in males indicating the reason for higher incidence of myocardial infarction in males when compared to females.10
CONCLUSION
Schlesinger in his study correlated the thrombosis and angina pectoris with coronary arterial pattern and concluded that the coronary artery disease is more prevalent in left coronary arterial dominance.1 Left coronary dominance have high mortality while performing cardiac catheterisation for acute coronary syndromes. Left coronary dominance is the only predictor of peri procedural myocardial infarction following the implantation of second generation drug eluting stents and was also associated with higher rate of myocardial infarction during follow up. Left coronary dominance and co-dominance had higher mortality in hospitals after performing percutaneous intervention for acute coronary syndrome.12 In our study Right dominance is found in 83%, left dominance in 14.5% and co dominance in 2.5% cases. Considering the risk of higher mortality in left coronary dominance and coronary co-dominance pattern, more prevalence of myocardial infarction in left coronary dominance, the present study was done. This study would be helpful to the cardiologist, radiologists and surgeons of The Hyderabad Karnataka region.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in the reference 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=415http://ijcrr.com/article_html.php?did=4151. Schlesinger, M. J. Relation of the anatomic pattern to pathologic conditions of the coronary arteries. Arch.Pathol.30:443, 1938.
2. Ayer AA, Rao YG. A radiographic investigation of coronary arterial pattern in human hearts. J Anat Soci India. Jun 1957; 6(1) 63-67.
3. Subhash D Joshi, Sharda S Joshi et al. Origins of the coronary arteries and their significance. Clinics 2010; 65 (1):79-84.
4. Dr. Hussein Ali Fakhir, Pattern of coronary artery dominancy by coronary angiography in Iraqi patients and the relationship with coronary artery disease. Journal of college of education 2012; 3(2):180-189.
5. Fazliogullari Z et al. Coronary artery variations and median artery in Turkish cadaver hearts. Singapore Med J 2010; 51(10) : 775.
6. Fazlul Aziz Main et al. Coronary Artery Dominance: What pattern exists in Pakistani Population? Annals of Pakistan Institute of Medical Sciences 2011; 7(1): 3-5.
7. Jose Roberto Ortale et al. The posterior ventricular branches of the coronary arteries in human artery. Arquivos Brasileiros de Cardiologia 2004; 82(5):468-471.
8. Madiha Awad El Sayed. Anatomical study of right coronary artery with special reference to its interventricular branch. Alexandria faculty of medicine 2008, vol.44 (2); 536-547.
9. Hirak Das, Geeta Das et al. A study of coronary dominance in the population of Assam. Journal of Anatomical Society of India 2010; 59 (2): 187-91.
10. Vasudeva Reddy J, Lokanadham S. Coronary Dominance in South Indian Population. Int J Med Res Health Sci.2013; 2(1):78-82.
11. Kumar Keshaw. Coronary arterial pattern and coronary heart disease. Anatomica Karnataka 2008; 3 (2): 27-34.
12. Nisha I. Parikh, Emily F. Honeycutt, Matthew T. Roe et al. Coronary Artery dominance and death in Acute Coronary Syndromes. Circ Cardiovasc Qual Outcomes, journal of American heart association November 2012(5) p1-7.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareA STUDY OF FORAMEN OF ARCUALE IN ATLAS VERTEBRA: INCIDENCE AND CLINICAL CORRELATIONS
English0911Patel Dinesh K.English Shinde Amol A.English Roy NilanjanEnglish Manvikar Purushottam R.English Bharambe VaishalyEnglishIntroduction: Atlas is the first cervical vertebra. Foramen tranversarium transmits vertebral vessels and sympathetic plexus. An additional foramen on the transverse process has been named foramen of Arcuale or Arcuate foramen.
Aim: To find incidence and clinical correlation of foramen of Arcuale.
Methodology: 32 atlas vertebrae from various colleges of Maharashtra were studied in the present study for presence of variant foramen.
Results: Foramen of Arcuale was seen bilaterally in 3 atlas vertebrae giving a incidence of 9.37%. There were no other abnormalities in the bones.
Conclusion: The course of the vertebral artery may be distorted with this extra foramen. This variation has been a known contraindication for C1 lateral mass screw fixation procedures. Knowledge of this variation will prove helpful for radiologists during CT and MRI and neurosurgeons during cervical surgery.
EnglishForamen of Arculae, Arcuate foramen, Atlas, Vertebral artery, Foramen transversariumINTRODUCTION
Atlas is the first cervical vertebra. It is a ring shaped vertebra with anterior and posterior arch but no body. Normally we see a single foramen transversarium bilaterally on the transverse process. It transmits vertebral artery, vertebral vein and sympathetic plexus. The third part of the vertebral artery leaves the foramen transversarium on its way to the cranial cavity. It grooves the superior surface of the posterior arch of atlas vertebra, just behind the superior articular facet. The groove is called the groove for vertebral artery or sulcus arteria vertebralis. It transmits vertebral artery and suboccipital nerve. Sometimes the groove is converted into a foramen by an osseous bridge called foramen of Arcuale or Arcuate foramen. It has also been named as Kimmerle’s anomaly, foramen sagittale, foramen atlantoideum, foramen retroarticulare superior, canalis vertebralis. [1] [2] The Aim of this study is to investigate the incidence of extra foramina in the Atlas vertebrae and to discuss its clinical importance.
MATERIAL AND METHODS
32 atlas vertebrae from various medical and dental colleges of Maharashtra were studied for variations in foramen transversarium. Any Variation in number and position of foramen transversarium were noted
RESULTS
Extra foramen on transverse process were seen bilaterally in 3 atlas vertebrae giving an incidence of 9.37% . No “incomplete canal for vertebral artery” or “retrotransverse foramen” were observed. No other abnormality was seen in each of these bones. The foramina were situated at the lateral part of the posterior arch behind the lateral mass as seen in Figures 1 and 2.
Showing A – Foramen transversarium and B – Foramen of Arcuale
DISCUSSION
When the groove for vertebral artery (while arching over the posterior arch of atlas vertebra), gets converted into an osseous tunnel by formation of a bony arch over it, the so formed foramen through which the artery now traverses is called as arcuate foramen. Such a foramen can be a complete foramen or it can be in form of an incomplete arch. [3,4]. Patel et al [5] in a study of atlas vertebra in Gujarat region give a 13% incidence of foramen of Arcuale which is higher than 9.37% incidence reported by present study. Krisnamurthy A et al [1] give a 8.33% incidence of foramen of Arcuale in atlas vertebra. This incidence coincides with present study. They conclude that this variation should be considered in patients with symptoms of vertebrobasilar insufficiency like shoulder pain vertigo and headache. A study of 60 atlas vertebra by Ozgur Ckmak et al in Turkey give a 11.6 % incidence of arcuate foramen which is more than incidence of our study. They state that patients with arcuate foramen have many complaints which may be due to compression of the sympathetic plexus around the vertebral artery. So presence of arcuate foramen should be considered in patients of vertigo, headache, shoulder pain and neck pain. A cervical spine radiography is indicated in such cases.[6] Brown and Verheyden [7] have described a case of a 1 year old boy who underwent surgery for cleft palate and suffered “posterior fossa infarction” following the surgery. A threeview cervical spine radiographic series showed no fracture or subluxation, with the disk spaces appearing normal. A questionable calcific density was however observed superior to the posterior arch of C1. This could be because of possible presence of a arcuate foramen. They stated that some surgeons prefer to operate on cleft palate with the neck in full extension. In this position it is possible that the extension of the neck in presence of an arcuate foramen, could lead to bilateral occlusion of the vertebral arteries resulting in “posterior fossa infarction”. They have therefore suggested that during such surgeries the neck be extended only as far as is necessary to perform the procedure, rather than extending it more to make the repair easier on the surgeon. Cushing K et al [8] give a relation between tethering of vertebral artery in the foramen of arcuale and dissection of the artery from repetitive trauma during neck movements. P Potaliya et al [9] gave a 13.33 % incidence of accessory foramen transversarium .They state that this finding could be helpful to orthopedic surgeons, neurosurgeons and radiologists to avoid misdiagnosis in their clinical practice. A qualitative analysis of atlas vertebra by C. Gupta et al gives a Incidence of 5.7%. Presence of bridges to form foramen on the groove may indicate ossification of posterior atlanto occipital membrane. This variation may predispose to vertebrobasilar insufficiency and cervicogenic syndromes on strenuous neck movements.[10] S.S. Baeesa et al in a study of Saudi population gave a 16 % incidence of foramen of Arcuale. They attributed various cases of stroke, subarachnoid bleeds, vertebrobasilar insufficiency to presence of foramen of Arcuale. They state that theories on formation of the foramen are controversial and that some authors have reported presence of this foramen even in fetuses and children where it was present in cartilaginous form indicating a congenital origin. Another theory stated that the foramen could develop as a result of degenerative calcification of atlanto-occipital membrane. The vertebral artery accompanied by venous plexus, periarterial sympathetic plexus, suboccipital and 1st cervical nerves passes through the bony foramen arcuale. The canal can therefore compress any or all of these structures as the neck rotates. So radiographic study is indicated in cases of spine surgery and screw fixation in the atlas vertebra.[3] Michael J Huang and John Glaser state that C1 lateral mass screw fixation is contraindicated in patients with foramen of arcuale. Preoperative radiographs are indicated to avoid endangering the vertebral artery during screw fixation. Also the foramen of arcuale is known to be an associated factor in cases of migraines and vertebrobasilar artery stroke.[11] In a study of south Indian population, R Agrawal et al give an incidence of 10.7 % for foramen of Arculae. This incidence coincides with present study (9.37%). They opine that this abnormal foramen can cause compression of vertebral artery resulting in compromised blood flow.[12] Kwaiatkowska et al did a morphometric study of foramen transversarium in Poland. Vertebral and basal arteries supply blood directly to the brain and the spinal arteries. Any abnormality in course of vertebral arteries may hence lead to deficient blood supply to the cerebellum and the brainstem posing a threat to the vascular-cerebral system.[13]
CONCLUSION
Vertebral artery passes through the foramen transversarium of atlas before entering foramen magnum. An extra foramen will cause additional external pressure on the artery. Presence of foramen of Arcuale have been noted by studies in various countries giving a incidence from 8 to 16 %. We found a incidence of 9.37% .Presence of foramen of Arcuale should be considered in patients of vertigo, headache, migraine, shoulder and neck pain. Cervical spine radiography is indicated in cases of C1 lateral mass screw fixation and other spine surgeries to avoid damage to the vertebral artery. Excess extension of neck should also be avoided during surgery to avoid compression and resulting tethering of 3rd part of vertebral artery in case of presence of foramen of Arcuale.
ACKNOWLEDGEMENT
The 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 the authors/editors/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Source of funding: As this study was carried out in the dissection hall of our Department, there was no separate financial aid provided for it.
Conflict of interest: There is no conflict of interest
Englishhttp://ijcrr.com/abstract.php?article_id=416http://ijcrr.com/article_html.php?did=4161. A. Krishnamurthy, S. R. Nayak, S. Khan, Latha V. Prabhu,Lakshmi A. Ramanathan, C. Ganesh Kumar, Abhishek Prasad Sinha arcuate foramen of atlas: incidence, phylogenetic and clinical significance Romanian Journal of Morphology and Embryology 2007, 48(3):263–266.
2. Abduelmenem Alashkman and Roger Soames, Bilateral foramina on the posterior arch of atlas, Rev Arg de Anat Clin,2014,6(2): 90-94.
3. S.S. Baeesa, F. Rakan . Bokhari, M. Khalid, Bajunaid, J. Mohammad, Al-Sayyad, Prevalence of the foramen arcuale of the atlas in a Saudi population, Neurosciences 2012’ 17 (4): 345-351
4. G. Paraskevas, B. Papazioga, A Tzaveas, K Natsis, S Spanidou, P. Kitsoulis, Morphological parameters of the superior articular facets of the atlas and potential clinical significance. Surg Radiol Anat. 2008 Nov;30(8):611-7.
5. Z. Patel, A Zalawadia, C.A. Pensi C A . Study of Arcuate Foramen in Atlas Vertebrae in Gujarat Region. NJIRM. 2012; 3(2): 73-75.
6. O. Cakmak, E. Gurdal, G. Ekinci, E. Yildiz, S. Cavdar, Arcuate foramen and its clinical significance, Saudi Med J, 2005, 26(9):1409-1413.
7. M. Brown and C. Verheyden. Posterior Fossa Infarction following Cleft Palate Repair and the Arcuate Foramen. Plastic and Reconstructive Surgery. 11/2009; 124(5):237-9.
8. K.E. Cushing, V. Ramesh , D. Gardner-Medwin, N.V.Todd,A. Gholkar, P. Baxter., P.D. Griffiths, Tethering of the vertebral artery in the congenital arcuate foramen of the atlas vertebra: a possible cause of vertebral artery dissection in children, Dev Med Child Neurol, 2001,43(7):491-496.
9. P. Potaliya, A. Dadhich, D.S. Chawdhary, Accessory foramen transversarium and it’s incidence in atlas vertebrae, Indian Journal of Clinical Anatomy and Physiology,2014,1(1):8-9.
10. C. Gupta, P. Radhakrishnan, V. Palimar, A.S. D’souza, N.L. Kiruba, A quantitative analysis of atlas vertebrae and its abnormalities, J. Morphol. Sci., 2013, vol. 30, no. 2, p. 77-81.
11. M.J. Huang and J.A. Glaser, Complete Arcuate Foramen Precluding C1 Lateral Mass Screw Fixation in a Patient with Rheumatoid Arthritis: Case Report, Iowa Orthop J. 2003; 23: 96-99.
12. R. Agrawal, S Sanathi, S. Agrawal, K. Usha. Posterior arch of atlas with abnormal foramina in south Indians.JASI, 2012,61(1):30-32.
13. B. Kwiatkowska, J. Szczurowski, D. Nowalkowski, Variation in foramina transversaria of human cervical vertebrae in the medieval population from Sypniewo (Poland), Anthropological Review’2014 ,77 (2), 175-188.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareIMPLANT AN ABSOLUTE ANCHORAGE: A CASE OF IMPLANT SUPPORTED RETRACTION OF BIMAXILLARY DENTOALVEOLAR PROTRUSION
English1216Eshan AwasthiEnglish Narendra SharmaEnglish Abhilasha GoyalEnglish Deoashish GuptaEnglish Vaibhav KhareEnglishStudies have shown that orthodontic mini-implants serve as an important anchorage method, for orthodontists at all treatment stages, reducing the patient`s compliance and achieving more predictable results. Implant serves as an absolute anchorage taking anchorage from skeleton with no reactionary force on posterior teeth during reaction
Aim: This case report describes the treatment of a 31-year-old female who had incompetent lips with severe bimaxillary dentoalveolar protrusion.
Methodology: The preferred treatment alternative for such malocclusion is extraction of four first premolars and utilization of extraction spaces retraction of the anterior teeth. To maintain the extraction space, maximum anchorage is required. Mini-implants were used for absolute anchorage to get a good facial profile.
Conclusion: Post treatment the profile improved, competency of lips was achieved and cephalometric superimposition revealed that no anchorage loss was seen with all extraction space being utilized for retraction. Hence implant serves as an effective tool as an absolute anchorage
EnglishImplant, Miniscrew, Absolute anchorageINTRODUCTION
Protrusiveness and proclination of the maxillary and mandibular incisors along with increased procumbency of the lips is a condition known as bimaxillary dentoalveolar protrusion .1 This condition is commonly seen in the Asian as well as African– American populations.2-8 . The usual objective of orthodontic treatment of such condition includes the retraction and retroclination of maxillary and mandibular incisors with a resultant decrease in soft tissue procumbency and convexity.9 The treatment of choice for these patients is to extract all first bicuspids. In this case, maximum anchorage of the posterior teeth is of great importance for two reasons; to retract the anterior teeth to their greatest extent and increase the chances of correcting the profile. With the introduction of dental implants10-11, mini-plates,12-13 microimplants and mini-screws/implants as anchorage,14-19 it has become possible to achieve absolute anchorage 20. Therefore, this case report demonstrates the efficacy of miniimplants as an anchorage aid in an adult with severe bimaxillary dentoalveolar protrusion with incompetent lips.
CASE REPORT
A 31-year-old female patient reported in the orthodontic clinic with the chief complaint of poor esthetics due to forwardly placed upper and lower front teeth.
Extra-oral examination- The patient had an apparently symmetric face with mesoprosopic face form and incompetent lips. On profile examination patient had a convex facial profile. The smile of the patient was symmetric and consonant with 100% maxillary incisor display on smiling. (Figure 1a)
Intra-oral examination – Revealed all teeth in upper and lower arch are present till 2nd molar. U shaped upper and lower arch. The gingival health was satisfactory. Class I molar and canine relationship bilaterally. (Figure 1b)
Functional examination- Patient showed normal speech pattern, oronasal breathing and a typical swallowing pattern. The path of closure of mandible was normal.
Examination of study casts- Showed apparently symmetrical arches with a Class I molar and canine relationship. .There was 5mm overjet and 4mm overbite.
Cephalometric analysis- Revealed that patient was in CVMI stage VI (completion) and had Class II skeletal bases with average angle case and, proclined upper and lower incisors. The soft tissue analysis revealed a protrusive upper lip and lower lip with an acute nasolabial angle.
Diagnosis: Skeletal Class II malocclusion with average growth pattern. Angle`s Class I, Dewey`s type 1
Problem List
• Convex facial profile
• Incompetent lips
• Upper and lower proclination
• Increased overjet and overbite
Treatment Objectives
• To improve facial profile
• To correction proclination of upper and lower arch. • To achieve normal Overjet and Overbite
Treatment progress:
MBT 0.022 in prescription was bonded to upper and lower arch. All 1st premolar were extracted. Initial leveling and alignment was carried out with wire sequence was 0.016 in, 0.016 x 0.022 in , 0.017 x 0.025 in HANT, , 0.016 x 0.022 in , 0.017 x 0.025 in, 0.019 x 0.025 in , 0.021 x 0.025 in SS wire. Mini screw implant (1.3mm diameter , 6mm long) were placed in all four quadrants interdentally between 2nd premolar and 1st molar. Retraction was done using a crimpable hook distal to lateral incisor in a 0.019 x 0.025 in SS wire (Figure 2)
RESULTS
The active retraction continued for eight months and the total treatment duration was 18 months. At the end of the treatment the profile of the patient improved, competency of the lips was achieved, proclination corrected and normal overjet and overbite was attained. (Figure 3a-b, 4) DISCUSSION Bimaxillary dentoalveolar protrusion, which is characterized by dentoalveolar flaring of both the maxillary and mandibular anterior teeth, with resultant protrusion of the lips and convexity of the face, is commonly seen in Asian populations.2 It is accepted in orthodontics that extraction of permanent teeth reduces facial convexity3,4,21. On the basis of the patient’s chief complaint and the diagnosis of the malocclusion, extracting the maxillary and mandibular first bicuspids is a valid and viable option to decrease lip procumbency. The advances in the utilizing bone anchorage such as retromolar implant ,11 onplants 22,23, palatal implants 24,25,mini-plates 26,mini-screws 27 and mini-implants 20 make it possible to overcome previous limitation of orthodontic tooth movement and perform en masse movement in the desired direction. As shown in the reported case, the use of mini-implants provided absolute anchorage for the desired tooth movement. To date, clinical efficacy 14,20,28,29,30 and stability29,31 of temporary orthodontic skeletal anchorage devices have been widely described. With the use of the mini-implants, maximum en masse retraction of the maxillary and mandibular anterior teeth was possible without patient compliance. As can be seen in the current report, the use of mini-implants provided a better system for controlling anchorage and facilitating our mechanics.
CONCLUSION
• Mini-implants in this case report showed significant improvement in correction of proclination, profile and competency of lips also improved.
• Mini-implants proved as an absolute anchorage for en masse retraction of the anterior teeth.
• Mini-implants can be used to simplify the treatment in such Class I bimaxillary dentoalveolar protrusion by reducing the patient`s compliance.
ACKNOWLEDGEMENT
Our sincere thanks to Dr Sunita Shrivastav and Dr RH Kamble for their guidance. Authors acknowledge the immense help received from the scholars whose articles are cited and in-cluded 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=417http://ijcrr.com/article_html.php?did=4171. Proffit, W.R., Fields, H.W., Sarver, D.M., Contemporary Orthodontics, 2007. fourth ed. Mosby Elsevier, St. Louis, MO.
2. Lamberton, C.M., Reichart, P.A., Triratananimit, P. Bimaxillary protrusion as a pathologic problem in the Thai. Am. J. Orthod.1980; 77 (3), 320–329.
3. Lew, K. Profile changes following orthodontic treatment of bimaxillary protrusion in adults with the Begg appliance. Eur. J. Orthod.1989; 11 (4), 375–381.
4. Tan, T.J. Profile changes following orthodontic correction of bimaxillary protrusion with a preadjusted edgewise appliance. Int. J. Adult Orthod. Orthognath. Surg.1996; 11 (3), 239–251.
5. Fonseca, R.J., Klein, W.D. A cephalometric evaluation of American Negro women. Am. J. Orthod.1978; 73 (2), 152–160.
6. Rosa, R.A., Arvystas, M.G. An epidemiologic survey of malocclusions among American Negroes and American Hispanics. Am. J. Orthod.1978; 73 (3), 258–273.
7. Farrow, A.L., Zarrinnia, K., Azizi, K. Bimaxillary protrusion in black Americans – an esthetic evaluation and the treatment considerations. Am. J. Orthod. Dentofacial Orthop.1993; 104 (3), 240–250.
8. Scott, S.H., Johnston Jr., L.E. The perceived impact of extraction and nonextraction treatments on matched samples of African American patients. Am. J. Orthod. Dentofacial Orthop.1999; 116 (3), 352–360.
9. Bills, D.A., Handelman, C.S., BeGole, E.A. Bimaxillary dentoalveolar protrusion: traits and orthodontic correction. Angle Orthod. 2005;75 (3), 333–339.
10. Roberts, W.E., Helm, F.R., Marshall, K.J., Gongloff, R.K. Rigid endosseous implants for orthodontic and orthopedic anchorage. Angle Orthod.1989; 59 (4), 247–256.
11. Roberts, W.E., Marshall, K.J., Mozsary, P.G. Rigid endosseous implant utilized as anchorage to protract molars and close an atrophic extraction site. Angle Orthod.1990; 60 (2), 135–152.
12. Sugawara, J., Daimaruya, T., Umemori, M., et al. Distal movement of mandibular molars in adult patients with the skeletal anchorage system. Am. J. Orthod. Dentofacial Orthop.2004; 125 (2), 130–138.
13. Choi, B.H., Zhu, S.J., Kim, Y.H. A clinical evaluation of titanium miniplates as anchors for orthodontic treatment. Am. J. Orthod. Dentofacial Orthop.2005; 128 (3), 382–384.
14. Park, H.S., Kwon, T.G. Sliding mechanics with microscrew implant anchorage. Angle Orthod.2004; 74 (5), 703–710.
15. Park, H.S., Bae, S.M., Kyung, H.M., Sung, J.H. Micro-implant anchorage for treatment of skeletal Class I bialveolar protrusion. J. Clin. Orthod.2001; 35 (7), 417–422.
16. Park, H.S., Kwon, O.W., Sung, J.H. Microscrew implant anchorage sliding mechanics. World J. Orthod. 2005a; 6 (3), 265–274.
17. Park, H.S., Lee, S.K., Kwon, O.W. Group distal movement of teeth using microscrew implant anchorage. Angle Orthod. 2005b;75 (4), 602–609.
18. Park, Y.C., Chu, J.H., Choi, Y.J., Choi, N.C. Extraction space closure with vacuum-formed splints and miniscrew anchorage, J. Clin. Orthod. 2005c; 39 (2), 76–79.
19. Park, H.S., Yoon, D.Y., Park, C.S., Jeoung, S.H. Treatment effects and anchorage potential of sliding mechanics with titanium screws compared with the Tweed-Merrifield technique. Am. J. Orthod. Dentofacial Orthop.2008; 133 (4), 593–600.
20. Kanomi, R.. Mini-implant for orthodontic anchorage. J. Clin. Orthod.1997; 31 (11), 763–767.
21. Kurz, C. The use of lingual appliances for correction of bimaxillary protrusion (four premolars extraction). Am. J. Orthod. Dentofacial Orthop. 1997;112 (4), 357–363.
22. Block, M.S., Hoffman, D.R.. A new device for absolute anchorage for orthodontics. Am. J. Orthod. Dentofacial Orthop.1995; 107 (3), 251–258.
23. Armbruster, P.C., Block, M.S. Onplant-supported orthodontic anchorage. Atlas Oral Maxillofac. Surg. Clin. North Am.2001; 9 (1), 53– 74.
24. Wehrbein, H., Glatzmaier, J., Mundwiller, U., Diedrich, P.The Orthosystem – a new implant system for orthodontic anchorage in the palate. J. Orofac. Orthop. 1996a.; 57 (3), 142–153.
25. Wehrbein, H., Merz, B.R., Diedrich, P., Glatzmaier, J. The use of palatal implants for orthodontic anchorage. Design and clinical application of the orthosystem. Clin. Oral Implants Res. 1996b; 7 (4), 410– 416.
26. Umemori, M., Sugawara, J., Mitani, H., Nagasaka, H., Kawamura, H. Skeletal anchorage system for open-bite correction. Am. J. Orthod. Dentofacial Orthop. 1999; 115 (2), 166-174.
27. Costa, A., Raffainl, M., Melsen, B. Miniscrews as orthodontic anchorage: a preliminary report. Int. J. Adult Orthod. Orthognath. Surg. 1998; 13 (3), 201–209.
28. Creekmore, T.D., Eklund, M.K. The possibility of skeletal anchorage. J. Clin. Orthod. 1983;17 (4), 266–269.
29. De Pauw, G.A., Dermaut, L., De Bruyn, H., Johansson, C. Stability of implants as anchorage for orthopedic traction. Angle Orthod. 1999;69 (5), 401–407.
30. Chae, J.M. A new protocol of Tweed-Merrifield directional force technology with microimplant anchorage. Am. J. Orthod. Dentofacial Orthop. 2006 ;130 (1), 100–109.
31. Miyawaki, S., Koyama, I., Inoue, M., Mishima, K., Sugahara, T., Takano-Yamamoto, T. Factors associated with the stability of titanium screws placed in the posterior region for orthodontic anchorage. Am. J. Orthod. Dentofacial Orthop. 2003;124 (4), 373–378.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareBIOCHEMICAL COMPOSITION AND IN-VITRO THROMBOLYTIC ACTIVITY OF MELISSA OFFICINALIS GROWING NATURALLY IN KURDISTAN REGION\IRAQ
English1721Lana Yousif MutalibEnglishThe present study was aimed to evaluate different parts of Melissa officinalis plant from biochemical composition and thrombolytic activity.
Methods: Leaf and stem part of Melissa officinalis growing naturally were assessed for total phenolic, total flavonoid and total tannin contents. Both parts were examined for the invitro thrombolytic activity.
Results: Significant greater amount of total phenolic (27.882 ± 0.544 mcg GAE\g DW) , total flavonoid (256.708 ± 1.447 mcg QE\g DW) and total tannin contents (424.266 ± 1.026 mcg GAE\g DW) were expressed by the leaf part (p < 0.01) in comparison to the stem part. A significant thrombolytic activity were expressed by both parts in comparison to the control negative (distilled water) (p value < 0.0001) at all tested concentration rage. Greatest thrombolytic activity were detected at high concentration (1000 mcg\ml) for both parts. Generally the thrombolytic activity exhibited by the leaf part was higher than that of stem part.
Conclusion: From the results of study we concluded that leaf part of Melissa officinalis was richest in phytochemical constituents with moderate thrombolytic activity.
EnglishMelissa officinalis leaf, Melissa officinalis stem, Thrombolytic activityINTRODUCTION
Hemostasis failure of circulatory system causes thrombus formation consequently blockage of circulatory vascular system leading to series complications such as acute myocardial or cerebral infarction, at times causing death. Allopathic thrombolytic agents used are altepase, streptokinase, anistreplase, urokinase and tissue plasminogen activator (TPA) which are characterized by series side effects such as bleeding, intracranial haemorrhage, severe anaphylactic shock, and lacks specificity [1,2]. Different medicinal uses have been reported for plants from epidemiological researches and studies in addition to their usage in folk medicine. Thrombolytic activity were proven for some foods experimentally, having ability of clot lysis. Significant observations were recorded for some herbs exhibiting thrombolytic effect [3]. Melissa officinalis, family Lamiaceae is perennial aromatic herb, widely used for food and cosmetics. Different medicinal uses have been reported for the plant such as antispasmodic, anti-diabetic, antioxidant, anti-inflammatory, antibacterial and antiviral [4-10]. Variant phytochemical constituents were recorded in Melissa officinalis plant such flavonoid, tannin, phenolic compounds [11,12]. Melissa leaf was the preferred part of plant as medicinal part described by pharmacopeia, often whole herb were used as herbal remedy in some places [13,14]. Lemon balm locally known as “Trinj” is commonly used herb by Kurdish community either for culinary or medicinal purposes. The present study was aimed to find the chemical composition and thrombolytic activity of different parts of Melissa officinalis growing naturally in Erbil city, Kurdistan Region\Iraq.
MATERIALS AND METHODS:
Plant collection:
Arial parts of Melissa officinalis were collected in mountain places (Shaqlawa) of Erbil city, Kurdistan Region\Iraq at March 2015, have been identified by Department of Pharmacognosy, College of Pharmacy \ Hawler Medical University. Stem and leaf parts of plant were dried in shade. Dried plant part materials were kept in closed container under 21-23 o C.
Chemical composition:
Plant materials have been evaluated for quantitative chemical compositions by estimation of total phenolic, total flavonoid and total tannin contents of both parts separately
Estimation of total phenolic contents:
Total phenolic compounds have been estimated according to the Folin-Ciocalteu method with slight modifications [15]. One ml of extract prepared from (0.5g) crude drug was mixed with (9 ml) of distilled water. One ml of FolinCiocalteu reagent was added to diluted extract and allowed to stand at room temperature for 5 minute, then (10ml) of (7%) sodium carbonate were added. The volume have been adjusted to (25ml) and incubated at room temperature for 90 minutes. The absorbance level was measured at 750nm using UV visible spectrophotometer. Total phenolic content was estimated from calibration curve obtained from measuring the absorbance of standard concentration of gallic acid [20, 40, 60, 80 and 100 mcg\ml in distilled water]. The results were expressed as mcg gallic acid equivalent (GAE) \ g of dry weight (DW).
Estimation of total flavonoid:
Total flavonoid was measured by the aluminium chloride colorimetric method [16]. Aliquot of (1 ml) of extract prepared from (1g) was added to (10 ml) volumetric flask containing (4 ml) of distilled water. Then (0.3 ml) NaNO2 5% was added to the flask, after 5 min (0.3 ml) AlCl3 solution (10%) was also added. At 6th min, (2 ml) NaOH (1 M) was added and the total volume was made up to (10 ml) with distilled water. The solution was shaken and the absorbance level was measured versus prepared reagent blank at 510 nm. The total flavonoid content was estimated from calibration curve obtained from measuring absorbance of standard concentration of querstine [20, 40, 60, 80 and 100 mcg\ml in ethanol (80%)] The results was expressed as mcg querstine equivalents (QE)\ g dry weight (DW).
Estimation of total tannin content:
Total tannin content have been estimated according to the Folin-Ciocalteu method described by Tamilselvi et al, 2012 [17] with slight modifications. (0.1 ml) of the plant material extract prepared from (0.5g) crude drug was added with (7.5 ml) of distilled water and (0.5 ml) of Folin-Ciocalteu reagent, to the mixture add (1ml) of (35%) sodium carbonate solution. The volume completed to (10ml) with distilled water. The mixture was shaken and incubated at room temperature for 30 min and absorbance was measured at 725 nm. Total tannin content were measured from calibration curve obtained from measuring absorbance of standard concentration gallic acid [20, 40, 60, 80, 100of gallic acid\ml prepared in distilled water]. Total tannin content were expressed as mcg gallic acid equivalent (GAE)\ g dry weight (DW).
In-vitro thrombolytic assay:
Plant extract preparation:
Powdered plant parts [leaf (MOL) and stem (MOS) separately] introduce for aqueous ethanolic (80%) extraction using ultrasonic assisted extractor as described by Alupuli et al, 2009 [18]. Extracts were concentrated and dried under vacuum using rotary vapour machine. The dried extracts were reconstituted using distilled water at a concentration of 10mg\ml serving as stock solution, then a serial dilution extracts were prepared with concentrations of [200, 400, 600, 800 and 1000 mcg/ml], the solutions were kept overnight. Later the insoluble material were removed through filtration, the clear solution have been evaluated for thrombolytic activity [19,20].
Streptokinase (SK) solution preparation:
Lyophilized Streptokinase vials of 1500000 I.U commercially available in pharmacies (Abbott). One vial content were reconstituted using sterile distilled water, mixed thoroughly. This suspension was used as a standard stock from which 100μL (30,000 I.U) was used for in-vitro thrombolytic activity evaluation [19,20].
Blood sampling:
Five ml blood sample were drawn from health human volunteers (n=5), without recent history of anticoagulant and contraceptive therapy [at least 7-10 days duration]. (0.5 ml) of blood sample were transferred in a sterile aseptic condition to ten previously weighed properly labelled eppendorf tubes [19,20].
Thrombolytic assay:
Thrombolytic assay were carried out according to the described method by Sweta et al, 2007 and Daginawala et al, 2006 [19, 20]. Each properly labelled filled eppendorf tube were incubated at 37 0 C for 45 min. for clot formation. After clot formation the serum was withdrawn without disturbing the clot using syringe. Each tube was weighed again to obtain the clot weight according to the following equation:
weight of clot= weight of clot filled tube - weight of empty
tube
To each eppendorf tube add (0.1ml) of each concentration of extracts of different parts of Melissa officinalis separately, further more incubate the tubes for 90 min at 37 0 C. After incubation the supernatant fluid released from the clot lysis were removed using syringe without disturbing the clot and the tubes were re weighed. Streptokinase (SK) drug and distilled water were used as control positive and control negative respectively. The deviation in the weight of clot between two periods of incubation were expressed as percentage of clot lysis according to the following equation:
% clot lysis = [weight of released clot \ weight clot before
lysis]x 100
Statistical analysis:
All experiments were carried out in triplicate, the results were expressed as mean ± standard deviation (SD). Comparison between means were performed using one tail unpaired t-test method using Graph pad prism 6 program considering p value < 0.001 statistically significant.
RESULTS
Chemical composition
Chemical composition comprising in estimation total phenolic, total flavonoid and total tannin contents of both parts (leaf and stem) of Melissa officinalis plant from standard curves obtained from gallic acid and querstine (figure.1, figure.2 and figure.3), respectively. A significant chemical constituents have been detected in leaf part in comparison to the stem part of the plant (p value Englishhttp://ijcrr.com/abstract.php?article_id=418http://ijcrr.com/article_html.php?did=4181. Collen D. Coronary thrombolysis: streptokinase or recombinant tissue-type plasminogen activator. Ann Intern Med 1990;112: 529–38.
2. Naderi GA, Asgary S, Jafarian A, Askari N, Behagh A, Aghdam RH. Fibrinolytic effects of ginkgo biloba extract. Exp Clin Cardiol 2005; 10(2): 85–7.
3. Yamamoto J, Yamada K, Naemura A, Yamashita T, Arai R. Testing various herbs for antithrombotic effect. Nutrition 2005; 2:580–7.
4. Enjalbert F, Bessiere J, Pellecuer J, Privat G, Doucet G. Analysis of species of Melissa. Fitoterapia 1983; 54: 59-65.
5. Auf’mkolk M, Ingbar JC, Kubota K. Extracts and auto-oxidized constituents of certain plants inhibit the receptor-binding and the biological activity of graves’ immunoglobulins. Endocrinology 1985; 116: 1687- 93.
6. Romeo V, Serena De Luca PA, Poiana M. Antimicrobial effect of some essential oils. J Essent Oil Res 2008; 20: 373-9.
7. Adjorjan B, Buchbauer G. Biological properties of essential oils: an apdated review. Flav Fragr J 2010; 25: 407-26.
8. Spiridon L, Colceru S, Anghel N, Teaca CA, Bodirlau R, Armatu, A. Antioxidant capacity and total phenolic contents of oregano (Origanum vulgare), lavender (Lavandula angustifolia) and lemon balm (Melissa officinalis) from Romania. Nat Prod Res 2011; 25:1657- 61.
9. Birdane YO, Buyukokuroglu ME, Birdane FM, Cemek M, Yavuz H. Anti-inflammatory and antinociceptive effects of Melissa Officinalis L. in rodents. Rev Méd Vét 2007; 158:75-81.
10. Chung MJ, Cho SY, Bhuiyan MJH, Kim KH, Lee SJ. Anti-diabetic effects of lemon balm (Melissa officcinalis) essential oil on glucose and lipid regulating enzymes in type 2 diabetic mice. Brit J Nutr 2010; 104: 180-8.
11. Scarpati ML, Oriente G. Isolamente e constituzione dell’acido rosmarinico (dal Rosmarinus off.). Ric Sci 1958; 28: 2329-33.
12. Adzet T, Ponz R, Wolf E, Schulte E. Content and composition of M. officinalis oil in relation to leaf position and harvest time. Planta Med 1992; 58: 562-4.
13. Pharmacopoea Bohemoslovaca, 4th ed. (PhBS IV). Prague: Avicenum; 1987.p. 101- 103/I, 409-410/III.
14. Govt. of India. Ministry of Health and Family Welfare India Pharmacopeia. New Delhi: Controller of Publications; 1996. p. A53-5.
15. Velioglu YS, Mazza G, Gao L, Oomah BD. Antioxidant activity and total phenolics in selected fruits, vegetables and grain products. J Agric Food Chem 1998; 46(10): 4113- 7.
16. Zhishen J, Mengcheng T, Jianming W. The Determination of flavonoid contents in mulberry and their scavenging effects on superoxide radicals. Food Chem 1999; 64 (4): 555-9.
17. Tamilselvi N, Krishnamoorthy P, Dhamotharan R, Arumugam P, Sagadevan E. Analysis of total phenols, total tannins and screening of phytocomponents in Indigofera aspalathoides (Shivanar Vembu) Vahl EX DC. J Chem Pharm Res 2012; 4(6): 3259-62.
18. Alupuli A, Calinescu I, and Lavric V. Ultrasonic vs. microwave extraction intensification of active principles from medicinal plants. AIDIC Conference Series 2009; 09: 1-8
19. Sweta P, Rajpal SK, Jayant YD, Hemant JP, Girdhar MT, Hatim FD. Effect of Fagonia arabica (Dhamasa) on in vitro thrombolysis. BMC Complement Altern Med 2007; 7: 36.
20. Daginawala HF, Prasad S, Kashyap RS, Deopujari JY, Purohit HJ, Taori GM. Development of an In vitro model to study clot lysis activity of thrombolytic drugs. Thromb J 2006; 4: 14.
21.Blazek Z, Suchár A. Über die Möglichkeit der Aufnahme der Krautdrogen von Melissa officinalis L., Mentha piperita L. und Salvia officinalis L. an Stelle der Blattdrogen in die Arzneibücher. Pharmazie 1956; 11: 671-7.
22. Zou ZW, Xu LN, Tian JY. Antithrombotic and antiplatelet effects of rosmarinic acid, a water soluble component isolated from radix Salviae miltiorrhizae (danshen). Yao Hsueh Hsueh Pao 1993; 28: 241-5.
23. Anonymous. Monographs on the medicinal uses of plants. Exeter: European Scientific Cooperative on Phytotherapy; 1996.
24. Agata I, Kusakabe H, Hatano T, Nishibe S, Okuda T. Melitric acids A and B, new trimeric caffeic acid derivatives from Melissa officinalis. Chem Pharm Bull 1993; 41:1608-11.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareA GUIDE TO MANAGEMENT OF VARIOUS ENDODONTIC PERIODONTAL LESIONS - A CASE SERIES
English2229Rajendran MaheaswariEnglish A. SelvamEnglish M. Jeeva RekhaEnglish A. MahalakshmiEnglish Tukaram Kshirsagar JaishreeEnglishAim: To explain the key to identify the primary disease and secondary disease of the endodontic periodontal lesion and its management using a case series.
Case description: Four cases belonging to different types of endodontic periodontal lesion such as primary endodontic with secondary periodontic lesion, primary periodontic with secondary endodontic lesion, combined lesion, iatrogenic periodontal lesion were explained. The appropriate management and its outcome for each case was elaborated and justified.
Discussion: In all the four cases, patient presented with established chronic secondary disease. Hence all the cases were planned to complete the endodontic therapy initially and then proceed with periodontal therapy such as open flap debridement, hemisection and bone graft, platelet rich fibrin and guided tissue regeneration.
Conclusion: Treatment outcome will be more predictable if the clinician has more thorough knowledge about the diagnosis, treatment sequence with inter-disciplinary approach .Thereby the immediate and true management of the endodontic- periodontic lesions can impede the loss of the natural tooth and delay the more complex treatment.
EnglishEndo perio lesion, Platelet rich fibrin, Palato radicular groove, Hemisection, Iatrogenic perforationINTRODUCTION
Interrelationship of pulp and periodontium begins from the embryonic stage of development of the tooth since they have a common origin (dental papillae). Thus pulp and periodontium has embryonic, functional and anatomic relationship (1). Effect of periodontal disease on the pulp was first described by Turner and Drew in 1919(5). In 1964, Simring and Goldberg described relationship of periodontal and pulpal disease (6). Studies stated that bacterial plaque is the main cause for coexistence of periodontal and pulpal lesion(9-12).The accurate identification of pathway for spread of infection is still a controversy due to presence of various routes such as apical foramen, accessory, lateral, and secondary canals, dentinal tubules and iatrogenic perforation (2,3, 4, 7, 8). According to the primary disease with its secondary manifestation, endodontic periodontal lesions are classified by, Khalid S in 2014 as (13)-
(1) Retrograde periodontal disease: (a) Primary endodontic lesion with drainage through the periodontal ligament, (b) Primary endodontic lesion with secondary periodontal involvement;
(2) Primary periodontal lesion;
(3) Primary periodontal lesion with secondary endodontic involvement;
(4) Combined endodontic-periodontal lesion;
(5) Iatrogenic periodontal lesion. Clinically, a deep narrow probing defect is detected on any aspect of the tooth in cases of primary endodontic lesion with drainage through the periodontal ligament. It represents the sinus tract of the endodontic lesion (13). In cases of primary endodontic lesion with secondary periodontal involvement, long-term existence of the defect, results in advancement of the periodontal disease (13). The primary periodontal lesion with secondary endodontic involvement is due to progression of periodontal infection through lateral canal foramen or apical foramen. Pulp remains vital in most cases of primary periodontal lesion (13). In conditions of combined endodontic-periodontal lesion, the tooth has a nonvital pulp, infected root canal system and a coexisting periodontal defect (13). Iatrogenic periodontal lesions could be due to any adverse condition during dental treatment such as root perforations, coronal leakage along the margin of restoration, dental injuries or trauma, vertical root fractures, use of chemicals such as hydrogen peroxide (17) Identification and elimination of the primary etiopathogenesis of the existing condition is the key route for the success of treatment. Management of the cases in the above conditions mainly depend upon factors such as elimination of the primary cause of the lesion, functional need for the tooth, its restorability after treatment, the prognosis of the tooth, patient cooperation etc(14,15,16,17) Management of these cases often requires combined team approach of an endodontist and a periodontist. In regular practice, endodontic treatment is often followed up by periodontal therapy. In this case report, few cases of periodontitis associated with endodontic lesions and its management has been discussed in the following sections.
CASE REPORTS
Case 1: Primary endodontic with secondary periodontic lesion
A 33 years old female patient reported to Department of Periodontics with a complaint of recurrent swelling and pus discharge in relation to #36 with the history of endodontic treatment in # 36, 6 months back. On clinical examination, the root canal treated #36 presented with grade II furcation involvement and with the probing depth of 8mm with pus discharge from periodontal pocket (Fig.1 and 2). Intra oral periapical radiograph revealed inter dental bone loss in between 36 and 37 and periradicular radiolucency in relation to both mesial and distal root of #36 (Fig.3). After phase 1 therapy, persistence of periodontal pocket in relation to #36 was noted, hence open flap debridement was planned. Under local anesthesia, on elevation of mucoperiosteal flap, Cul-de-sac furcation involvement was detected in relation to #36 (Fig.4). Degranulation and debridement of the furcation defect was done. On achieving hemostasis, flaps were approximated and sutured with black silk 3-0 (Mersilk (Ethicon) – Johnson and Johnson pvt Ltd, India) and periodontal dressing was given. Evaluation after 6 months revealed no signs of inflammation, reduced probing depth with satisfactory radiographic bone fill (Fig.5 and 6).
Case 2: Primary periodontic with secondary endodontic lesion
A 32 years old female patient was referred from Department of Endodontics for management of mobility of tooth #12. On clinical examination, it was root canal treated #12 and presented with grade II mobility with probing depth of 8mm on its palatal aspect (Fig.7). On careful examination, a palato radicular groove was detected in relation to #12 extending beyond the cervical margin. IOPA revealed periradicular radiolucency in #12 (Fig.8). Non surgical Phase 1 therapy with temporary splinting was done and the tooth was kept under observation. During re evaluation after 3 months, surgical management was planned. Under local anesthesia, mucoperiosteal flap was elevated in relation to #12. Dehiscence was seen labially (Fig.9) and a palato radicular groove extending till the apical third of the root with a three walled intra osseous defect was detected (Fig.10). After complete debridement, the palato radicular groove was restored with glass ionomer cement (GIC) (GCFuji I, Blackwell supplies, Essex) (Fig.13). The labial and palatal defect of #12 was planned to fill with demineralized bone graft and platelet rich fibrin (PRF). PRF was prepared by centrifuging 10ml of patient venous blood. Part of PRF was mixed with bone graft and the remaining PRF was used to prepare membrane. Mixture of demineralised bone matrix (Osseograft, Encoll,U. S. A) and PRF was packed well into the labial(Fig.11) and palatal defect(Fig.13). Labial defect was covered with PRF membrane (Fig.12). Flaps were approximated and sutured with black silk 3-0 (Mersilk (Ethicon) – Johnson and Johnson pvt Ltd, India) and periodontal dressing was given. Sutures were removed after 2 weeks post operatively and the patient was reviewed at frequent intervals. Post operative review after 8 months revealed obvious reduction in tooth mobility with probing depth of 2mm (Fig.14). Radiograph also revealed satisfactory bone fill around tooth #12 (Fig.15).
Case 3: Combined lesion
A 45 years old male patient reported to Department of Periodontics with frequent food impaction associated with throbbing pain in relation to #46. On clinical examination, probing depth of 7mm was detected in relation to mesial aspect of #46 along with grade III furcation involvement. Grade III gingival recession in relation to mesial root of #46 was associated with pus discharge and the tooth was found to be non vital on pulp testing (Fig.16). IOPA revealed peri radicular radiolucency in relation to mesial root of #46 (Fig.17). On considering the clinical condition, it was planned for a nonvital hemisection. After phase 1 therapy, patient was referred to Department of Endodontics for endodontic management of 46. On review after three months, surgical management was planned. Under local anesthesia, buccal and lingual full thickness flap was elevated in relation to #46 and thorough degranulation and debridement was done. Tooth was bisected with diamond coated round disc and mesial half of the tooth along with mesial root was completely removed (Fig.18). Socket was curetted well and irrigated with normal saline. Hemostasis was achieved. Flaps were approximated and sutured with 3.0 black silk (Mersilk (Ethicon) – Johnson and Johnson pvt Ltd, India). Post operative wound healing was uneventful (Fig.19 and 20). Prosthetic rehabilitation was done with fixed partial denture prosthesis (Fig.21). Case 4: Iatrogenic Periodontal lesion A 35 years old male patient, referred from Department of Endodontics for periodontal opinion regarding frequent discomfort of a root canal treated tooth. History of root canal treatment in relation to 36 about a year ago and reported with a complaint of frequent discomfort and pain of the same tooth. On clinical examination, a probing depth of 8mm was detected in relation to #36 (Fig.22). IOPA revealed an root canal treated #36 with perforation extending to furcation area along with inter-radicular radiolucency (Fig.23). This case was planned for hemisection of #36 followed by prosthetic rehabilitation (Fig.24 and 25). The treatment of #36 was similar to case 3.
DISCUSSION
In day to day practice, assessment and treatment planning of an endo perio lesion is challenging as it often ends up in dilemma whether to initiate the treatment with endodontic therapy followed by periodontal treatment or only with periodontal therapy or both in most of cases. As a general rule it is often practiced to complete the treatment of the primary disease alone, if the secondary disease has just begin to progress and in cases of combined presentation of primary and secondary disease it is advised to treat both the disease (18-21) . In all the four cases, patient presented with established chronic secondary disease. Hence all the cases were planned to complete the endodontic therapy initially and then proceed with periodontal therapy. In case 1, patient presented with periodontal disease as secondary disease since she had undergone endodontic treatment 6 months ago. The secondary periodontal disease would have not been considered during the endodontic management and hence it has been mistreated leading to gross destruction of the periodontal apparatus (grade 2 furcation involvement) of the affected tooth #36. As there was grade 2 furcation involvement with 8mm periodontal pocket, closed curettage would not have been sufficient and so open flap debridement was done. Bone regeneration at the end of 6 months indicates the success of proper debridement of infection. In case 2, The main etiological factor being Palato radicular groove (PRG), as these grooves acts as pathway of entry of infection into periodontal apparatus and periapical region. Hence it is considered as primary periodontal lesion with secondary endodontic involvement. The primary aim of treatment was to obliterate the groove and end the communication of infection from oral cavity to periodontal structures. Hence open flap debridement was done and groove was restored with glass ionomer cement. Glass ionomer cement was opted due to its biocompatibility, resistance to water degradation at tooth cement interface, better sealing and bonding ability (22,23). Since the defect was a three walled defect with dehiscence of upto 8 mm, the defect was filled with xenografts along with platelet rich fibrin due to its osteoconductive property and better healing. As the etiological factor was removed, a satisfactory periodontal regeneration with bone fill at the end of 8 months was observed. In Case 3 and 4, bone defect involving the mesial root of mandibular first molar with furcation involvement was present. Due to severity of the defect and intention to save the periodontal support of the remaining roots, hemisection with open flap debridement was done for both the cases. Post operative review depicted good soft tissue healing with sound periodontal support which was necessary for prosthetic rehabilitation.
CONCLUSION
Treatment outcome will be more predictable if the clinician has more thorough knowledge about the diagnosis, treatment sequence with inter-disciplinary approach .Thereby the immediate and true management of the endodontic- periodontic lesions can impede the loss of the natural tooth and delay the more complex treatment.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholar whose articles are cited and included in reference 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=419http://ijcrr.com/article_html.php?did=4191. Mandel E, Machtou P, Torabinejad M. Clinical diagnosis and treatment of endodontic and periodontal lesions. Quintessence Int. 1993;24:135-9.
2. Jansson L, Ehnevid H, Lindskog S, Blomlöf L. The influence of endodontic infection on progression of marginal bone loss in periodontitis. J ClinPeriodontol 1995;22:729-73.
3. Jansson L, Ehnevid H, Blomlöf L, Weintraub A, Lindskog S. Endodontic pathogens in periodontal disease augmentation. J ClinPeriodontol 1995;22:598-602.
4. Jansson L, Ehnevid H, Lindskog S, Blomlöf L. Relationship between periapical and periodontal status. A clinical retrospective study. J ClinPeriodontol 1993;20:117-23.
5. Turner JH, Drew AH. Experimental injury into bacteriology of pyorrhea, Proc R Soc.Med (Odontol) 1919;12:104.
6. Simring M., Goldberg M.The pulpal pocket approach: retrograde periodontitis, J Periodontol 1964; 35:22.
7. Adriaens PA, de Boever JA, Loesche WJ. Bacterial invasion in root cementum and radicular dentin of periodontally diseased teeth in humans: a reservoir of periodontopathic bacteria. J Periodontol 1988; 59(4):222-230.
8. Adriaens PA, Edwards CA, de Boever JA,Loesche WJ. Ultrastructural observations on bacterial invasion in cementum and radicular dentin of periodontally diseased human teeth. J Periodontol 1988.;59(8): 493-503.
9. Haapasalo M, Ranta H, Ranta K,Shah H. BlackpigmentedBacteroides spp. in human apical Periodontitis.Infect Immun. 1986;53(1):149-153.
10. Trope M, Tronstad L, Rosenberg ES, Listgarten M. Darkfield microscopy as a diagnostic aid in differentiating exudates from endodontic and periodontal abscesses. J Endod. 1988; 14(1); 35-38.
11. Jansson L, Ehnevid H, Bloml¨of L, Weintraub A,Lindskog S. “Endodonticpathogens in periodontal disease augmentation. J Clin Periodontol 1995: 22(8); 598-602.
12. DahleUR, Tronstad L, Olsen I. “Characterization of new periodontal and endodontic isolates of spirachet´es,” Eur J Oral Sci.1996 :104(1); 41-47.
13. .Khalid S. Al-Fouzan. A New Classification of Endodontic-Periodontal Lesions Hindawi Publishing Corporation International Journal of Dentistry Volume 2014, Article ID 919173, 5 pages http://dx.doi.org/10.1155/2014/919173
14. Cohen S, Burns RC. Pathways of the pulp, 4thEdition, 1990;840- 844.
15. Newman, Takei, Carranza, et al. Carranza’sClinical Periodontology, 10th edition, 2007.
16. Lindhe J, Karring T and Lang NP.ClinicalPeriodontology and Implantology, 4th edition, 2003.
17. Walton RE, Torbinejad M. Principles and practice of endodontic, 1st Edition, 1986; 665-667.
18. Richard E Walton and Mahmoud Torabinejad. Principles and Practice of Endodontics. 3rd Edition Philadelphia W B Saunders Company; 2002 pp. 467-84.
19. Rotstein I, Simon JH. Diagnosis, prognosis and decision-making in the treatment of combined periodontal-endodontic lesions. Periodontol 2000 2004;34:165-203.
20. Harrington GW, Steiner DR, Ammons WF. The periodontalendodontic controversy. -Periodontol 2000 2002;30:123-30.
21. Meng HX. Periodontic-endodontic lesions. Ann Periodontol 1999;4:84-9.
22. Maldonado A, Swartz ML, Phillips RW. An in vitro study of certain properties of a glass ionomer cement. J Am DentAssoc 1978; 96: 785-791.
23. Vermeersch G, Leloup G, Delmee M, Vreven J Antibacterial activity of glass-Ionomer cements, compomers and resin composites: relationship between acidity and material setting phase. J Oral Rehabil 2005; 32: 368-374.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareHEALTH EDUCATION REGARDING HUMAN PAPILLOMA VIRUS (HPV VACCINE) FOR PRIMARY PREVENTION OF CERVICAL CANCER FOR PARENTS OF ADOLESCENT GIRLS
English3036Paapa DasariEnglish Haritha SagiliEnglish Subitha LakshminarayanEnglishObjective: To assess the existing knowledge regarding causation and prevention of carcinoma cervix and to increase their awareness though a health education program addressing prevention especially by HPV vaccination among teachers and parents of school children.
Material and Methods: This was a cross sectional interventional study conducted in St. Joseph’s of Cluny School, in Puducherry. Health education regarding carcinoma cervix and its prevention was given by an illustrated lecture using powerpoint presentation and Question answer sessions. Pretest and post test questionnaire in Tamil (Local Language) and English was used. Study population was 325 mothers including school teachers. Statistical Analysis: SPSS 16 was used. All categorical variables were presented as percentages and the pre-test and post test questionnaire were compared by using Chi square test.
Results: Knowledge of causation by HPV virus improved from 50% to 98% on post test (pEnglishCarcinoma Cervix, Primary prevention, HPV Vaccine, Health education, Parents of adolescent girlsINTRODUCTION
Cervical cancer is the most common cancer among women in India and is also the most common cuase of mortality when deaths due to cancer are considered. Approximately 510,000 new cases are diagnosed and 288,000 deaths are registered per year World wide. In India, 132,000 new cases were diagnosed and 74,000 deaths were accounted due to carcinoma cervix1 . The cause for carcinoma cervix is well established and it is proven beyond doubt that that Human Papilloma Virus (HPV) is the causative agent in more than 95% of cases. There is long latent period as long as 20 years between the infection with pathogenic HPV and the development of cancer. Primary prevention of cervical cancer is being undertaken in developed World by using Quadrivalent or bivalent vaccine2 . Australia was the first country since 2007 to provide free vaccination to the school going children and now more than 110 countries are implementing HPV vaccination . In India it is not yet incorporated in to child or adult national immunization schedule though it was approved by FDA as early as 20061,3 and is available in India. The public aware ness about this modality of prevention is lacking although Indian Academy of Pediatrics Committee on Immunisation (IAPCOI) recommends offering HPV vaccine to all female children who can afford the vaccine (Category 2 of Indian Academy of Paediatrics categorisation of vaccines). In this context, this study aimed to assess the existing knowledge regarding causation and prevention of carcinoma cervix and to increase their awareness and clear misconceptions though a health education programme addressing prevention especially by HPV vaccination. The target population was school teachers and parents of adolescent school girls.
MATERIAL AND METHODS
This was a cross sectional interventional study conducted in one of the best girl’s schools ( St. Joseph’s of Cluny) in Pondicherrycherry after interacting with the principal and teachers. The summary of the importance of the programme was mailed to the Principal. The project was approved by our Institutional Scientific Committee and Ethics committee ( JIP/IEC/SC/2013/3/398). The programme was conducted in 2 sessions after the school hours. The school authorities informed to the parents of students class 6th to 10th to attend and participate voluntarily in the health education programme. However only mother’s of the adolescent girls attended the programme. Though more than 500 mothers attended the programme, 325 were included in the study as per the sample requirement. The sample size was calculated assuming 50% would have knowledge. With 80% power , 5% alpha error and one sided hypothesis testing the sample size was estimated to be 305. All subjects were approached personally by the investigators and oral informed consent was taken for inclusion into the study. They were told that the programme is being conducted to find out the awareness regarding cervical cancer and its prevention among them and information would be given about cause and prevention of the same by an illustrative lecture in English and Tamil and there will be a question and answer session at the end of the session They were also assured that the identity and the information provided by them would be kept confidential. A self administered questionnaire (In English and local language Tamil) was given to all participants (Pre-test) who gave informed consent for taking part in the study.(Annexure-1). An illustrative Lecture on prevention of carcinoma cervix and HPV vaccine administration and side effects was delivered by the principal investigator. Any doubts/queries were cleared to the participant by the investigator and co- investigators. Post test was conducted at the end of the programme. After the post-test activity was over, they were also given a had-out containing information regarding HPV vaccine .
Statistical Analysis
Data was processed by means of SPSS 16 and presented as proportions. All categorical variables like knowledge regarding Carcinoma cervix , HPV Vaccine were presented as frequencies or percentages The pretest and post test scores were compared by using Chi square test. Differences in the proportions along with 95% confidence intervals is expressed .All statistical analysis was carried out with 5 % level of significance and p value of Englishhttp://ijcrr.com/abstract.php?article_id=420http://ijcrr.com/article_html.php?did=4201. Human Papilloma Virus and related cancers, India. WHO/ICO ,3 red edidtion. Summary report Update June 22,2010.
2. Morbidity Mortality weekly report. Advisory committee on Immunization Practices (ACIP) recommended inmmunisation schedule for persons aged 0 through 18 years and adults aged 19 years and older. United States.2013.www,cdc.gov/mmwr/ preview/mmwrhtml/mm63e0128a1.htm.
3. Food and Drug Administration. Product approval-prescribing information [package insert]. Gardasil [human papillomavirus quadrivalent (types 6, 11, 16, and 18) vaccine, recombinant], Merck and Co, Inc: Food and Drug Administration 2009. Available at http://www.fda.gov/biologicsbloodvaccines/vaccines/approvedproducts/ucm094042.htm. Accessed May 25, 2010.
4. Barry D, Increasing knowledge about HPV and HPV Vaccine amongest adolescents and adults through a school based setting:A Capstone Project.2013. http://scholarworks.umass.edu/nursing_dnp_capstone/31
5. Pandey D. Vanya V, Bhagat S, Binu VS, Shetty J. Awareness and attitude towards Human papilloma Virus (HPV) vaccine among medical students in a Premier Medical School in India. PLoS ONE 7(7): e40619. doi:10.1371/journal.pone.0040619
6. Allen JD, Othus MKD, Shelton RC, Norman N, Tom L, del Carmen MG.Parental decision making about the HPV vaccine. Cancer Epidemiol Biomarkers Prev; 2010; 19(9) : 2187–98.
7. Bair, R.M., Mays, R.M., Sturm, L.A., and Zimet, G.D. Acceptability of the human papillomavirus vaccine among Latina mothers. Journal of Pediatric and AdolescentGynecology, 2008 ;21(6): 329-334. doi:10.1016/j.jpag.2008.02.007
8. Diwaker H. Knowledge and awareness about health seeking behaviour and acceptability of cervical cancer vaccine in Urban women in comparision with school students. J South Asian Feder Obstet Gynae. 2012;4 :47-53.
9. Do kyung Young and Wong Yi Ker.Awareness and accepatability of human papilloma virus vaccine: an application of the instrumental variables bivariate prohibit model.BMC Public health 2012;12:31
10. Bernard, D.M., Cooper, S.C., McCaffery, K.J., Scott, C.M., Skinner S.R. The domino effect: Adolescent girls’ response to human papillomavirus vaccination. Medical Journal of Australia 2011;194(6):297-300. Retrieved from https://www.mja.com.au/ journal/2011/194.
11. Kennedy, A., Sapsis, K., Stokley, S., Curtis, C.R., and Gust, D. Parental attitudes toward human papillomavirus vaccination: Evaluations of an educational intervention, 2008. Journal of Health Communication, 2011;16, 300-313. doi:10.1080/10810 730.2010.532296
12. Kjaer SK, Sigurdsson K, Iversen OE, et al. A pooled analysis of continued prophylactic efficacy of quadrivalent human papillomavirus (types 6/11/16/18) vaccine against high-grade cervical and external genital lesions. Cancer Prev Res (Phila) 2009;2:868–78
13. Gee J, Naleway A, Shui I, et al. Monitoring the safety of quadrivalent human papillomavirus vaccine: Findings from the Vaccine Safety Datalink. Vaccine 2011;29;8279–84
14. Lu, B., Kimar, A., Castellsague, X., and Giuliano, A.R. . Efficacy and safety of prophylacticvaccines against cervical HPV infection and disease among women: A systematic reviewand metaanalysis. BioMed Central Infectious Disease,2014 11(13), 1-16. doi:10.1186/1471-2334-11-13
15. CDC. FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR 2010;59:630–2.
16. Sheridan A. and White, J.. Annual HPV vaccine coverage in England in2009/2010 [pdf]. .http://data.parliament.uk/DepositedPapers/Files/DEP2012-1386/PQ119371-2.pdf
17. Kadis, J.A. McRee, A., Gottlieb, S.L., Lee, M.R., Reiter, P.L., Dittus, P.J., Brewer, N.T.. Mothers’ support for voluntary provision of HPV vaccine in schools. Vaccine, 2011 29,2542-2547. doi:10.1016/j.vaccine.2011.01.067 .
18. Kelminson, K., Saville, A., Seewald, L., Stokley, S., Dickinson, L.M., Daley, M.F., Kempe, A. Parental views of school-located delivery of adolescent vaccines. Journal ofAdolescent Health, 2012; 51, 190-196. doi:10.1016/j.jadohealth.2011.11.016
19. WHO Human papillomavirus vaccines. WHO position paper. 2009;118–131
20. Pealman S et al. Knowledge and Awareness of HPV Vaccine and acceptability to vaccinate in Sub-Saharan Africa: A systematic Review. PLoS ONE 9(3): e90912. doi:10.1371/journal. pone.0090912
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareA CLINICO-ENDOSCOPIC STUDY OF UPPER GI DISORDERS IN RURAL POPULATION OF PONDICHERRY
English3740B. ArjunEnglish A. AnnamalaiEnglish R. BalamuruganEnglish Sunil S. ShivekarEnglish M. KavirajEnglishUpper gastrointestinal disorders are commonly seen in routine clinical practice. Delay in their diagnosis and treatment may lead to fatal complication like cancer. The endoscopic examination of upper GI is not only important in diagnosing common upper GI disorders, but also helpful in identification of premalignant conditions like Barrets esophagus and malignant lesions. This is a retrospectively study of esophagogastroduodenoscopy (EGD) data of 1030 patients reported with various complains of Upper GI symptoms in Department of Surgery, endoscopy division. A total of 1030 patients were investigated. 144 (14%) patients were showed normal findings where as 886 (86%) cases had abnormal findings. The result of present study showed male predominance associated with the upper GI disorders. Gastritis was commonest disorder diagnosed in 701 (79.1%) cases. The duodenitis, oesophagitis, Hiatus hernia, GERD and round worms in duodenum were reported in 296 (33.4%), 328 (37.0%), 69
(7.78%), 21 (2.37%) and 4 (0.45%) cases respectively. 18(2.03%) of the cases were reported with Adenocarcinoma of stomach. Gastritis is the most common upper GI disorder seen the patient population. Timely diagnosis by upper GI endoscopy with patient education and risk factor management is essential to control upper GI disorders in this community.
EnglishEndoscopy, Upper GI disorders, GastritisINTRODUCTION
The prevalence of common upper gastrointestinal disorders like gastritis, duodenitis, oesophagitis, hiatus hernia and adenocarcinoma of stomach are varies between different communities (1). The risk factors like smoking, alcohol, tobacco, food habits, drugs, physical or mental stress, foreign bodies and bacterial infections are actively plays an important role in predisposition and progression of these disorders (2) (3). The upper GI disorders are an outcome of inflammatory response (4). It is a hetrogenous process, which may lead to wide range of complications and manifestations. If left untreated or partial treatment all gastric disorders may lead to lifelong problem in an individual. Some time it may results in malignancy. Gastric disorders are found both in male and female of any age group (5) In most upper gastric disorder patients upper endoscopy is the first line of procedure for investigation, treatment and diagnosis (6). It is used for the examination of lining of esophagus (swallowing tube), stomach, and upper part of the small intestine (duodenum) (7). The epidemiological data on incidence and prevalence of gastric disorders showed wide variation among the different population (8). The pattern of GI disorders is unevenly spread all over the world. Due to improved lifestyle, the incidence of upper gastric disorders has been declining in some part of the world (9). However the knowledge about Upper GI disorders in certain communities is still not sufficient to prepare the guidelines for preventive measures. The present study is a retrospective study carried out in department of surgery Sri Manakula Vinayagar medical college and Hospital with the primary aim to study incidence of various upper GI Tract disorders in patients with the complains of upper gastrointestinal disorders.
MATERIALS AND METHODS
This was a retrospective study of esophagogastroduodenoscopy (EGD) data recorded at a tertiary care hospital in Pondicherry over a period of one year (Jan- Dec 2014). Patients with abdominal pain, difficulty in swallowing, prolonge nausea, blood in vomiting, heart burn, unexplained weight loss, anemia were subjected to endoscopy on a request from concerned consultant physician. This study includes the result of endoscopies done in 1030 patients, which are clinically suspected for upper GI tract disorders. The histopathology study data of 75 patients suspected of adenocarcinoma was also included in this study. RESULTS All The patients who were undergone upper GI endoscopy in the Department of Surgery, Sri Manakula Vinayagar Medical College and Hospital, Pondicherry, for upper gastrointestinal symptoms like heartburns, dyspepsia, Belching, acid brush, dysphagia and upper abdominal pain were included in this study. A total of 1030 patients were investigated by upper GI endoscopy for a period of one year. 144 (14%) patients were shown normal findings where as 886 (86%) cases had abnormal findings (Table.1). The majority of upper GI disorders 660 (45.92%) were in the age group of years as shown in table no .2. The percentage of cases in other age groups of , , and 70> were 5(0.5 %), 299 (20.80%), 419 (29.15%) and 56 (3.89%) respectively. Among the upper GI diseases, the Gastritis was the commonest disorder detected in 701 (79.1%) cases. The deuodenitis, oesophagitis, Hiatus hernia and GERD were reported in 296 (33.4%), 328 (37.0%), 69 (7.78%) and 21 (2.37%) cases respectively. A rare finding of round worms in duodenum was seen in 4 patients (0.45%). The biopsies were taken from patients with suspected adenocarcinoma of stomach and 18 (2.03%) cases were confirmed positive by histopathological examination. (Table.1). In present study the upper GI disorders were predominantly reported in male (59.85%) as compared to female (40.15%) (Table.3)
DISCUSSION
In last few years research studies from all over the world has observed the change in incidence of various gastrointestinal diseases, such as acid-peptic disease, Gastritis and gastric cancer, oesophagitis, hiatus hernia, peptic ulcer and GERD (1). In the present retrospective study 86% patients were reported abnormal findings with gastritis (79.1%) as major disorder in this area, which is similar to other studies from Delhi, Hyderabad and Mumbai (10). Occasionally gastritis can be severe or even life-threatening due to symptoms or internal bleeding. (11). The gastritis is multifactorial disorder, which can cause by infection of H. pylori, smoking, alcohol, physical or mental stress and diet. The H. pylori induced gastritis can easily be treated with the specific antibiotics (12). Change in food habit along with life style modification will positively help in controlling the gastritis in community. The daily practice of yoga with physical exercise also can assist in reducing the incidence of gastritis associated with stress. The prevalence of oesophagitis, deuodenitis are comparatively low in this population. The present study showed that upper GI disorders were predominantly found in male compared to female age grouped between 30-50 years, which showed the strong association between gender and risk factors in development of upper GI disorders (13) (14). In present study, 18 patients (2.03%) were diagnosed with adenocarcinoma by histopathological study. This shows that adenocarcinoma of stomach is uncommon in this population. This may be because of timely treatment, public awareness, modification of life style in this population (15). The endoscopy findings of the 4(0.45%) patients showed the uncommon appearance of round worms in the duodenum. The incidence of hiatus hernia and GERD were reported with 7.78% and 2.37% respectively which is comparable with other studies (7) (16). The result of present study showed the incidence of GERD and hiatus hernia are relatively low but not uncommon. The incidence of hiatus hernia and GERD is increase with the age in western population, we have also found the similar association in our patients, who were age grouped between 30-50 years (1)
CONCLUSION
There are no documented reports available on the prevalence of upper GI disorders in Pondicherry, a southern coastal state. This report will be the basis for the future studies on upper GI disorders in this region. The gastritis, duodenitis, oesophagitis, hiatus hernia and GERD are frequent upper GIT disorders found in population. The presence of worms in the duodenum is less common than other disorders, however the upper GI endoscopy will be useful tool for the differential diagnosis of worms infestation in patients with epigastric pain. Along with the diagnosis and treatment, all the clinicians should educate the patients about the role of H. pylori infection, food habits, personal hygiene, lifestyle, stress and exercise in development of upper GI disorders, which can help in bringing down the incidence of gastrointestinal disorder.
ACKNOWLEDGEMENT
Authors acknowledge the great help received from the scholars whose articles 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. Authors are grateful to IJCRR editorial board members and IJCRR team of re-viewers who have helped to bring quality to this manuscript.
Englishhttp://ijcrr.com/abstract.php?article_id=421http://ijcrr.com/article_html.php?did=4211. E Caglar, B Baysal, and A Dobrucal. The changing pattern of upper gastrointestinal disorders by endoscopy data of the last 40 years. Diagnostic and Therapeutic Endoscopy 2014; 1-5.
2. Gastrits overview available from: URL:http:/www.gastritis. com/2007, http://pubmed.com
3. C bode, JC bode. Alcohol’s Role in Gastrointestinal Tract Disorders. Gastrointestinal Tract Disorders 1997; 22: 93-96.
4. Ando T1, Nobata K, Watanabe O, Kusugami K, Maeda O, Ishiguro K, Ohmiya N, Niwa Y, Goto H. Abnormalities in the upper gastrointestinal tract in inflammatory bowel disease. Inflammopharmacology. 2007: 15(3):101-104.
5. Akash Nabh, Muhammed Sherid, Charles Spurr and Subbaramia Sridhar. Endoscopy of GI Tract. Diagnostic Endoscopy- InTech. 2013; 4: 38-69.
6. HK Aduful, SB Naaeder, R Darko, BN Baako, Clegg-lamptey and KN krumah. Upper gastrointestinal endoscopy at the korle teaching hospital. Ghana Medical Journal 2007; 41:1: 12-16.
7. E Jeje, T Olajide, B Akande et al. Upper Gastrointestinal Endoscopy - Our Findings, Our Experience in Lagoon Hospital, Lagos, Nigeria. Macedonian Journal of Medical Sciences. 2013; 15: 6(2): 168-173.
8. B Loffeld and D Liberov. The changing prevalence of upper gastrointestinal endoscopic diagnoses: A single-centre study. The Journal of Medicine 2012; 70: 5: 222-226.
9. H Miwa. Life style in persons with functional gastrointestinal disorders--large-scale internet survey of lifestyle in Japan. Neurogastroenterol Motil. 2012; 24(5): 464-471.
10. Olga et al. Gastritis staging. International Journal of Surgical Pathology 2008; 16(2): 150-154.
11. Serra Kayaçetin, Servet Güre?çi. What is gastritis? What is gastropathy? How is it classified? Turk J Gastroenterol 2014; 25: 233-247.
12. P Sharma, KK Kumar, M Mahajan, P Gupta et al. Histopathological Spectrum of various gastroduodenal lesions in North India and prevalence of Helicobacter pylori infection in these lesions: a prospective study. Int J Res Med Sci 2015; 3(5): 1236-1241.
13. I Bhaskar, TF Biswas, Upper GI Endoscopy at Community Based Hospital -A Prospective Study. SSRG-IJMS 2015; 2(1): 13-15.
14. PO Ayuo, J Kiplagat. Upper gastrointestinal endoscopy findings in patients referred with upper gastrointestinal symptoms in eldoret, Kenya: A retrospective review upper gastrointestinal endoscopy findings. East African Medical Journal 2014; 91(8): 267-273.
15. Springer. Lifestyle factors associated with gastritis. International Journal of Clinical Oncology 2003; 8(6): 362-368.
16. S Kumar, HI Pandey, A Verma, P Pratim. Prospective analysis of 500 cases of upper GI endoscopy at Tata Main Hospital. (IOSRJDMS) 2014; 13(1): 21-25.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcarePOSTERIOR REVERSIBLE ENCEPHALOPATHY SYNDROME (PRES) IN PREGNANCY
English4144Pratik J. MavaniEnglish Hina V. OzaEnglish Hafsa M. VohraEnglishAims and Objective: Explain association and outcome of Posterior Reversible Encephalopathy Syndrome in Pregnancy.
Method: This is a Retrospective Study based on obstetric patients visited at Civil Hospital, Ahmedabad, Gujarat, India withconvulsion and/or alteration of sensations in the period of 2 YEARS from July 2013 to July 2015. These patients diagnosed as Posterior Reversible Encephalopathy Syndrome with help of MRI Brain. Details of these patients like history, examination and investigation findings recorded and final data analysis done.
Results: All patients with Posterior Reversible Encephalopathy Syndrome had convulsions and alteration of sensations. Development of Posterior Reversible Encephalopathy Syndrome is more common in primigravida, antenatal patients with average age of 21 year. There is increased rate of preterm delivery and Neonatal ICU admissions in neonates which increases morbidity and mortality of babies.
Conclusion: Posterior Reversible Encephalopathy Syndrome develops more commonly in Primigravida Antenatal patients during Third decade of their life. In Posterior Reversible Encephalopathy Syndrome there are increased incidences of unconsciousness, Caesarean delivery, Intensive Care Unit admissions (peripartum morbidity), preterm babies (Neonatal ICU admission) and perinatal mortality. Though Posterior Reversible Encephalopathy Syndrome increases maternal morbidity, no maternal mortality seen.
EnglishPosterior reversible encephalopathy syndrome, MRI brainINTRODUCTION
Posterior Reversible Encephalopathy Syndrome (PRES)1,2 is a clinicoradiological entity that was explained by Hinchey3 . This condition has been designated by a variety of names like Reversible Posterior Leuko encephalopathy Syndrome, Reversible Posterior Cerebral Oedema Syndrome and Reversible Occipital Parietal Encephalopathy
ASSOCIATIONS
• Posterior Reversible Encephalopathy Syndrome can develop in association with a vast array of conditions. However, regardless of the underlying cause, the main abnormality is cerebral vasogenic oedema3 . • Hypertensive encephalopathy, eclampsia-preeclampsia, renal failure, vasculitis, immunosuppressive treatment, electrolyte imbalance and hyper calcaemia have been reported to be major causes of this syndrome.
PATHOPHYSIOLOGY
• ONE THEORY posits a hypertension-induced auto regulatory failure. In Posterior Reversible Encephalopathy Syndrome auto regulatory response maintaining blood pressure is abnormal resulting in a breakdown of the normal blood brain barrier and culminating in vasogenic brain oedema.1,2
• SECOND THEORY posits that excessive arteriolar vasoconstriction results in decreased blood flow, ischemia. Sepsis that leads to endothelial injury also seem to have a role in the pathogenesis.1,2 This Oedema presents without infarction. Therefore accurate treatment is imperative to halt progression and if we remove the cause we can prevent permanent damage. The preferential involvement of the parietal and occipital lobes is thought to be related to the relatively poor sympathetic innervation of the posterior circulation.
DIAGNOSIS
Clinical Manifestations of Posterior Reversible Encephalopathy Syndrome:
• It is clinically characterized by variable associations of seizure activity, alteration of sensations, headache, visual abnormalities, nausea/vomiting, and focal neurological signs.3,6,7,8,11
• Consciousness impairment may range in severity from confusion, somnolence, and lethargy to encephalopathy or coma
Radiological Characteristics of Posterior Reversible Encephalopathy Syndrome:
• It was believed to consistently produce bilateral and symmetric regions of oedema typically located in the white matter and predominating in the posterior parietal and occipital lobes.3,4,6,11
• Cerebral MRI is the key investigation for the diagnosis of Posterior Reversible Encephalopathy Syndrome.
• Fluid-attenuated inversion recovery (FLAIR) sequences also visualize the lesions.
The four radiological patterns of Posterior Reversible Encephalopathy Syndrome11:-
1. Holohemispheric watershed pattern (23 %)
2. Superior frontal sulcus pattern (27 %)
3. Dominant parietal-occipital pattern (22 %)
4. Partial or asymmetric expression of the primary patterns (28 %)
TREATMENT
It is important to treat patients with Posterior Reversible Encephalopathy Syndrome as soon as recognized to avoid the risk of irreversible injury. However, permanent neurological impairment occurs in a minority of patients. 5,7
Correction of the underlying cause of Posterior Reversible Encephalopathy Syndrome:
• In Preeclampsia-eclampsia related Posterior Reversible Encephalopathy Syndrome definitive treatment consists of immediate delivery (i.e. induction or caesarean section), general measures (e.g. Intravenous fluids, thrombo prophylaxis), Blood pressure control, prevention and/or treatment of seizures must be provided.
General measures
• Patients with Posterior Reversible Encephalopathy Syndrome require the symptomatic measures usually taken in the Intensive Care Unit. The need for upper airway protection should be evaluated continuously in patients with marked consciousness impairment or seizure activity. 9,10
Antiepileptic treatment
• Intravenous benzodiazepines (clonazepam 1 mg or diazepam 10 mg) given. The dose can be repeated up to three times if necessary.
• Patients with refractory status epilepticus need midazolam, propofol or thiopental in titrated doses until remission of the clinical seizure activity.
• Inj. mannitol 100 ml intravenous 8 hourly.
MATERIAL AND METHOD
Study type: Retrospective study
No. of patients (n): 9
Place: B. J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India.
Exclusion criteria: Obstetric Patients having Convulsion and not having alteration of sensations in whom MRI not done.
The obstetrical outcomes studied.
• Peripartum maternal morbidity and mortality
• ICU admission
• Preterm delivery The neonatal outcomes studied
• Admission to the neonatal intensive care unit
• Perinatal mortality
• Prematurity
RESULTS
• Majority cases of Posterior Reversible Encephalopathy Syndrome seen during period of early 3rd decade of life with an average of 21yr.
• Majority of patients (approximately 66.6%) develop Posterior Reversible Encephalopathy Syndrome during their 1st pregnancy.
• Antenatal patients are more likely (approximately 55.5% among all patients) to develop Posterior Reversible Encephalopathy Syndrome.
• Posterior Reversible Encephalopathy Syndrome has inverse relationship with socioeconomic status.
• All patients had convulsions with average of 3-4 times and alteration of sensations.
• Approximately 11% patients had c/o headache and 22% patients had c/o vomiting and epigastric Pain.
• Approximately 66% patients were conscious. Whereas 34% patients were Unconscious.
• Average Systolic Blood pressure was 160 mm hg and Average Diastolic Blood Pressure was 98 mm hg among all cases of Posterior Reversible Encephalopathy Syndrome.
• Approximately 22% chances of preterm delivery and Neonatal ICU admission of new born. Rate of perinatal mortality of new born is 11%.
Alteration of Renal Functions and Liver Functions was seen in 22% cases which was not so significant.
• Approximately 11% cases needs intensive care unit support to maintain O2 saturation and treatment of pulmonary Oedema. Although no mortality recorded because of early diagnosis and treatment.
DISCUSSION
• Risk of development of Posterior Reversible Encephalopathy Syndrome decreases as parity, socioeconomic status and age increases. Among various clinical features all patients develop convulsion and alteration of sensations. Minority develops nausea, vomiting and unconsciousness.
• Pregnancy Induced Hypertension has direct relationship with Posterior Reversible Encephalopathy Syndrome.
• Posterior Reversible Encephalopathy Syndrome itself not causes alterations of liver and renal functions and it’s not necessary to have altered liver and renal functions to develop Posterior Reversible Encephalopathy Syndrome.
• Posterior Reversible Encephalopathy Syndrome increases morbidity of obstetric patients and itself not so fatal if diagnosed and treated earlier. So not causes maternal mortality. As a part of its treatment, Termination of pregnancy is needed which increases preterm delivery and also morbidity and mortality of newborns.
CONCLUSION
Posterior Reversible Encephalopathy Syndrome seen more commonly in primigravida antenatal patients during third decade of their life. Though Posterior Reversible Encephalopathy Syndrome increases maternal morbidity, no maternal mortality reported. In Posterior Reversible Encephalopathy Syndrome patients there are increased incidences of unconciousness, caesarean section, intensive care unit admissions (peripartum morbidity), preterm delivery (Neonatal ICU admission) and perinatal mortality.
LIMITATIONS
It is not possible to do MRI of all patients with eclampsia. So as we cannot judge how many percent of Eclampsia patients will develop Posterior Reversible Encephalopathy Syndrome.
ACKNOWLEDGMENT
This Research paper is made possible through the immense help and support from my Professors, Senior, Hospital staffs and Friends. First and foremost, I would like to thank GOD for his unconditional guidance as I make my Research. Second, I would like to thank my Professors for their most support and encouragement for giving me this research. Finally, I sincerely thank to my Senior and Friends who advised and helped me to complete this research paper.
Englishhttp://ijcrr.com/abstract.php?article_id=422http://ijcrr.com/article_html.php?did=4221. Bartynski WS (2008) Posterior reversible encephalopathy syndrome, part 1: fundamental imaging and clinical features. AJNR Am J Neuroradiol 29: 1036–1042.
2. Bartynski WS (2008) Posterior reversible encephalopathy syndrome, part 2: controversies surrounding pathophysiology of vasogenic oedema. AJNR Am J Neuroradiol 29: 1043–1049.
3. Hinchey J, Chaves C, Appignani B, et al (1996) A reversible posterior leukoencephalopathy syndrome. N Engl J Med 334: 494–500.
4. McKinney AM, Short J, Truwit CL, et al (2007) Posterior reversible encephalopathy syn- drome: incidence of atypical regions of involvement and imaging findings. AJR Am J Roentgenol 189: 904–912.
5. Schwartz RB, Bravo SM, Klufas RA, et al (1995) Cyclosporine neurotoxicity and its rela- tionship to hypertensive encephalopathy: CT and MR findings in 16 cases. AJR Am J Roentgenol 165: 627–631.
6. Casey SO, Sampaio RC, Michel E, Truwit CL (2000) Posterior reversible encephalopathy syndrome: utility of fluid-attenuated inversion recovery MR imaging in the detection of cortical and subcortical lesions. AJNR Am J Neuroradiol 21: 1199–1206.
7. Lee VH, Wijdicks EF, Manno EM, Rabinstein AA (2008) Clinical spectrum of reversible posterior leukoencephalopathy syndrome. Arch Neurol 65: 205–210.
8. Burnett MM, Hess CP, Roberts JP, Bass NM, Douglas VC, Josephson SA (2010) Presenta- tion of reversible posterior leukoencephalopathy syndrome in patients on calcineurin inhibitors. Clin Neurol Neurosurg 112: 886–889.
9. Servillo G, Striano P, Striano S, et al (2003) Posterior reversible encephalopathy syndrome (PRES) in critically ill obstetric patients. Intensive Care Med 29: 2323–2326.
10. Kozak OS, Wijdicks EF, Manno EM, Miley JT, Rabinstein AA (2007) Status epilepticus as initial manifestation of posterior reversible encephalopathy syndrome. Neurology 69: 894–897.
11. Bartynski WS, Boardman JF (2007) Distinct imaging patterns and lesion distribution in posterior reversible encephalopathy syndrome. AJNR Am J Neuroradiol 28: 1320–1327.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241720EnglishN2015October20HealthcareA COMPARATIVE STUDY OF EFFECTS OF A STATIONARY CYCLE AND MOTORIZED TREADMILL AS AN ADJUNCT TO CONVENTIONAL EXERCISES IN IMPROVING THE FUNCTIONAL STATUS OF PATIENTS
WITH KNEE OSTEOARTHRITIS
English4554Shivani Vaid (P.T.)EnglishObjective: To determine the effectiveness of different interventions: conventional exercises, and a stationary cycle and motorized treadmill as an adjunct to it in improving the functional status of patients with knee osteoarthritis.
Method: Experimental study (RCT type of study). 95 patients with knee osteoarthritis fulfilling the inclusion and exclusion criteria of the study were studied. Patients were randomly allotted by envelope method to any of the three groups. All patients were subjected to a standardized assessment including the detailed demographic details, Visual Analogue Scale (VAS) for assessing pain, 36, 61 The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for pain, stiffness and physical function,
33, 62 Timed Up and Go test (TUG) for assessing physical function and balance, 63, 64, 65 and Single Leg Standing test (SLST) for assessing balance, 65 were taken post 1 week and post 2 weeks of the intervention. The intervention was given on thrice a week schedule for total two weeks follow up. Difference between the three groups was compared by statistical methods.
Result: The study shows that irrespective of the demographic characteristics and the other parameters (OA grade, leg dominance, U/L or B/L, etc.), all the three intervention groups A, B and C are homogenous and comparable and effective intervention types showing statistically significant difference.
Conclusion: The study shows a statistically highly significant result of Group C, i.e. motorized treadmill within sub maximal limits should be used as an adjunct to conventional exercises for treating Grade I and Grade II knee osteoarthritis patients in improving their functional status.
EnglishKnee osteoarthritis, Conventional exercises, Stationary cycle, Motorized treadmillINTRODUCTION
There are more than hundred types of arthritis. The most common type of arthritis is osteoarthritis (OA) or degenerative joint disease. It is a leading cause of disability and commonly affects the middle aged and elderly, although younger people may be affected as a result of injury or overuse. It is often more painful in weight bearing joints such as knee, hip and spine than the wrist, elbow and shoulder joints. Knee OA is a degenerative disease of knee joint, more common in people older than 40 years, predominantly considered a wear and tear process, where there is gradual degradation of the hyaline cartilage that covers the articulating surfaces of the bones of the knee joint. Symptoms may include joint pain, tenderness, stiffness, effusion, decreased movement secondary to pain, muscle weakness, ligament laxity, and radiological changes such as loss of joint space and osteophytes.17 Activities like walking, squatting and stair climbing are affected the most. The incidence of knee OA in India is as high as 12%. According to the International Journal of Rheumatic Disease 2011, the Community Program for Control of Rheumatic Disease (COPCORD) studies conducted in India revealed a significantly higher prevalence of knee pain in the rural (13.7%) compared to urban (6%) community.18, 20 According to The European League against Rheumatism (EULAR) committee report 2012, knee OA is likely to become the 4th most important global cause of disability in women and the 8th most important in men. Moreover, studies over the years have suggested that postural stability and balance control are also altered in people with OA, increasing their risk to falls.12, 14 These findings suggest that modification of traditional rehabilitation programs may improve the overall effectiveness of exercise therapy for people with knee OA. The management of OA is broadly divided into non pharmacological, pharmacological and surgical. Surgical management is generally reserved for failed medical management where functional disability affects the patient’s quality of life. Exercises are considered one of the major interventions in the conservative or non pharmacological treatment of patients with knee osteoarthritis.1, 35 Stationary cycle, a low impact aerobic exercise, proves to be beneficial to improve general fitness, pain and function in patients with knee OA by unloading compressive forces on the knee joints.1, 26 Motorized treadmill, though considered a high impact aerobic exercise, if the speed and inclination is kept within the submaximal limits, 15 may prove to be a better low impact exercise for patients with knee osteoarthritis, as the person is required to walk in the functional position, which is required for the activities in daily living. The present study compares the effects of a stationary cycle and motorized treadmill as an adjunct to conventional exercises in improving the functional status of patients with knee osteoarthritis.
MATERIALS
• Plinth
• Chair with arm rest
• Measuring tape - small - Large (30 m)
• Weighing scale – manual with 1 kg increment
• Stadiometer instrument
• Stop watch application available in mobile
• Pillows
• Sandbag or cloth pad
• Motorized treadmill (Kamachi company)
• Stationary cycle (Body Gym company) • Climbing stool • Parallel bars • Pen, pencil, eraser and sharpener • Ruler and stapler • Notebook • Written informed consent • Patient information sheet • Data collection sheet • Exercise handouts
METHOD STUDY DESIGN: Experimental study (RCT type of study)
SETTING OF THE STUDY: This study was conducted in Physiotherapy department, SSG Hospital, Vadodara.
DURATION OF THE STUDY: Study was completed over a period of four months i.e. December 2013 to March 2014.
SAMPLE SIZE: The difference between means of TUG of group A and group B is 0.76 and S.D (standard deviation) of group A is 0.48 and group B is 0.91 (from pilot study done on 30 knee OA patients referred to OPD 16, S.S.G Hospital, Vadodara, Gujarat, India fulfilling the inclusion and exclusion criteria of the study). With α risk 5% and power 90, the minimum expected sample size in each group came to 20, considering non responsive rate 20%, the minimum total sample size came to 72. [Ref: Med Cal C Version 12.50] 95 patients with knee osteoarthritis fulfilling the inclusion and exclusion criteria of the study were studied.
STUDY POPULATION: Patients coming to Outpatient department and being referred to OPD-16, College of Physiotherapy, S.S.G Hospital, Vadodara, Gujarat, India, at morning time, as new patients with knee OA, fulfilling the inclusion and exclusion criteria of the study.
SAMPLING METHOD: Patients were randomly allotted by envelope method to either of the Three groups: Group A: Conventional Exercises
Group B: Conventional Exercises + Stationary Cycle (voluntary speed) Group
C: Conventional Exercises + Motorized Treadmill (sub maximal speed, 0 inclinations)
SELECTION CRITERIA:
Inclusion criteria: 1
. Age: 40-75 years;
2. Grade I or II on Lawrence and Kellegren Radiological Classification;
3. Osteoarthritis knee (OA Knee) diagnosed according to the American College
Exclusion criteria:
1. Pace maker use or used;
2. Unstable heart conditions;
3. Going to participate in another physical activity program;
4. Inability to pedal a stationary cycle;
5. Inability to walk;
6. Previous knee or hip arthroplasty;
7. Epilepsy;
8. Presence of tumor or cutaneous lesion that could interfere with the procedure;
9. Previous traumatic history;
10. Other significant neurological and musculoskeletal disorders.
DATA COLLECTION AND METHODOLOGY
A written and informed consent about enrolment in the interventional study and maintaining adequate privacy and confidentiality was taken from all the patients included in the study. All patients were subjected to a standardized assessment including the detailed demographic details, Visual Analogue Scale (VAS) for assessing pain, 36,61 The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for assessing pain, stiffness and physical function,33,62 Timed Up and Go test (TUG) for assessing physical function and balance,63,64,65 and Single Leg Standing test (SLST) for assessing balance in patients.65 A detailed clinical, past, personal and family history was taken to rule out any other cause other than idiopathic or primary knee osteoarthritis. Subcommittee on Osteoarthritis of the American College of Rheumatology has defined OA as “A heterogeneous group of conditions that lead to joint symptoms and signs which are associated with defective integrity of articular cartilage, in addition to related changes in the underlying bone at the joint margins.”19 Patients of knee OA were taken from the new cases referred to OPD-16, College of Physiotherapy, S.S.G Hospital, Vadodara. They were randomly allotted by envelope method to any of the three groups: Group A: Conventional Exercises Group B: Conventional Exercises + Stationary Cycle (voluntary speed) Group C: Conventional Exercises + Motorized Treadmill (sub maximal speed, 0 inclinations)
Group A patients were given Conventional exercises according to the American Academy of Orthopedic Surgeons (AAOS) guidelines and protocol for knee conditioning, which includes:
Group B patients were given stationary cycle as a form of exercise adjunct to the conventional exercises. It was given for 10 minutes after the conventional exercises at patient’s voluntary speed.1 (Figure 11.1 and 11.2)
Group C patients were given motorized treadmill as a form of exercise adjunct to the conventional exercises. It was given for 10 minutes after the conventional exercises at sub maximal speed according to Modified Bruce Protocol, 37 starting with the default lowest speed of treadmill being 0.8 miles per hour and gradually increasing, but not exceeding the speed of 1.7 miles per hour, and at 0 degree inclination level. (Figure 12.1 and 12.2)
Each group and each patient was given the same attention by the physiotherapist and the exercises were given with same care and precaution. Patients were allowed to follow the orthopedic advices and the prescribed medication. The assessment was done using the outcome measures VAS, WOMAC, TUG and SLST taken on the date of admission to OPD-16. These outcome measures were again taken post 1 week and post 2 weeks of the intervention. The intervention was given on thrice a week schedule for total two weeks follow up. Difference between the three groups was compared by statistical methods.
RESULT
The result states that irrespective of the demographic characteristics (age, sex, BMI, etc.) and the other parameters (OA grade, leg dominance, U/L or B/L, etc.), all the three intervention groups A, B and C are homogenous, comparable and effective intervention types showing statistically significant difference.
The study shows a statistically significant result of Group A, i.e. conventional exercises as an intervention type, in improving VAS and TUG scores, and a highly significant result in improving WOMAC scores, but there was statistically no significant result in improving SLST scores, in patients with knee osteoarthritis. (Table 2)
The study shows a statistically significant result of Group B, i.e. stationary cycle adjunct to conventional exercises as an intervention type, in improving VAS and SLST scores, and a highly significant result in improving WOMAC and TUG scores, in patients with knee osteoarthritis. (Table 3)
The study shows a statistically highly significant result of Group C i.e. motorized treadmill adjunct to conventional exercises, as an intervention type, in improving all the four outcome measures scores VAS, WOMAC, TUG and SLST scores, in patients with knee osteoarthritis.(Table 4)
DISCUSSION
Osteoarthritis (OA) also called as degenerative joint disease (DJD) is the most common of all joint diseases to affect mankind. Although joint inflammation is implied by the suffix ‘itis’, in osteoarthritis, inflammation is typically found only after there has been substantial articular degeneration.38 Approximately 40% of adults older than the age of 70 suffer from OA of the knee, 80% of people with OA knee have limitation of movement, and 25% cannot perform their major daily activities of living.39 Predisposition to knee OA increases in Asians, especially Indians as there is a common thread that binds millions of inhabitants in near similar lifestyles ranging from squatting and kneeling to sitting cross legged on ground for prayers.40 Knee OA is associated with considerable disability and functional limitation is an inevitable consequence. Studies over the years have suggested that postural stability and balance control are also altered in people with OA, increasing their risk to falls, 12, 14 the need for a specific intervention type hence becomes important. Oliveria AM, Peccin MS, Silva KN, Teixeira LE, Trevisani VF. (2012) studied the impact of exercise on the functional capacity and pain of patients with knee osteoarthritis on a thrice a week intervention for 8 weeks comparing the exercise group which included stationary cycle along with exercises and an instruction group and concluded Quadriceps strengthening exercises for eight weeks are effective to improve pain, physical function, and stiffness of patients with knee OA. Strengthening exercises combined with stretching and stationary bike should be implemented in rehabilitation programs of patients with knee OA.1 The present study compared the conventional exercises and stationary cycle as an adjunct to conventional exercises as two different intervention groups A and B, and found that group B gives more significant results than group A (table 2 and 3), which supports the conclusion of the above study, that strengthening exercises combined with stretching and stationary bike should be implemented in rehabilitation programs of patients with knee OA. Moreover the present study also compared motorized treadmill as an adjunct to conventional exercises i.e. group C with the other two groups A and B, and found that group C gives the most significant results out of the three groups, with pvalue Englishhttp://ijcrr.com/abstract.php?article_id=423http://ijcrr.com/article_html.php?did=4231. Oliveria AM, Peccin MS, Silva KN, Teixeira LE, Trevisani VF. Impact of exercise on the functional capacity and pain of patients with knee osteoarthritis: a randomized clinical trial. Rev Bras Rheumatol 2012; 52(6):870-882.
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