Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcareCYTOLOGICAL EVALUATION OF SEROUS BODY FLUIDS: A TWO YEAR EXPERIENCE IN TERTIARY CARE CENTRE FROM CENTRAL INDIA English0106Preeti Rihal ChakrabartiEnglish Priyanka KiyawatEnglish Amit VarmaEnglish Purti AgrawalEnglish Shilpi DosiEnglish Monal DixitEnglishBackground: Cytological examination of serous body fluids is extremely important since it throws light on the cause, presence of metastatic cells, typing of unknown cases, staging and prognosis of cancer. Aims and Objectives: 1) To study and evaluate current trends in cytological evaluation of serous effusions for various pathological conditions in a tertiary care centre. 2) To analyse their frequency in relation to diagnosis. Material and Methods: Our Study was cross-sectional study performed in Department of Pathology, Sri Aurobindo Medical College and Post Graduate Institute from 1st January 2013 to 31st December 2014. Serous effusions included in the study were pleural, pericardial and peritoneal in origin. All other fluids were excluded from the study. The clinical history and relevant parameters were noted and correlated clinically. Conventional smears and cytospin method were performed on all fluids. Both air dried and wet fixed smears in methyl alcohol were used and stained with Papanicolaou(PAP) and May-Grunwald-Giemsa(MGG) stain. Results: Out of 902 cases, 400(44.3%) were pleural fluid, 485(53.7%) were peritoneal fluid and 17 (1.9%) were pericardial fluids. 820 (90.9%) were of benign effusion and 82(9.1%) were of malignant effusion. Total transudate cases in our study were 622 (68.9%) and exudates were 280 (31.04%). Male to female ratio was 1.5:1 with youngest patient 20 years old and eldest was 85years old. Conclusion: Benign effusions are common in younger age group and malignant in older age group. Combined approach to morphology with May-Grunwald-Giemsa (MGG) and Papanicolaou (PAP) helped in better interpretation than either methods used individually. Preliminary fluid analysis for cytology in resource limited settings, still remains the most convenient and cost effective method in arriving at the diagnosis, thereby reducing the need for invasive investigations and their related complications. Presence and absence of malignant cells at times can be the only clue to the presence of malignancy thereby affecting the prognosis and treatment outcome of the patient. EnglishSerous effusion, Transudate, Exudate, AdenocarcinomaINTRODUCTION The three body cavities (pleura, peritoneum, pericardial) have a common embryologic origin in the mesenchymal embryonic layer. They are lined by mesothelial cells and are supported by appropriate connective tissue, vascular and nervous apparatus. Parietal and visceral layer are separated by thin layer of lubricating fluid that provides the movement of two membrane against each other in the absence of disease.[1] However, in pathological states the serous cavities develop spontaneous effusions and hence provide useful specimen for cytological evaluation. Cytomorphological examination of exfoliated cells in effusions may also provide information of various inflammatory conditions of serous membranes, infection with bacteria, fungus, viruses and parasitic infestations. It can also provide evidence of fistulous connection with a serous cavity. [2] Cytological examination of exfoliated cells in serous cavity effusions is challenging in clinical cytopathology. Twenty percentage of all effusions examined are directly or indirectly related to the presence of malignant disease, with carcinoma of lung as the most common underlying cause.[3] Cytological examination of serous effusion is important for the diagnosis of cancer, for staging and the prognosis of the patient. It is better than biopsy of the serous cavity lining for the diagnosis of malignancy affecting any of the cavities as focal lesion on a serous surface may be missed by biopsy. This leads to false negative results. But in effusions malignant cells exfoliate and accumulate from all the surfaces lining that cavity which represent entire serous cavity. Hence, the diagnostic performance of the cytomorphological study of effusion may be attributable to the fact that the cell population present in the sediment is representative of a much larger surface area than that obtained by needle biopsy.[4,5] The rate of detection of malignant cells is increased further if multiple effusion specimens are evaluated consecutively. This study was conducted to assess the trends of various types of effusions for pathological conditions diagnosed in a tertiary care centre in Central India. MATERIAL AND METHODS The present study was performed to analyse serous effusions for various pathological conditions submitted for evaluation in the Department of Pathology, Sri Aurobindo Medical College and Post Graduate Institute, Indore, Madhya Pradesh from 1st January 2013 to 31st December 2014. All the cases of neoplastic and non neoplastic diseases with serous effusion from pleura, pericardium and peritoneal cavity were included. All other fluids were excluded. Clinical details and relevant history were noted and correlated accordingly. The samples of serous effusions were received in the rubber stopper labelled glass bottles, sterile containers as well as in properly closed large jars in case of large volumes with properly filled requisition forms. Whenever delay was anticipated in processing the sample, sample was store at temperature of 2-60 C. Smears were prepared using the sediment obtained by routine centrifugation at 2000-3000 rpm for 5 minutes and by cytospin method. Both wet fixed (methyl alcohol) and air dried smears were used. They were stained with Papanicolaou (PAP) and May-Grunwald- Giemsa (MGG). Papanicolaou (PAP) stain helped in better interpretation of nuclear features and May-Grunwald- Giemsa (MGG) stain for cytoplasmic features. RESULTS In the present study, total 902 serous fluid samples were studied. Out of 902 fluids, 400 were pleural fluids, 485 were peritoneal fluids and 17 were pericardial fluids. The maximum number of cases (25.6%) were observed in the 4th decade and minimum number (3.10%) were observed in 2nd decade with none in 1st decade of life. Age range of the patients in the present study was from 20 to 70 years. Male preponderance was noted with the ratio of male to female being 1.5:1. [Table 1] Out of 400 cases of pleural effusion, maximum number of cases(108) were observed in the age group of 21-30 years with male preponderance; male to female ratio being 1.8:1. Total 262 cases were transudate in nature and 138 were exudate in nature. Transudate effusions had protein level less than 3 gm% and exudate effusions had more than 3 gm%. Out of 138 cases of exudate in nature, cytological examination revealed, 33 cases were of malignant effusion and 105 cases were of non malignant causes of exudative effusion [Table 2]. Of all the 33 cases of malignant effusion, male preponderance was observed; with male to female ratio 1.2:1 and lung carcinoma being the most common primary site. Of all the pleural effusions, 240 cases were straw coloured, 103 were turbid, 45 were haemorrhagic and 12 were clear in nature.[Table 3] Out of total 485 cases of peritoneal effusion, maximum number of cases(139) were observed in the age group of 31-40 years with female preponderance; male to female ratio was 1:1.4. Total 349 cases were transudate in nature and 136 were exudate in nature. Cytological examination revealed, out of 136 cases of exudate in nature, 46 cases were of malignant effusion and 90 cases were non malignant causes of exudative effusion [Table 2]. Of all the 46 cases of malignant effusion, female preponderance was observed; male to female ratio was 1:5 and ovarian carcinoma being the commonest primary site. Of all the peritoneal effusions, 300 cases were of straw coloured, 70 cases were turbid, 66 cases were haemorrhagic and 49 were clear in nature [Table 3]. Out of 17 cases of pericardial effusion, maximum number of cases(5) were observed in 21-30 years with slight male preponderance; male to female ratio being 1.1:1. Total 11 cases were of transudate in nature, 6 cases were of exudate in nature [Table 2]. On cytological examination of total 6 cases of exudative pericardial effusion, 3 cases were of malignant effusion and 3 were non malignant cause of exudative effusion. Of all the pericardial effusions, 5 were straw coloured, 3 were turbid, 7 were haemorrhagic and 2 were clear [Table 3]. Cytological examination of benign effusions showed singly scattered and sheets of reactive mesothelial cells with clear spaces or windows in between them scattered among macrophages and inflammatory cells [Figure 1]. In malignant effusions, three dimension balls, aggregates forming gland like structures with lumen, and papillary structures were commonly observed [Figure 2,3]. Adenocarcinoma was the most common morphological pattern observed in our study. DISCUSSION The cytological examination of body effusion is a complete diagnostic modality which aims at pointing out the etiology of effusions. The diagnostic performance of the cytologic study of fluid may be attribute to the fact that the cell population present in representative of a much larger surface area than that obtained by needle biopsy.[4,5] Examination of effusion cytology is sometimes tricky as morphology of reactive mesothelial cells may mimic malignant cells. Hence, distinction between reactive mesothelial cells and malignant cells on cytological examination of fluid cytology is a diagnostic challenge. The present study was undertaken to analyse the trends of various serous effusions in Central India and to study the significance of fluid cytology in the diagnosis of various non-neoplastic and neoplastic conditions. In the present study, the most common effusion was peritoneal followed by pleural effusion. Our study correlated with finding of Sherwani R et al. [5] In pleural fluid examination, male preponderance was seen with male to female ratio 1.8:1. Our study show concordance with study by Romero et al [6] and Rasik Hathila et al. [7] However, maximum number of patients with pleural effusion were seen in the 4th decade in the present study. Out of 400 cases of pleural effusions of which maximum number of cases (262) were transudate in nature. Differentiation from transudate on routine examination of fluid is mainly based on levels of protein (Transudate less than 3 gm% and exudate more than 3gm %), Rasik Hathila et al [7] had similar finding. On the cytological examination, transudative effusions are usually characterised by a majority of lymphocytes or other mononuclear cells. In present study, all the transudative effusions had more than 50% lymphocytes which was comparable with study of Kushwaha et al [8] which showed 83.33% of samples of transudative effusion had more than 50 % of lymphocytes. The pattern of predominantly polymorphonuclear cells were observed in most cases of exudative effusion and clinically suspected cases of pneumonia, post myocardial infection and emphysema. Of all the 138 cases of exudative pleural effusion, 33 cases were malignant effusion with male preponderance and lung carcinoma was the most common primary site which is in agreement with study of Lim et al.[9] Breast carcinoma followed by ovarian carcinoma was the next most commonest primary site in the pleural effusion group [Fig 4]. On the basis of cytomorphology, metastatic adenocarcinoma was the most common finding in malignant pleural effusion. Di Bonito et al [10] studied on cytomorphological diagnosis in pleural effusion with autopsy confirmation and found most cases were of adenocarcinoma. Hallman et al,[11] also did a comprehensive study on cytology of fluid from different cavities in children and found lymphoreticular neoplasm to be the cause of almost all malignant effusion in children. Here we found two cases of Non Hodgkins Lymphoma, both were seen in children. In peritoneal fluid examination, female predominance was observed with male to female ratio 1:1.4 and ovarian malignancy was the most common primary site. Jha R et al [12] reported gastric malignancy as the commonest primary in their study, however in female patients ovarian malignancy was the commonest which correlated with our study. Parson et al,[13] Wilailak et al,[14] Monte SA et al [15]and Karoo et al [16] also found ovarian malignancy as commonest primary site, shedding malignant cells in peritoneal fluid. In peritoneal effusion, out of 485 cases, maximum number of cases(349) were transudate in nature. Rasik Hathila et al [7] had similar findings. Of all the 136 cases of exudative effusion, 46 were malignant in nature. Of all the malignant peritoneal effusions, ovarian carcinoma was commonest followed by gall bladder carcinoma and other gynaecological cancers. [Fig 5] In pericardial fluid examination, male predominance was observed; male to female ratio being 1.1:1, maximum number of cases were transudate in nature which was in concordance with the finding of Rasik Hathila et al. [7] Of all the 6 cases of exudative effusion, cytological examination revealed 3 cases were malignant effusion of metastatic adenocarcinoma showing a female predominance. Out of 3 cases, 2 cases had primary in the breast and one was case of unknown primary and succumbed to death. In a study by Robert E et al, [17] metastatic adenocarcinoma with primary from the breast was the commonest finding which correlated with our study. The most common transudate causes were clinically suspected cases of pericarditis, post myocardial infarction, rheumatic heart disease and exudative causes were pericardial inflammation and infection. Pericardial fluid cytology is not of value in making an early diagnosis of cancer, although on several occasion positive fluid cytology did expose an underlying undiagnosed malignancy. Most commonly, it provides the information that a known or suspected cancer has metastasized, in which case corrective surgery is contraindicated. [17] On the basis of tumor cell morphology and its arrangement, diagnosis of different types of malignancy were made. Adenocarcinoma was the most common morphological pattern observed in present study. Breast carcinomas of the medium or large cell type are easily recognized as malignant in effusion because cells have classical features of metastatic adenocarcinoma. The most characteristic feature is presence of large, three-dimensional clusters of round, oval or irregular configuration wherein cells are superimposed on each other. Nuclear features of cancer cells are usually classic and comprise of nuclear enlargement, granularity of chromatin, prominent nucleoli and abnormal mitosis. Lung adenocarcinoma also showed similar cytomorphological features. Sometimes papillary configuration were also seen. However, there remains a group of poorly differentiated adenocarcinoma which can be easily recognized as malignant but fail to display any of the features that make recognisation of tumor type possible. Metastatic ovarian carcinomas also showed adenocarcinoma as commonest cytomorhological pattern. The exact identification of tumor type may be possible in some cases, although in most women a histological diagnosis of tumor type was available. Irrespective of the type of malignant lymphoma, the cancer cells never form cohesive clusters, instead lie singly. Tumor cells have spherical to oval nuclei with irregular contour, nuclear indentation with prominent nucleoli and scant cytoplasm [Figure 6]. Cytological evaluation of body fluid helps in evaluating presence or absence of cancer cells and hence affecting staging, prognosis and treatment plan for the patients. CONCLUSION Benign effusions are common in younger age group and malignant in older age group. Reactive mesothelial cells with window effect were commonly observed in benign effusions. Papillary structures and three dimensional balls were observed in malignant effusions. Combined approach to morphology with May-Grunwald- Giemsa (MGG) and Papinicolaou (PAP) helped in better interpretation than either methods used individually. Preliminary fluid analysis for cytology in resource limited setting still remains the most convenient and cost effective method in arriving at the diagnosis, thereby reducing the need for invasive investigations and their related complications. Cytological analysis of serous effusions have a better diagnostic performance vis-a-vis needle biopsy as the population of cells obtained in a sediment is representative of a larger surface area than the latter. Serous effusions may be present in a case of malignancy either as a manifestation of progression of disease or maybe attributable to any other cause except malignancy. This results in the upstaging or downstaging of tumour and thereby affects treatment plan and prognosis for the patient. Therefore cytological analysis of various effusions should be requested along with its clinicopathological correlation. Englishhttp://ijcrr.com/abstract.php?article_id=451http://ijcrr.com/article_html.php?did=4511. LG Koss, MR Melamed. 5th Edition. Philadelphia: Lippincott Williams and Williams; 2005. Editors. Koss’ Diagnostic Cytology and Its Histopathologic Bases; 919-22. 2. Shidham VB, Falzon M. Serous effusions. In: Gray W, Kocjan G: editors. Diagnostic Cytopathology, 3rd Edition. Churchill Livingstone, Elsevier 2010; 115-175. 3. Ali SZ, Cibas Es. Serous cavity fluid and cerebrospinal fluid cytopathology. New York Springer ;2012:77-131. 4. Frist B, Kahan AV, Koss LG. Comparison of the diagnostic values of biopsies of pleura and cytological evaluation of pleural fluids. Am J Clin Pathol 1979;72:48-5. 5. Sherwani R, Akhtar K, Naqvi AH, Akhtar S, Abrari A, Bhargava R. Diagnostic and prognostic significance of cytology in effusions. J cytol 2005;22:73-7. 6. Romero S, Candela A, Martin C, Hernandez L, Trigo C, Gil J. Evaluation of different criteria for the separation of pleural transduates and exudates. Chest 1993;104:399-404. 7. Hathila RN, Dudhat RB, Saini PK, Italiya SL, Kaptan KR, Shah MB. Diagnosyic importance of serous fluid examination for detection of various pathological conditions- A study of 355 cases. Int J Med Sci Public Health 2013;2:975-979. 8. Kushwaha R, Shasikala P, Hiremath S, Basavraj HG. Cells in pleural fluid and their fluid in differential diagnosis.J Cytol 2008;25:138-43. 9. Lim MH, Garrettc J, Mowlem L, Yap E. Diagnosing malignant pleural effusions: how do we compare? N Z Med J 2013;126:42- 48 10. Luigi DiBonito, Giovanni Falconieri, Isabella Colautti, Daniela Bonifacio, Sandra Dudine: The Positive Peural Effusion. Acta Cytol 1992;36:329-32. 11. James R. Hallman, Kim R.Geisinger: Cytology of fluids from Pleural, Peritoneal, Pericardial cavities in children. Acta Cytol 1992;36:329-32. 12. Jha R, Shrestha HG, Sayami G, Pradhan Sb. Study of effusion cytology in patients with simultaneous malignancy and ascitis. Kathmandu university medical journal 2006;4:483-487. 13. Parsons SL, Lang MW, Steele RJ. Malignant ascitis: a 2-year review from the teaching hospital. Eur J Surg Oncol. 1996;22:237- 9. 14. Wilailik S, Linasmita V, Srivannaboon S. Malignant Ascitis in female patients, a seven year review. J Med Assos Thai 1999;82:15-9. 15. Monte SA, Ehya H, Lang WR. Positive effusion cytology as the initial presentation of malignancy. Acta Cytol. 1987;4:448-52. 16. Karoo RS, Lyold TDR et al, Garcea G, Redway HD, Robertson GSR. How valuable is ascitic fluid cytology in detection and management of malignancy. Post graduate medical journal 2003;79:291-299. 17. Robert E. Zipf, William W.johnston. The role of cytology in the evaluation of Pericardial effusions. Chest 1972;62:593-96

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcareMANAGEMENT OF IPSILATERAL FRACTURE OF HIP AND SHAFT OF FEMUR English0714Vetrivel Chezian SengodanEnglish S. ElangovanEnglish J. Saravana KumarEnglishBackground: Ipsilateral fractures of the hip with fracture of shaft of femur are rare injuries. They warrant special diagnostic and therapeutic considerations. Various techniques and implants have been developed to manage these fractures. No single device has been proved to be superior to others. Material and Methods: 8 patients (6 male and 2 female) with ipsilateral hip and shaft of femur fractures were treated with various fixation devices. Among the hip fractures there were 2 femoral neck and 6 peritrochanteric fractures. Functional outcome was assessed using the Friedman and Wyman classification. Results: All the 8 hip fractures united in a mean duration of 3 months. No osteonecrosis of the femoral head was noted. Of the femoral shaft fractures 5 united in a mean of 8.5 months, 3 were non-unions. One patient developed deep infection, which resolved with debridement and antibiotic treatment. Functional results were good in 4 patients, fair in 2 and poor in 2. Conclusion: Early diagnosis of all injuries and operative treatment are important to improve the functional outcome in ipsilateral hip and shaft fractures. Basically, each technique has individual advantages and disadvantages, and all are technically demanding. Most important factor determines the outcome is the anatomical reduction and stable internal fixation of both fractures. EnglishHip fracture, Reconstruction nail, Long proximal femoral nail, Compression screwINTRODUCTION Ipsilateral femoral hip and shaft fractures are rare injuries. It was reported by Delaney and Street in 1953. [1] The incidence is 5-6% of all femoral fractures. [2] Increase in the incidence may be due to better data reporting, better recognition of the injury pattern and better resuscitation efforts. Normally, this type of injury is caused by high energy trauma like a motor vehicle accident, fall from height and industrial accidents. Associated injuries are very common.[3] The attributed mechanisms include axial compression against the acetabular roof, when the hip in flexion and abduction. Trauma force found to cause buckling of the shaft and shearing the neck of femur. Hence hip fractures are non-displaced or minimally displaced and shaft factures are severely comminuted. Therefore, hip fractures are easily missed and shaft fractures bear significant healing problems. [4] Isolated femoral neck fractures may have high rates of head osteonecrosis and neck nonunion, but combined neck and shaft fractures are reported to have a relatively better outcome. [3-5] This is attributed to the fact that the majority of energy sustained in this type of trauma is dissipated in the shaft of the femur. No single device has been shown to be absolutely superior to others. Swiontkowski (1 987) suggested that there had been nearly 60 recommended methods of managing this fracture combination in his 176 cases collected from 20 series.[6] A variety of management modalities have been described to treat this complex fracture pattern ranging from conservative approach to recently introduced reconstruction nails. These techniques include simultaneous transcervical screwing and shaft plating, intramedullary fixation with additional transcervical fixation, [7, 8] retrograde intramedullary nailing with femoral neck-lag screws,[2] reversed intramedullary fixation with cephalo medullary locking,[9] Ender pins with percutaneous Knowles pins,[10,11] Gamma (long) nailing, and recently introduced reconstruction nailing.[3, 12] All these approaches have their own surgical difficulties. But the ultimate goal of treatment is anatomical reduction and stable fixation of both fractures so that the patient can be mobilized early. MATERIALS AND METHODS The study period ranged from June 2012-December 2014. The total number of patients was eight. The study was conducted in Coimbatore medical college hospital after ethical committee approval. Ipsilateral fracture of the hip and shaft of the femur were included in our study. All the patients had plain radiographs of the pelvis including both hips, thigh including knee and hip joint. Both orthopaedic and non orthopaedic associated injuries are documented. Hip fractures were classified into two main groups, neck and peritrochanter. They were further classified into Garden (neck fractures) and Boyd and Griffin (trochanter). The femoral shaft fractures were also classified with Winquist classification of comminution, [13] site and also into open or closed fractures. Once the patient’s general condition stabilized, they were treated with various operative procedures like reconstruction nail, long proximal femoral nail. (PFN), long dynamic hip screw (DHS) plate and cancellous screws with retrograde intramedullary nailing. In our series, other systemic injuries were found in 4 patients. Two patients had more than three bone fractures. One patient had head injury. Spinal and epidural anesthesia were used in 6 and 2 patients respectively. Reconstruction nails were used for 3 of our patients. While using reconstruction nail, the proximal fracture is fixed first with cephalic screws followed by distal femoral locking. Internal rotation may be necessary to reduce the hip fracture into anatomical position, [14] and this can be done by first fixing the femoral shaft fracture. [15] Dynamic hip screw (DHS) and Long DHS plate fixation was used in 2 patients. Both of them had femoral shaft fractured at the level of proximal 3rd of the femur. Hence we decided to use DHS to fix both fractures. In one case DHS was used for trochanteric fracture fixation, and compression plate for femoral shaft fracture fixation. Minimally displaced trochanteric fracture was fixed first and the shaft was fixed next. Long proximal femoral nail was used in one patient to fix both the fractures. In one patient wound debridement and external fixation was done. Once constitutional symptoms, erythrocyte sedimentation rate and C- reactive protein were normal, femoral neck fracture was fixed with AO cancellous screws. While the soft tissues around the shaft fracture site healed, external fixator was removed and later fixation done with retrograde intramedullary interlocking nailing. After the operation, patients were allowed to ambulate with partial weight bearing as early as possible. Quadriceps strengthening and knee-motion exercise were encouraged. Patients were followed-up in the outpatient department at 4-6 week intervals to assess the clinical and radio graphical fracture healing processes. Protected weight bearing was advised until bony union. Radio graphical union was defined as bridging trabeculae across the fracture site or solid callus with cortical density connecting both fracture fragments. Nonunion was defined as a fracture site which remained unhealed one year after treatment or a fracture which required a second surgery to achieve union. [4, 16] Functional results (Table 1) were assessed according to the Friedman and Wyman classification.[7] RESULTS The diagnosis of neck fracture was not delayed in our series. Hip fractures were classified into two main groups, neck (n = 2) and peritrochanter (n = 6). Among the femoral shaft fractures 3 were open fractures. The data of shaft fracture pattern and grading of comminution are described below [Table 2 and 3] Mean duration of surgery is 140 min. Average blood loss is 450 ml. The mean union time was 3.0 months (range 1.5- 7.0 months) for hip fractures and 8.5 months (range 6-11 months) for shaft fractures. Time of fixation was generally within 7 days, expect one patient who was operated on 10 th day due to head injury. Complications were knee stiffness (two patients) and one deep wound infection. Three patients had non-union of the shaft of the femur. In our series on two year follow up, femoral head osteonecrosis was not encountered even in a single case. Fat embolism was also not encountered in our series. Results (Table 4) were evaluated based on the criteria adopted by Friedman and Wyman classification.[7] Four patients (50%) had a good functional result, two patients (25%) had fair result and in two patients the result (25%) was poor. DISCUSSION Ipsilateral femoral hip and shaft fractures are a challenge to the orthopaedic surgeons. High velocity injury like traffic accidents accounts for majority of cases. Most of the patients were young men and had multi-system injuries. Associated injuries are quite common, because of the high velocity impact, [7, 8, 10 and 15]. The diagnosis of hip fracture can be easily missed, if an anteroposterior radiograph of pelvis or hip is not taken. Early recognition of all fractures is of paramount importance in planning the surgical treatment, and is the first step towards good results. A careful examination and proper roentgenograms of the hip are necessary. In our opinion, entire shaft, hip and knee-joint X-rays are mandatory, to minimize the late detection of these injuries. Three major issues in this type of fracture management are 1) optimal timing of fracture stabilization, 2) deciding which fracture should be stabilized first neck or shaft 3) optimal hardware combinations for fixation. Polytrauma patients with long bone fractures are advised to undergo surgical ducted in Coimbatore medical college hospital after ethical committee approval. Ipsilateral fracture of the hip and shaft of the femur were included in our study. All the patients had plain radiographs of the pelvis including both hips, thigh including knee and hip joint. Both orthopaedic and non orthopaedic associated injuries are documented. Hip fractures were classified into two main groups, neck and peritrochanter. They were further classified into Garden (neck fractures) and Boyd and Griffin (trochanter). The femoral shaft fractures were also classified with Winquist classification of comminution, [13] site and also into open or closed fractures. Once the patient’s general condition stabilized, they were treated with various operative procedures like reconstruction nail, long proximal femoral nail. (PFN), long dynamic hip screw (DHS) plate and cancellous screws with retrograde intramedullary nailing. In our series, other systemic injuries were found in 4 patients. Two patients had more than three bone fractures. One patient had head injury. Spinal and epidural anesthesia were used in 6 and 2 patients respectively. Reconstruction nails were used for 3 of our patients. While using reconstruction nail, the proximal fracture is fixed first with cephalic screws followed by distal femoral locking. Internal rotation may be necessary to reduce the hip fracture into anatomical position, [14] and this can be done by first fixing the femoral shaft fracture. [15] Dynamic hip screw (DHS) and Long DHS plate fixation was used in 2 patients. Both of them had femoral shaft fractured at the level of proximal 3rd of the femur. Hence we decided to use DHS to fix both fractures. In one case DHS was used for trochanteric fracture fixation, and compression plate for femoral shaft fracture fixation. Minimally displaced trochanteric fracture was fixed first and the shaft was fixed next. Long proximal femoral nail was used in one patient to fix both the fractures. In one patient wound debridement and external fixation was done. Once constitutional symptoms, erythrocyte sedimentation rate and C- reactive protein were normal, femoral neck fracture was fixed with AO cancellous screws. While the soft tissues around the shaft fracture site healed, external fixator was removed and later fixation done with retrograde intramedullary interlocking nailing. After the operation, patients were allowed to ambulate with partial weight bearing as early as possible. Quadriceps strengthening and knee-motion exercise were encouraged. Patients were followed-up in the outpatient department at 4-6 week intervals to assess the clinical and radio graphical fracture healing processes. Protected weight bearing was advised until bony union. Radio graphical union was defined as bridging trabeculae across the fracture site or solid callus with cortical density connecting both fracture fragments. Nonunion was defined as a fracture site which remained unhealed one year after treatment or a fracture which required a second surgery to achieve union. [4, 16] Functional results (Table 1) were assessed according to the Friedman and Wyman classification.[7] RESULTS The diagnosis of neck fracture was not delayed in our series. Hip fractures were classified into two main groups, neck (n = 2) and peritrochanter (n = 6). Among the femoral shaft fractures 3 were open fractures. The data of shaft fracture pattern and grading of comminution are described below [Table 2 and 3] Mean duration of surgery is 140 min. Average blood loss is 450 ml. The mean union time was 3.0 months (range 1.5- 7.0 months) for hip fractures and 8.5 months (range 6-11 months) for shaft fractures. Time of fixation was generally within 7 days, expect one patient who was operated on 10 th day due to head injury. Complications were knee stiffness (two patients) and one deep wound infection. Three patients had non-union of the shaft of the femur. In our series on two year follow up, femoral head osteonecrosis was not encountered even in a single case. Fat embolism was also not encountered in our series. Results (Table 4) were evaluated based on the criteria adopted by Friedman and Wyman classification.[7] Four patients (50%) had a good functional result, two patients (25%) had fair result and in two patients the result (25%) was poor. DISCUSSION Ipsilateral femoral hip and shaft fractures are a challenge to the orthopaedic surgeons. High velocity injury like traffic accidents accounts for majority of cases. Most of the patients were young men and had multi-system injuries. Associated injuries are quite common, because of the high velocity impact, [7, 8, 10 and 15]. The diagnosis of hip fracture can be easily missed, if an anteroposterior radiograph of pelvis or hip is not taken. Early recognition of all fractures is of paramount importance in planning the surgical treatment, and is the first step towards good results. A careful examination and proper roentgenograms of the hip are necessary. In our opinion, entire shaft, hip and knee-joint X-rays are mandatory, to minimize the late detection of these injuries. Three major issues in this type of fracture management are 1) optimal timing of fracture stabilization, 2) deciding which fracture should be stabilized first neck or shaft 3) optimal hardware combinations for fixation. Polytrauma patients with long bone fractures are advised to undergo surgical. Reconstruction nailing Reconstruction nailing is a technically demanding procedure with a steep learning curve. The advantages of recon nails include using one incision to treat the combined fractures and saving the bony stock for the insertion of proximal screws for hip fractures. [4, 17] If the reduction is performed in a closed manner, the infection rate and blood loss can be reduced. Other advantages are better cosmetic appearance and shorter hospital stay. Biomechanically, they are load-sharing devices and early rehabilitation is possible. [18] Two-dimension stabilization provided by recon nails. [19] Technical problems include placement of screws into the neck. This can be achieved by significant internal rotation of femur. Figure 1a showed the pre operative x ray of a 22 year old female with ipsilateral shaft and trochanter fracture. Figure1 b showed immediate post operative x ray with good reduction. Figure 1c showed 1 year follow up X-ray showing no visible callus at the fracture site. The reconstruction nails available are theoretically and practically the best option when done by closed means and locked at the either ends. The studies carried out in the anatomic specimens for the suitability of the femoral neck fixation revealed the strength of the reconstruction nail to be 2.5 times superior to the strength of screw fixation of the femoral neck.[20] The two sliding screws for stabilization of the femoral neck with distal locking capability aids the strength and stability. But the central placement of the screw is difficult. Introduction of 135° nail dictates that the screws often come to lie in a superior position on the antero-posterior view. The lack of radiolucent jig for proximal screw insertion makes visualization of the screws on the lateral projection difficult. Introduction of nail requires excessive adduction and flexion which can pose difficulty in fatty and obese patients. The risk of avascular necrosis of the femoral head looms largely due to the damage of the blood vessels at the base of the femoral neck as the nail is driven through the pyriform fossa has been reported by Swiontowski et al[2] Bose et al [21] reported high complication rate after Russel Taylor reconstruction nails. In their series of 11 patients, there were two delayed union, two cases of shortening of the femur, one had a mal-alignment, and three technical errors during the surgery leading to fracture complications. Retrograde nailing Retrograde nailing for the femoral shaft fractures, ipsilateral femoral neck fractures fixation by cancellous screws as suggested by Oh et al [22] can provide easy fixation and favorable results are reported. Theoretically, this seems to be an attractive treatment modality, reducing the incidence of damage of blood supply to the femoral head and fixation of the hip fracture independently. This treatment strategy may involve morbidity associated with an arthrotomy, and sometimes difficulty in removing the nail, as the entry point for the nail is the knee joint. Other disadvantages are knee stiffness, more blood loss and large operative scar. Knee stiffness was seen in our patient who undergone this treatment modality. Figure 2 a showing x-ray of 30 year old man with compound fracture of shaft and neck of femur with external fixator. Fig b shows AO cancellous screw fixation for fracture neck fracture. Fig c showing the radiograph after external fixator removal. Fig 4 showing retrograde nailing for fracture shaft of femur. Proximal Femoral Nailing (PFN) The PFN is available in 130-135° and has a 6° proximal mediolateral angle to facilitate easy insertion from the trochanter. The entry portal of the PFN through the trochanter limits the surgical injury predominantly to the tendinous hip abductor musculature only, unlike those nails which need the entry through the pyriform fossa. The stabilizing and the compression screws of the PFN adequately compress the fracture leaving between them a bone block for further revision of the proximal hip should the need arises. PFN allow the biologically viable fragments to heal around the nail. [24] Almost all the load is transferred to the nail and negligible portion to the medial femoral cortex. Hence intra medullary implant itself acts as a buttress to prevent excessive fracture collapse and shaft medialization. We feel that the long PFN rigidly stabilizes both the factures adequately leading to osseous healing. It also offers the advantage of a reamed and unreamed implantation technique, high rotational stability of the head-neck fragment, and the possibility of static or dynamic distal locking. Figure 3 a showing ipsilateral fracture shaft and trochanter in a 52 year old man. Fig b showing the x ray following fixation with long PFN Douša et al [25] reported good results of ipsilateral fractures of the proximal femur and the femoral shaft treated by the long PFN in 147 cases. They found results do not differ from those reported by other authors. Our patient operated with this technique the functional result was good. Dynamic Hip Screw Device (DHS) Technically, it is much easier to fix such fractures with a plate plus screws or DHS (than an intramedullary nail with screws or a reconstruction nail). It achieves a union rate of 77 to 93% in the femoral shaft and 93 to 100% in the femoral neck, with 77 to 93% of patients achieving good outcomes. [26] The advantages of this technique include reliable and familiar methods of fixation for each fracture. The disadvantages include increased blood loss and periosteal stripping of the femoral shaft, extensive surgical dissection, with potential need for bone graft. A high incidence of infection was reported after plating for femoral shaft fractures. [9] But in our patients who was operated with this technique no infection was noted. Figure 4 a showing radiograph of a 55 yr old man with minimally displaced neck and comminuted shaft of femur fracture. Figure b showing the same patient treated with Dynamic compression and derotation screw with long barrel plate Figure 5 a showing radiograph of a 55 year old man radiograph showing left sided peritrochanteric fracture with spiral fracture in the upper third of femur. Fig b showing the same patient treated with dynamic hip compression screw and barrel plate. Complications The two major complications are nonunion and osteonecrosis. Osteonecrosis represents perhaps the most devastating complication, especially in a young adult. Wiss et al. [9] reported a 6% incidence of osteonecrosis at an average follow up of 32 months. Swiontkowski et al. [2] reported that 2 of 9 (22%) patients who were followed for a minimum of 3 years developed osteonecrosis. Alho [3] found that the incidence of osteonecrosis in ipsilateral femoral neck shaft fractures is less than that in simple femoral neck fracture. Clinical examination and radiographs were reviewed in this study and no head osteonecrosis occurred after a median of nearly two years of follow-up. No further studies such as bone scan, tomography, computed tomography or magnetic resonance imaging were used to assess the viability of the femoral head. Though numerous authors report a union rate of 100% for both fracture, nonunion of the femoral neck and shaft remains a potential serious complication. Wiss [9] and co-workers reported an 18% incidence in his patients. In our serious there were three cases of the femoral shaft nonunions which required revision surgery. Missed neck The world literature reveals an incidence of 19-31% of hip fractures missed during the initial presentation.[2,3 ] Conventional nails in conjunction with cancellous screws by the miss-a-nail technique are appropriate for fractures detected intraoperatively or postoperatively. “Miss a nail technique”: Antegrade nailing for the comminuted femoral shaft fractures and the cancellous screw fixation around the nail for the fixation of the hip fracture. Closed reamed antegrade IM nailing with supplemental screw fixation of ipsilateral femoral neck and shaft fractures did not produce uniformly successful results because of the high rates of varus malunion of the femoral neck fracture. [9] CONCLUSION Early diagnosis and surgical treatment are important for the better functional outcome in the management of ipsilateral fracture of the hip and shaft of the femur. Basically, each technique has individual advantages, disadvantages and is technically demanding. Most important factor determines the outcome of this combined injury is the anatomical reduction and stable internal fixation of both fractures. ACKNOWLEDGEMENT Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Englishhttp://ijcrr.com/abstract.php?article_id=452http://ijcrr.com/article_html.php?did=4521. Delaney W M, Street D M. Fracture of femoral shaft with fracture of neck. Treatment with medullary nail for shaft and Knowles pins for neck. J Int Coll Surg 1953; 19: 303-12. 2. Swiontowski M, Hansen S, Kellam J. Ipsilateral fractures of the femoral neck and shaft- a treatment protocol. J Bone Joint Surg Am. 1984;66:260–8.[PubMed: 6693453] 3. Alho A. Concurrent ipsilateral fractures of the hip and femoral shaft. A meta-analysis of 659 cases. Acta Orthop Scand 1996;67:19-28. 4. Wu CC, Shih CH. Ipsilateral femoral neck and shaft fractures: retrospective study of 33 cases. Acta Orthop Scand 1991;62:346- 51. [PubMed: 1882674]  5. Jain P, Maini L, Mishra P, Upadhyay A, Agarwal A. Cephalomedullary interlocked nail for ipsilateral hip and femoral shaft fractures. Injury 2004;35:1031-8. 6. Swiontkowski M F. Ipsilateral femoral shaft and hip fractures. Orthop Clin North Am 1987; 18 (I): 73-84. 7. Friedman R J, Wyman E T Jr. Ipsilateral hip and femoral shaft fractures. Clin Orthop 1986; 208: 188-94. 8. Zettas JP, Zettas P. Ipsilateral fractures of the femoral neck and shaft. ClinOrthop. 1981;160:63–73. [PubMed: 7285439] 9. Wiss DA, Sima W, Brien WW. Ipsilateral fractures of the femoral neck and shaft. J Orthop Trauma. 1992;6:159–66. [PubMed: 1602335] 10. Casey MJ, Chapman MW. Ipsilateral concomitant fractures of the hip and femoral shaft. J Bone Joint Surg Am. 1979;61:503– 9. [PubMed: 438236] 11. Barquet A, Femandez A, Leon H. Simultaneous ipsilateraltrochenteric and femoral shaft fracture. ActaOrthop Scand. 1985;56:36–9. [PubMed: 3984701] 12. Russell TA. Ipsilateral femoral neck and shaft fractures.ClinOrthopRelat Res. 1986;208:188–94. [PubMed: 3720122] 13. Winquist R A, Hansen S T, Clawson D K. Closed intramedullary nailing of femoral fractures. A report of five hundred and twenty cases. J Bone Joint Surg (Am) 1984; 66: 529-39. 14. Leung KS, So WS, Leung PC (1993) Treatment of ipsilateral femoral shaft fractures and hip fractures. Injury 24(1):41–45. 15. Bernstein SM (1974) Fractures of the femoral shaft and associated ipsilateral fractures of the hip. Orthop Clin North Am 5:799–819. 16. Wu CC. Treatment of femoral shaft aseptic nonunion associated with plating failure: emphasis on the situation of screw breakage. J Trauma 2001;51:710-3. 17. Hossam EM, Adel MH, Emad EY. Ipsilateral fracture of the femoral neck and shaft, treatment by reconstruction interlocking nail. Arch Orthop Trauma Surg 2001;121:71- 4. 18. Rahul Kakkar, Kumar S, Singh AK (2005) Cephalomedullary nailing for proximal femoral fractures. Int Orthop (SICOT) 29 (1):21–24. 19. Rehnberg L, Olerud C. The stability of femoral neck fractures and its influence on healing. J Bone Joint Surg [Br] 1989;71:173-7. 20. Ramser JR, Mihalko WM, Carr JB, Beaudoin AJ, Kruse WR. A comparison of femoral neck fixation with the reconstruction nail versus cancellous screws in anatomic specimens. ClinOrthopRelat Res. 1993;290:189–96. [PubMed: 8472448] 21. Bose WJ, Corces A, Anderson LD. A preliminary experience with the Russel Taylor reconstruction nail for complex femoral fractures. J Trauma. 1992;32:71–6.[PubMed: 1732578] 22. Oh CW, Oh JK, Park BC, Jeon IH, Kyung HS, Kim SY, et al. Retrograde nailing with subsequent screw fixation for ipsilateral femoral shaft and neck fractures. Arch Orthop Trauma Surg. 2006;126:448–53. [PubMed: 16810555] 23. Abalo A, Dossim A, OuroBangna AF, Tomta K, Assiobo A, Walla A. Dynamic hip screw and compression plate fixation of ipsilateral femoral neck and shaft fractures. J Orthop Surg. 2008;16:35–8. 24. Gadegone WM, Salphale YS.Proximal femoral nail-an analysis of 100 cases of proximal femoral fractures with an average followup of 1 year. Int Orthop.2007;31:403–8. [PMCID: PMC2267603] [PubMed: 16823585] 25. Douša P, Bartoníek J, Pavelka T, Lunácek L. Ipsilateral fractures of the proximal femur and the femoral shaft. ActaChirOrthopTraumatolCech. 2010;77:378–88.[PubMed: 21040649] 26. Chen CH, Chen TB, Cheng YM, Chang JK, Lin SY, Hung SH. Ipsilateral fractures of the femoral neck and shaft. Injury 2000;31:719–22.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcareHEALTH AWARENESS ON MALARIA AND ITS RECENT DEVELOPMENTS IN COLLEGE STUDENTS, CHENNAI, SOUTH INDIA English1519K. SivasangeethaEnglish K. Mary SushiEnglish G. ThatchinamoorthyEnglish S. Mini JacobEnglishIntroduction: Among South-East Asia region, India shares two-thirds of the burden of malaria. In Tamil Nadu, Chennai is endemic for malaria in the past few decades. Health education and awareness of malaria among the community are indispensable. The present study was undertaken to create awareness and to assess the effectiveness of the awareness on malaria among Arts and Science college students in Chennai. Materials and Methods: This was questionnaire based cross sectional study conducted among college students in Chennai. Each student was given a pair of pre tested semi-structured questionnaire and was instructed to fill the Questionnaire A before and Questionnaire B at the end of the awareness program anonymously. Statistical analysis was done using McNemer’s test. Results: Age of students who participated in the study (501) ranged from 16 to 37 years. With regard to malaria transmitted by blood transfusion, Red Blood cells being commonly affected, availability of vaccines and eligibility for blood donation, the response rose significantly to 87%, 91%, 63% and 91% respectively after the awareness programme (p=0.000). Conclusion: By educating college students about malaria and its preventive aspects and its recent developments, it is possible to make them as ambassadors to create awareness and spread knowledge among their families, friends, and relatives and in the community. This helps in achieving the main objective of malaria control in reducing malaria cases and deaths by providing access to preventive methods, diagnostic testing and treatment to the entire population at risk. EnglishCollege students, Health awareness, MalariaINTRODUCTION Malaria is an entirely preventable and treatable mosquitoborne illness accounting for nearly 85% of infectious disease burden across the world.1,2 About 36% of the world population is exposed to the risk of contracting malaria. As per reports in the year 2007, India contributed 77% of the total malaria in Southeast Asia.2 In 2013, 97 countries had ongoing malaria transmission.1 Among South-East Asia region, India shares two-thirds of the burden (66%) followed by Myanmar (18%) and Indonesia (10%). India, along with six other countries is in the ‘control phase’ of the malaria elimination programme. In India, around 80% of malaria burden is confined to high risk areas like Odisha, Jharkhand, Chhattisgarh, Madhya Pradesh, Maharashtra, Rajasthan and north-eastern states except Sikkim.3 In Tamil Nadu, Malaria is confined to some of the Urban, Coastal and Riverine areas such as Corporation of Chennai, Ramanathapuram, Paramakudi, Thoothukudi, Kanyakumari, Krishnagiri, Dharmapuri and Thiruvannamalai.4 Chennai city is endemic for malaria for the past few decades. Nearly 70 percent of the malaria cases recorded in the State of Tamil Nadu occurs in Chennai City alone.5 In last two decades in Tamil Nadu deaths due to malaria was drastically reduced by its effective systematic campaign of surveillance, prevention and vector control, and aggressive screening and treatment.6 The National Health Policy (2002) had set the goals of reduction in mortality on account of malaria by 50% by 2010 and efficient control of morbidity. Reduction of malarial morbidity and mortality is also important to meet the overall objectives of reducing poverty and has been included in the Millennium Development Goals. To achieve these targets it is imperative to have active community participation in control of malaria. Community participation in turn depends on people’s knowledge and attitude towards the disease. There is a need to know existing knowledge and attitudes of population regarding malaria as a disease, its treatment and control.7 As per National Rural Health Mission (NRHM), Inter-sectoral collaboration for involvement of non-Health Departments/civil society organizations/corporate sector/local self government, Armed and Paramilitary Forces is also a part of strategies for prevention and control of malaria.8 In endemic areas, Health education and awareness of malaria among the community is indispensable. Most of this awareness programmes on malaria are focused on the vectors responsible for transmission, signs and symptoms of the disease and vector control measures and mosquito bite prevention methods. This is one the first such awareness program on malaria conducted among the Arts and Science college students in Chennai. The present study was undertaken with the aim to create awareness and to assess the effectiveness of the awareness on malaria among Arts and Science college students in Chennai. MATERIALS AND METHODS This was questionnaire based cross sectional study conducted from January 2014 to July 2014 by the Department of Experimental Medicine, The Tamil Nadu Dr. MGR Medical University, Chennai, after obtaining approval from the Institute Ethics Review Board. Chennai is capital of Tamil Nadu, one of the southern states of India, located in the Coromandel Coast of Bay of Bengal with approximately 4.68 million residents. Prior permission was obtained from the Principals of the Arts and Science Colleges for conducting the awareness program on malaria and to assess the knowledge of students before and after the program. The program was conducted at seven Arts and Science colleges in Chennai. The students who were willing to fill the questionnaire were included in the study. Each student was given a pair of pre tested semi-structured questionnaire, serially numbered and labeled as ‘A’ and ‘B’. Students were instructed to fill the Questionnaire A before the awareness program and Questionnaire B at the end of the awareness program anonymously. The filled ‘A’ questionnaire was collected from all students after 10 minutes before the start of the awareness program. The questionnaire was in English and included age, gender and religion. The following aspects were included in the questionnaire- spread of malaria by mosquitoes and Blood transfusion, affects Red Blood Cells (RBCs), availability of vaccines for malaria and eligibility for blood donation after malaria infection. Each question was given three responses 1- Yes, 2- No and 3- do not know. Students were instructed to mark one response accordingly. The awareness program was given through a power point presentation which included causative agent for malaria, modes of spread, sites of infection, signs and symptoms of malaria, diagnosis and duration of treatment, vector control measures and availability of vaccines. At the end of the program, the students were asked to fill the Questionnaire ‘B’ and the same was collected. All the forms were entered in the excel sheet and analyzed using SPSS software Version 11. Statistical analysis was done using McNemer’s test. RESULTS A total of 501 students participated in the study from seven colleges. Age of the students ranged from 16 to 37 years with mean of 20.46 years, SD 3.477. Twenty eight percent (28%) were male students and 72% were female students. Seventy five percent (75%) were Hindus, 20% were Christians and 5% were Muslims. Around 91% of students were already acquainted with the fact that malaria is spread by Mosquitoes as evidenced in their pre awareness response and there is no significant change in the post awareness response. Responses of the students before and after the awareness programme for spread of malaria by Blood transfusion, affects RBCs, availability of vaccines for malaria and eligibility for blood donation after malaria infection is shown in Fig 1. There were a significant rise in the percentage of students who answered correctly in the post awareness questionnaire (p=0.000). DISCUSSION There are many studies conducted nationally and internationally among students and community on their knowledge on signs and symptoms of malaria, causative agents and Vectors involved and their control measures.9-12 To the best of our knowledge, this is the first study reporting on the knowledge of college students on spread of malaria by blood transfusion, RBCs being affected, availability of vaccines and eligibility of blood donation after malarial attack. In the present study, majority of the students were aware that mosquitoes spread malarial infection. Similar results were reported by a study among households in South Africa and in University students from Pakistan.13,14 High baseline knowledge of mosquito transmitting malaria might be attributed to mosquito control measures taken during season by the Corporation of Chennai at two levels ie, control of adult mosquito population and source reduction.15 The World Health Organizations had taken vector borne diseases as the issue for World Health Day 2014 and had set the theme as Small bite; Big threat.16 After the awareness, the response to the transmission of Malaria by blood transfusion went up to 87%. In developing countries where malaria is endemic, transfusion-transmitted malaria is emerging as a major problem. The frequency of transfusion-transmitted malaria varies from 0.2 cases per million in non endemic countries to 50 or more cases per million in endemic areas.17 Transmission of malaria by blood transfusion was one of the first recorded incidents of transfusion-transmitted infection. Globally malaria remains as the most common transfusion transmitted infections.18 In India; the eligibility age for donating blood is 18 years of age. This is the time they are in first or second year of their college. As India is one the endemic countries for malaria, educating these students about the possibility of malaria transmitted by blood transfusion is absolutely essential, in spite of screening the collected blood units for malaria. The response to RBCs as the common site of infection has significantly increased to 91% after the awareness. Understanding that RBCs are commonly affected in malaria would help them to realize the need of taking blood smear by the field workers for diagnosing malaria. The timely collection and examination of blood smear is the key element in the National Malarial Control Strategy. Under the National Vector Borne Diseases Control Programme, the active case detection is carried out by multipurpose health workers (male) under primary health care system.19 Blood smear examination by the field workers helps in early detection of cases and start radical treatment to reduce the risk of transmission of malaria in the community. After the awareness programme, 63% of students knew that vaccines are not available for malaria. Malaria vaccines are considered amongst the most important modalities for potential prevention of malaria disease and reduction of malaria transmission.20 The complexity of the malaria parasite makes development of a malaria vaccine a very difficult task. Given this, there is currently no commercially available malaria vaccine, despite many decades of intense research and development effort.21 Authors from France had reported that 35% of their study population believed that vaccines are available for Malaria.22 A cross sectional qualitative and quantitative study from Ghana in 2007, where malaria vaccine trials had been carried out, reported 90% of the respondents were of the opinion that malaria can be prevented through vaccination. In the same study, 65.9% of respondents preferred vaccines to drugs for malaria control.23 Reports from another qualitative study from Kenya states that majority of the participants felt that malaria vaccine could bring added health benefit to the community.24 Recognizing that vaccines are not available for malaria at present, would make the students realize that vector control measures and early diagnosis and treatments are the only measures available in hand to restrain the spread of malaria. Ninety percent of the students were aware that persons positive for malaria should not donate blood for three months after the awareness programme. In India, as per Voluntary blood donation programme, an operational guideline, issued by National AIDS Control Organization, a person who is treated for malaria is deferred from donating blood for a period of three months.25 According to the U.S, Food and Drug Administration (FDA) screening guidelines, a person should wait for three years to donate blood after completing treatment for malaria, most travelers to an area with malaria are deferred from donating blood for 1 year after their return and former residents of areas where malaria is present will be deferred for 3 years.26 India, being endemic for malaria and deferring voluntary blood donors based on their treatment to malaria for a period of three years would considerably reduce the blood stock available in the blood bank. As most of the blood banks in India depend on college students for voluntary blood donations, it is imperative for these students to know the deferral criteria for blood donation after malaria attack. CONCLUSION By educating college students about malaria and its preventive aspects and latest facts about malaria, it is possible to make them as ambassadors to create awareness and spread knowledge among their families, friends, and relatives and in the community. This helps in achieving the main objective of malaria control in reducing malaria cases and deaths by providing access to preventive methods, diagnostic testing and treatment to the entire population at risk. Ethical Clearance: The study was approved by the Tamil Nadu Dr.M.G.R Medical University Ethics Committee. ACKNOWLEDGEMENTS Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors also acknowledge the Principals of the colleges for giving permission and the students for their participation. was obtained from the Principals of the colleges. No personnel identifiers were entered in the questionnaire. Conflict of Interest: Authors declare that no conflict of interest exists. Englishhttp://ijcrr.com/abstract.php?article_id=453http://ijcrr.com/article_html.php?did=4531. Factsheet on the World Malaria Report 2013 http://www.who. int/malaria/media/world_malaria_report_2013/en/ assessed on 29.04.2015. 2. Kumar A, Valecha N, Jain T, et al. Burden of Malaria in India: Retrospective and Prospective View. In: Breman JG, Alilio MS, White NJ, editors. Defining and Defeating the Intolerable Burden of Malaria III: Progress and Perspectives: Supplement to Volume 77(6) of American Journal of Tropical Medicine and Hygiene. Northbrook (IL): American Society of Tropical Medicine and Hygiene; 2007 Dec. Available from: http://www.ncbi. nlm.nih.gov/books/NBK1720/ assessed on 29.04.2015. 3. Binny Dua, Anita S Acharya. Malaria: current strategies for control in India. Indian Journal of Medical Specialities 2013;4(1):59- 66 4. http://www.nrhmtn.gov.in/vbdc.html assessed on 29.04.2015. 5. DivyaSubash Kumar, Ramachandran Andimuthu, Rupa Rajan, Mada Suresh Venkatesan. Spatial trend, environmental and socioeconomic factors associated with malaria prevalence in Chennai Malaria Journal 2014, 13:14 http://www.malariajournal.com/content/13/1/14 6. http://www.thehindu.com/news/national/tamil-nadu/remarkable-reduction-in-malaria-cases-in-chennai-corporation-area/article4654422.ece assessed on 29.04.2015 7. Arun Kumar Sharma, Sanjeev Bhasin and S. Chaturvedi Predictors of knowledge about malaria in India. J Vect Borne Dis 2007; 44(3): 189–197 8. mohfw.nic.in/WriteReadData/l892s/Chapter06-93270370.pdf assessed on 29.04.2015 9. Amul B. Patel, Hitesh Rathod, Pankil Shah, Viren Patel, JigneshGarsondiya, Rasmi Sharma. Perceptions Regarding Mosquito BorneDiseases In An Urban Area Of Rajkot City. National Journal Of Medical Research 2011; 1 (2):45-47 10. Shanker Matta, Rajesh Kumar G Singh, Rajat Srivastav. A Study On Awareness Regarding Malaria In Rural And Urban Areas Of Delhi During Commonwealth Games-2010.Indian J. Prev. Soc. Med 2012; 43(3): 295-298 11. Vala Mayur, Patel Umed, Joshi Nirav, Zalavadiya Dipesh, Bhola Chirag, Viramgami Ankit. Knowledge and Practices regarding commonly occurring mosquito borne diseases among people of urban and rural areas of Rajkot District, Gujarat. Journal of Research in Medical and Dental Science 2013; 1(2):46-51. 12. Karunamoorthi K. and Kumera A. Knowledge and health seeking behavior for malaria among the local inhabitants in an endemic area of Ethiopia: implications for control. Health, 2010 ;2: 575-581. doi:10.4236/health.2010.26085. 13. Govere J, Durrheim D, la Grange K, Mabuza A, Booman M. Community knowledge and perceptions about malaria and practices influencing malaria control in Mpumalanga Province, South Africa.S Afr Med J. 2000 ;90(6):611-6. 14. Ahmed M, Bota R, Jamali MS, Aziz A, Ilyas T. Malaria and Congo fever: Awareness among university students. Int J Trop Med Public Health. 2013; 2(1): 22-30. doi:10.5455-42/ijtmph. 15. http://ibnlive.in.com/news/chennai-corporation-declares-waron-mosquitoes-ahead-of-rains/290604-62-130.html assessed on 29.04.2015 16. http://www.who.int/mediacentre/news/releases/2014/smallbite-big-threat/en/ assessed on 29.04.2015 17. Bahadur S, Pujani M, Jain M. Use of rapid detection tests to prevent transfusion-transmitted malaria in India. Asian Journal of Transfusion Science2010;4(2):140-141. doi:10.4103/0973- 6247.67033. 18. Kitchen AD, Chiodini PL. Malaria and blood transfusion. Vox Sang. 2006;90(2):77-84. 19. nvbdcp.gov.in/doc/.../malaria%20surveillance%20-%203.doc assessed on 29.04.2015 20. http://www.who.int/immunization/research/development/Rainbow_tables/en/ assessed on 29.04.2015 21. http://www.who.int/malaria/areas/vaccine/en/ assessed on 29.04.2015 22. Pistone T, Guibert P, Gay F, Malvy D, Ezzedine K, Receveur MC, Siriwardana M, Larouzé B, Bouchaud OMalaria risk perception, knowledge and prophylaxis practices among travellers of African ethnicity living in Paris and visiting their country of origin in sub-Saharan Africa. Trans R Soc Trop Med Hyg. 2007;101(10):990-5. 23. Febir LG, Asante KP, Dzorgbo DB, Senah KA, Letsa TS, Owusu-AgyeiS Community perceptions of a malaria vaccine in the Kintampo districts of Ghana. 24. Malar J. 2013 May 7;12:156. doi: 10.1186/1475-2875-12-156. 25. Ojakaa DI, Ofware P, Machira YW, et al. Community perceptions of malaria and vaccines in the South Coast and Busia regions of Kenya. Malaria Journal2011;10:147. doi:10.1186/1475-2875- 10-147. 26. http://naco.gov.in/upload/Policies%20and%20Guidelines/29,%20voluntary%20blood%20donation.pdf assessed on 29.04.2015 27. http://www.cdc.gov/malaria/blood_banks.html assessed on 29.04.2015

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcareOUTCOME OF CONVENTIONAL TRABECULECTOMY WITH OR WITHOUT CATARACT SURGERY English2026Usha B.R.English M. S. UshaEnglish M. Brinda PrasadEnglishPurpose: To study the outcome of conventional trabeculectomy with or without cataract surgery in different types of glaucoma in low risk cases. Materials and Methods: 50 consecutive eyes, each undergoing conventional trabeculectomy and, 50 eyes combined with cataract surgery are included in this prospective study; each patient had a minimum period of follow-up for six months. Preoperative details of medications, visual acuity, slit lamp evaluation, applanation tonometry, cup to disc ratio and visual fields were compared with similar parameters postoperatively. “Complete success” was defined in this study as intraocular pressure (IOP) 5 years. There was no significant difference in IOP reduction between trabeculectomy and combined groups. 87% of long-term “Complete Success” rate in both the groups and 76% visual outcome of > 6/18 in the combined group may be attributed to minimum rate of complications. Conclusion: Conventional trabeculectomy without using antimetabolites is successful even in the present day glaucoma management in low risk glaucoma cases, when performed with technical precision aided by vigilant postoperative care. It is equally effective and convenient when combined with cataract surgery in relevant cases. EnglishGlaucoma, Conventional trabeculectomy, Combined surgery, Complete success, Intraocular pressure, AntimetabolitesINTRODUCTION Cairns1 in 1968, Watson and Grierson2 in 1981 popularized trabeculectomy and it is still regarded as the gold standard to which newer operations are compared. Various studies have shown that conventional trabeculectomy performed without using tissue antimetabolites or releasable sutures or laser suturelysis may yield satisfactory control of intraocular pressure (IOP) for many years3,4,5. Also patients who have financial constraints may not be able to continue with antiglaucoma medications. Conventional trabeculectomy is a safe and economic alternative for such patients, for better control of IOP, stabilization of visual field changes and optic disc damage. Glaucoma and cataract are main causes of visual impairment especially in the age group more than 60 years. Combined glaucoma and cataract surgeries may be considered in patients having glaucoma in its advanced stage with co-existing cataract6 . Despite the proved benefits of current augmented treatment with antimetabolites or shunts they are not totally taken up in developing countries because of their cost, their complexity and the need for regular follow-ups.7 A study done at Nepal mentions complications related to laser suturelysis (which requires costly equipment) like bleb leak and blebitis; early releasable sutures may have higher incidence of hypotony and bleb failure.8 Hence conventional trabeculectomy may be an ideal solution in low risk cases, at the least. MATERIALS AND METHODS This five year prospective study was designed to assess the outcome of conventional trabeculectomy with or without cataract surgery in various types of glaucoma at Mysore Race Club charitable Eye Hospital. Main indications for trabeculectomy were: Failed multidrug antiglaucoma medications, eyes with C/D 0.8 to 0.9, pseudoexfoliation glaucoma, post-angle closure attacks with > 180 degree posterior synechiae, normal tension glaucoma, eyes with severe visual field defects (as per Hodapp Anderson Criteria),9 one eyed, patients from remote rural places, with low compliance, poor socioeconomic status, etc. Cases with significant cataract which precluded fundal view with reduced visual acuity (< 6/24) in presence of uncontrolled glaucoma underwent combined cataract and glaucoma surgery. Exclusion criterion: Patients aged < 40 years, trauma, aphakia, uveitis, neovascular glaucoma, pseudophakic glaucoma, previous trabeculectomy. These were divided into two groups: Trabeculectomy (trab) group where only conventional trabeculectomy was done and, combined group where conventional trabeculectomy was combined with cataract surgery and intraocular lens (IOL) implantation. Only those eyes that had completed follow up for a minimum period of six months were included in this study. In every case details of preoperative antiglaucoma medications and their duration were noted. Each patient underwent preoperative slit lamp examination, Snellen’s visual acuity test, Goldmann applanation tonometry, gonioscopy, cup-todisc (C/D) ratio, which were compared with similar criteria postoperatively. Humphrey field analysis was done in most of the cases wherever it was possible; field test was performed four to eight weeks postoperatively in the combined group. Informed consent was obtained in all patients. Surgical technique: Conventional trabeculectomy was performed by two surgeons of good experience and expertise. Limbus based conjunctival flap was fashioned in upper nasal quadrant. A rectangular block of trabecular tissue was removed after creating a superficial triangular scleral flap of appropriate thickness. Meticulous suturing of scleral flap was done along with water-tight conjunctival closure with 10-0 nylon sutures. Proper postoperative care was taken in each case to detect / control hyphema, shallow anterior chamber, and inflammation, if any. Cataract surgery with IOL implantation was combined with trabeculectomy wherever indicated. Either extracapsular cataract extraction or small incision cataract surgery was performed at the same site; phacoemulsification and trab were done at two different sites. Postoperatively IOP was monitored closely after one week, two weeks, three weeks, four weeks, eight weeks, six months and 3-6 monthly thereafter and more frequently, if found necessary. Most of the cases were followed upto 4-5 years. Postoperative medication included a combination of prednisolone acetate and antibiotic eye drops in tapering doses for a period of 6-8 weeks. Early postoperative pressure spikes were treated with oral acetazolamide. Overdrainage and shallowing of anterior chamber or inflammation were managed with patching /appropriate medication. In every case IOP at the latest follow up was considered for this study. A clear corneal phaco with IOL implantation was performed if necessary, in eyes who developed cataract in the trab group subsequently and their IOP was closely monitored. Criterion of “successful outcome” in this study is defined as a postoperative IOP of < 21mm Hg or a 30% reduction of IOP when compared to the preoperative level; “complete success” is the term used when target pressure could be achieved without adding any glaucoma medication. The data was compiled and results were analyzed statistically using independent samples ‘t’- test or 2 way ANOVA, wherever relevant. RESULTS 50 consecutive eyes of 43 patients were included for study under conventional trab group; and 50 consecutive eyes of 48 patients under the combined group. There were 11 one-eyed patients in the trab group and 14 in the combined group. Post primary angle closure glaucoma in a 50 year old female, showing middilated pupil, patchy iris atrophy and glaucomflecken. Peripheral anterior synechiae seen on gonioscopy) in more than three quadrants necessitated trabeculectomy in this case. Figure 1: Post primary angle closure glaucoma in a 50 year old female, showing middilated pupil, patchy iris atrophy and glaucomflecken. Peripheral anterior synechiae seen (on gonioscopy) in more than three quadrants necessitated trabeculectomy in this case. In the combined group small incision cataract surgery was performed in 30 eyes, extracapsular cataract extraction was done in 3 eyes, at the same site; phacoemulsification and trab were done at two different sites in 17 eyes. Age is a major risk factor for glaucoma. Incidence of glaucoma increases with age.10, 11 Table 1 shows number of patients included under different types of glaucoma and their mean age under each category in trab group and combined group is compared. Patients in the combined group had a higher overall mean age (68.04 + 6.29) when compared to those in the trab group (60.54 + 9.46) which is statistically significant (P = 0.002) as analyzed by 2-way ANOVA test. ACG patients were of younger age in trab group (mean 53.4 + 7.26) in contrast to those in other group / subgroups, which is statistically significant (P = 0.017). Out of 43 patients in the trab group there were 21 females; and out of 48 patients 21 females in the combined group. It was observed that all 15 eyes with ACG in trab group and 6 out of 8 eyes in the combined group were females, confirming that ACG is more common among females. Table 2 shows preoperative and postoperative mean IOP in both the groups in all 4 categories, along with standard deviation, range and P-value. In both Trab and combined groups ACG patients were having higher IOP preoperatively. Postoperative mean IOP in both trab and combined groups at latest follow up is 13.08 + 3.52 and 13.70 + 3.31 mm Hg in both the groups respectively, when compared to the preoperative 34.36+ 10.51 and 32.28 + 7.64 mm Hg (P = 0.0000), which is highly significant, as seen also in each category (POAG, PXG, ACG and NTG), individually (P = 0.000). There is no significant difference in postoperative mean IOP after whether Trab alone or combined is done in PXG/ ACG / NTG eyes. Though the number of cases with NTG is less in this study, IOP reduced by < 50% postoperatively in all seven eyes and it maintained at same level even at sixth month follow up (8 mm Hg postoperatively when compared to preoperative 16 mm Hg). It was observed that in both the groups the postoperative mean IOP was < 16 mmHg in all categories during 100% visits, an IOP level at which visual fields are said to remain stable as mentioned in most of the studies (AGIS : 7).12 It was found that in the trab group out of 50 eyes 19 eyes were not on any antiglaucoma medication preoperatively, 24 eyes were on one or two medicines and seven eyes were on three or more drugs; corresponding figures in the combined group were 11, 27 and 12 eyes respectively. Following surgery 83 eyes did not require any glaucoma medication even when followed up for more than 5 years. One drug was started in six eyes in the trab group and, in seven eyes in the combined group between first and second year follow up, who had advanced field defects, to achieve a target pressure of < 18 mm Hg. In no case two or more drugs were needed even when followed up for 5 years. This indicates that “Complete success” was achieved in 87% of eyes in terms of IOP as defined earlier in this study. In only 13 eyes (13%) a single medication was started, which may be termed “Qualified success”. 13 It was noted that cystic bleb was present in 32 eyes, diffuse bleb in 63 eyes and flat bleb was found in five eyes. Nature of the bleb did not influence IOP in the present study. Out of 50 eyes in the trab group visual acuity (VA) maintained postoperatively at the preoperative level in 41 eyes; preexisting cataract progressed in six eyes; 3 more eyes developed early lenticular opacities. These cases underwent clear corneal phacoemulsification with IOL implantation, with constant monitoring of IOP. In the combined group visual acuity improved in all but four eyes. 76% of eyes improved to a visual acuity of > 20/80 In this group four eyes had near mature cataract; so fundus was not visible. These were postoperatively found to have near total glaucomatous optic atrophy and got VA < 20/200. In most of the eyes C/D and visual fields remained stationery following surgery. Four eyes with near mature cataracts in the combined group were postoperatively discovered to be having near total glaucomatous optic atrophy. C/D < 0.7 was found mainly in the ACG group. 60 eyes with C/D > 0.9 were associated with severe field defects. Out of 100 eyes 62 completed five years of follow up, their glaucoma parameters being stable. 34 eyes could be followed upto 4 years post operatively and remaining 4 eyes for 3 years. Mean duration of follow up in trab and combined groups was 46.66+/-9.14 months and 48.17+/-10.12 months respectively Details of complications noted in this study are shown in Table 4. DISCUSSION Rotterdam study, Roscommon, Beaver Dam, Dalby and several other studies emphasize that prevalence of glaucoma increases as age advances (above 50 years of age).10,11 In our study mean age in trab group is 60.54 +9.46 years. Pia Ehrnrooth13 observed that POAG cases had a mean age of 67.8 years. Andreas wedrich has reported that in combined surgery group mean age was 76.40 years,14 whereas in the present study it is 68.04 years. In the present study postoperative mean IOP achieved in the trab group is 13.08 + 3.52mm Hg. This is comparable to a study done by Y.A.Mutsch and F.Grehn in 99 eyes15 (14.7 mm Hg.) M.E. Gyasi at Ghana observed that postoperative mean IOP was 17.06 in 88.48% out of 191 eyes with open angle glaucoma following conventional trabeculectomy and recommended this in low risk cases.16 High success rate achieved in the present study may be due to several factors: 1. Selection of cases for surgery was restricted to low risk cases; high risk cases are supposed to have < 75% success rate following a conventional trabeculectomy.17 2. Precise operative technique plays a major role in yielding good results. IOP reduction with a limbus based conjunctival flap is supposed to be greater than with a fornix based flap.18 3. There were minimum postoperative complications in the present study which were medically managed. Incidence of hyphema is less when the excision of the tissueblock is anterior to the scleral spur (18% in a study by Konstas AG, 21 which is similar to our study). 4. Intensified postoperative care (IPC) has helped us to achieve target pressure comparable to surgery with antimetabolites.15 5. There were no bleb related complications in the present study because antimetabolites were not used. ME Gyasi,16 Becker - Shaffer (80-90% success rate) and many authors have obtained good results following conventional trabeculectomy in primary open angle glaucoma( POAG) (Table 5).17, 22 A combined surgery may be helpful in elderly patients especially with severe glaucoma and cataract, who may not withstand the stress of two separate surgical sessions.28 Andreas wedrich reported 91% complete success with IOP of 13.5 mm Hg in Phaco + Trab group,14 (v/s 86% success in the combined group in our study, with postoperative mean IOP of 13.7mm Hg); Chen H reported a mean IOP of 13.01 mm Hg in ECCE + Trab group and 12.63 mm Hg in Phaco + Trab group.6 Urban V reported a mean IOP of 15.3 mm Hg29 comparable with present study. Khurana AK reported postop mean IOP of 16.47 mm Hg with 93% complete success30; Edward J obtained a success rate of 88.2%31 It is recommended to observe IOP in these eyes for longer period and also to compare results of conventional trabeculectomy with wound modulated surgery. CONCLUSION Conventional trabeculectomy without wound modulation, with / without cataract surgery done for various types of glaucoma significantly reduces IOP postoperatively even in low risk cases. Success rate is almost equal in both trab and combined groups. Precise surgical technique and careful postoperative monitoring of every case are essential factors in obtaining a sustained reduction of IOP even for > 5 years. A combined surgery may help an elderly person with cataract in a developing country with financial constraints, to have a faster visual recovery along with good glaucoma control. 60% of eyes in our study presented with advanced glaucoma requiring trab / combined surgery between the age group of 60-70 years. This implies the requirement of efficient and economic health care delivery system for earlier detection and management of glaucoma in the community, thereby reducing severity of blindness due to glaucoma. Englishhttp://ijcrr.com/abstract.php?article_id=454http://ijcrr.com/article_html.php?did=4541. Cairns JE. Trabeculectomy. Preliminary report of a new method. Am J Ophthalmol. 1968. 66:673-9. 2. Watson, P.G. and Grierson. The Place of Trabeculectomy in the Treatment of Glaucoma. Ophthalmology, 88, 175-196. 3. D’Ermo F, Bonomi L, Doro D. A critical analysis of the longterm results of trabeculectomy. Am J Ophthalmol 1979. Nov;88(5):829-835 4. K B Mills Trabeculectomy: a retrospective long-term follow-up of 444 cases. Br J Ophthalmol. 1981 Nov; 65(11): 790–795. 5. Nouri-Mahdavi K, Brigatti L, Weitzman M, Cprioli J. Outcomes of trabeculectomy for primary open-angle glaucoma. Ophthalmology. 1995 Dec; 102(12):1760-9. 6. Chen H, Ge J, LiuX, LuF. The clinical analysis of 260 combined surgery of glaucoma and cataract. Yan Ke Xue Bao (Pubmed Article in Chinese - English) 2000 Jun; 16 (2): 102 - 5. 7. Editor,: “Glaucoma in the developing world” BMJ 2006 (4 Nov.); 33 : 932 8. Kumari R., Badhu BP, Das H. “Effectiveness of combination of permanent and releasable scleral flap sutures in trabeculectomy: A randomized clinical trial”, Kathmandu University Medical Journal 2006 Vol.4; No.4, Issue 16: 419 - 425. 9. Douglas R. Anderson, Vincent Michael Patella in: Automated Static Perimetery: Chapter 7: Interpretation of a single field, 2nd ed. Mosby; 1999 page 164. 10. Klein BEK, Klein R, Sponsel WE: Prevalence of glaucoma. Ophthalmology, 1992; 99: 1499 - 504. 11. Scott Fraser, Richard Wormald: Chapter 210, Epidemiology of Glaucoma, in: Ophthalmology, Vol. 2 by Myron Yanoff, Jay S. Duker, 2nd ed. MOSBY: 2004. pp 1413 - 14. 12. The AGIS investigators. The advanced glaucoma intervention study (AGIS): 7 “The relationship between control of intraocular pressure and visual field deterioration”, Am J Ophthalmol 2000 Oct; 130(4): 429 - 40. 13. Ehrnrooth P, Lento, Puska P, Laatikainenl. Long term outcome of trabeculectomy in terms of IOP. Acta Ophthalmol Scand 2002; 80: 267 - 71. 14. Andreas Wedrich, Rupert Menapace, Ursula Redax, Panos Papapanos and Michael Amon, Cataract surgery and trabeculectomy- technique and results. International Ophthalmology 1992; Volume 16, Numbers 4-5, 409-14. 15. Y.A. Mutsch and F.Grehn. Success criteria and success rates in trabeculectomy with and without intraoperative antimetabolites using intensified post operative care (IPC) ; Graefe’s Archive for clinical and experimental ophthalmology 2000 ;Vol. 238, number 11: 884 - 891. 16. ME Gyasi, WMK Amoaku, OA Debrah, EA Awini and P Abugri. Outcome of Trabeculectomies without Adjunctive Antimetabolites. Ghana Med J. 2006 June; 40 (2): 39-44. 17. R. Rand Allingham, Shields’ Text Book of Glaucoma, chapter 40: Filtering surgery, fifth ed. Lippincott Williams and Wilkins; 2005. pp 583 - 594. 18. Sandra J. Sofinski, Pranav Amin, and R.Rand Allingham, Chapter 226: Glaucoma filtration surgery. In Principles and Practice of Ophthalmology, Albert and Jakobiec, Azar, Gragoudas; volume 4, 2nd ed. W.B. Saunder company; 2000. pp 2959-60 19. B.Edmunds, JR Thompson, JF Salmon: Clinical study: The national survey of Trabeculectomy III-Early and late complications; Eye 2002; 16: 297 - 303. 20. Prasad VN, Narain M, Bist HK, Khan MM. Trepano - trabeculectomy (a combined operation for glaucoma); Indian J Ophthalmol 1984; 32: 73 -75. 21. Konstas AG, Jay JL, Modification of trabeculectomy to avoid postoperative hyphaema: “The guarded anterior fistula” operation; Br J Ophthalmol 1992; 76: 353. 22. Robert L Stamper, Marc F. Lieberman, Michael V. Drake In: Becker - Shaffer’s Diagnosis and therapy of the Glaucomas, Part VIII, chapter 36, 7th ed., Mosby ; 1999: pp 591 - 92. 23. Popovic V, Sjostrand J. Long term outcome following trabeculectomy: Retrospective analysis of intraocular pressure regulation and cataract formation. Acta Ophthalmol (Copenh) June 1991; 69: 299-304 24. Akafo SK, Goulstine DB, Rosenthal AR. Long-term, post trabeculectomy intraocular pressures. Acta Ophthalmol (Copenh) 1992; 70: 312. 25. Vesti E. Filtring blebs: Follow up of trabeculectomy. Ophthalmic surgery 1993; 24:249-255. 26. Pia Ehrnrooth: “Long term outcome of trabeculectomy in primary open angle Glaucoma and Exfoliation Glaucoma”: Department of Ophthal, university of Helsinki, Finland; 2005:17 -32. (http:// ethesis.helsinki.fi / julkaisut / laa / kli in vk /ehrnrooth) 27. Ghazala tabassum, Imran Ghayoor et al. The effectiveness of conventional trabeculectomy in controlling intra ocular pressure in our population. Pak J Ophthalmol 2013 Vol.29 No.1: 26-30. 28. Per Julius Nielsen, MD: Combined Small-Incision Cataract Surgery and Trabeculectomy- A prospective study with 1 year of Follow-up; Ophthalmic surg Lasers 1997; volume 28(1): 21-29. 29. Urban V, Kamman MT, Sturmer JP, Glaucoma and Cataract: Combined operation or, trabeculectomy first and cataract extraction later? Klin Monatsbl Augenheilkd (pubmed article in German – English) 2000 Feb; 216 (2): 105 –11. 30. Khurana AK et al. Combined SICS and trabeculectomy; Nepal J Ophthalmol 2011; 3(5): 13 – 18. 31. Edward J Rockwood. Outcomes of combined cataract extraction, lens implantation, and trabeculectomy surgeries. Am J Ophthalmol 2000 Dec; 130 (6): 704 –11.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcarePREVALENCE OF CARDIAC COMORBIDITIES AND ITS RELATION TO SEVERITY STAGING OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE English2733Vineeth AlexanderEnglish R. PajanivelEnglish K. Surendra MenonEnglish Arun PrasathEnglishBackground: Complexity of COPD and mortality from the disease is increased by co morbidities and exacerbations Objective: This study was conducted with aim to find the prevalence of cardiac co morbidity in COPD and its relation to severity staging of COPD. Methods: The present cross sectional study was done in Pulmonary Medicine outpatient department of Mahatma Gandhi Medical College and Research Institute, Pondicherry from March 2013 to June 2014. The study diagnosed and newly diagnosed of COPD patients were subjected to Pulmonary Function Test (PFT), assessment of blood pressure, electrocardiography and echocardiography. The statistical analysis was done to assess the cardiovascular status of the study subjects and its relation to severity staging of COPD. Results: In the total of 44 cases selected for study 42 (95.5%) were males and 2(4.5%) were females. On the basis of GOLD guidelines there were 5(11.4%), 13(29.5%), 16(36.4%) and 10(22.7%) mild, moderate, severe, and very severe COPD respectively. Right axis deviation, p-pulmonale, T-wave inversions, dominant R-wave, persistent S-wave in electrocardiography were present in 45.5%,52.6%,40.0%,33.3%,36.4% of severe and 54.5%, 36.8%, 60.0%, 58.3%, 63.6% in very severe cases of COPD. In echocardiography, right atrium and ventricle dilatation, left ventricular dysfunction, tricuspid regurgitation, and regional wall motion abnormalities were present in 55.6%, 46.15%, 50.0%, 37.5% of severe and 38.9%, 53.85%, 33.3%, 62.5% of very severe cases of COPD. Pulmonary artery systolic pressure and systemic hypertension increased with severity of COPD. Conclusion: Prevalence of cardiac co morbidities increases with the increase in severity of COPD. The severe and very severe stages of COPD are associated with significant cardiovascular diseases. EnglishCOPD, Electrocardiography, Echocardiography, Pulmonary artery systolic pressureINTRODUCTION Chronic obstructive pulmonary disease (COPD) is characterized by progressive airflow limitation that is not fully reversible1 . It is a leading cause of death worldwide2 . COPD bring forth high healthcare costs3 , imposes a significant burden in footing of disability and impaired quality of life4 . It is an important public health dispute that is both preventable and treatable. Among the diseases causing chronic morbidity and mortality throughout the world many elderly people suffer from COPD and die prematurely from it or its complications. In coming decades because of continued exposure to risk factors, COPD is projected to increase globally5 . COPD has been considered symptomatically as chronic bronchitis, anatomically as emphysema, physiologically as airflow obstruction in the past6 . Both genetic and environmental factors play a role in development of COPD. In addition to tobacco smoke, heavy exposure to occupational dusts, chemicals and indoor/outdoor air pollution may cause COPD. The hereditary deficiency of 1-antitrypsin is genetic risk factor for development of COPD7-9. The socioeconomic status is inversely related to the development of COPD10. Complexity and mortality of COPD is increased by its co morbidities and exacerbations11-14. COPD is a more complex systemic disease that has significant extra pulmonary effects along with pulmonary involvement15-17. In relation to COPD and its manifestations and co morbidities there are two different views. The first view is that there is systemic spillover of the inflammatory and reparatory events occurring in the lungs of COPD patients and second view is that the pulmonary manifestations occurring in COPD is just a form of expression of systemic inflammatory state with multiple organ compromise14,18. In two-thirds of the COPD patients there is one or two co morbidities19. The most common co morbidities described in association with COPD are arterial hypertension, coronary artery disease, heart failure, respiratory infections, lung cancer, diabetes mellitus and osteoporosis. There is significant impact of co morbidities on health status, healthcare costs and prognosis of COPD. The mortality is more from co morbid disease than COPD itself20-22. The most frequent and most important disease coexisting with COPD is cardiovascular diseases23, 24. Cardiovascular diseases particularly ischemic heart disease has been observed as the cause of death in COPD patients recently25, 26. It may be associated with smoking as it is a cause of both. But forced expiratory volume in first second (FEV1) is a well known risk factor for the development of ischemic heart disease that is independent of smoking habit27. There is limited studies and research into the co-morbidities of COPD. Most of the studies have analyzed the relation of COPD with several isolated diseases. This study was conducted to find the prevalence of cardiac co-morbidity in relation to severity staging of COPD. METHODOLOGY This study was an institutional cross sectional study done in Pulmonary Medicine outpatient department of Mahatma Gandhi Medical College and Research Institute, Pondicherry from March 2013 to June 2014. The study was approved by the institutional ethical committee. The study subjects were all the patients who were previously diagnosed and newly diagnosed of COPD attending the Pulmonary Medicine outpatient department of Mahatma Gandhi Medical College and Research Institute, Pondicherry selected by series allocation from March 2013 to June 2014. All patients with acute exacerbation of COPD unable to perform spirometry and patients with contraindication for spirometry like history of recent myocardial infarction, congenital heart disease were excluded from the study. A volunteer written consent was taken from all the patients before the study. The selected patients were subjected to Pulmonary Function Test (PFT) with flow sensing PFT machine of MIR Spirobank 2 and assessed for severity and stage of COPD according to GOLD guidelines as per follows. Classification of Severity of Airflow Limitation in COPD according to GOLD guidelines Based on Post Bronchodilator Forced Expiratory Volume in first second (FEV1).In patients with FEV1/Forced Vital Capacity (FVC) < 0.70: In the established cases of COPD and the newly diagnosed cases of COPD, blood pressure assessment, electrocardiography (ECG) and transthoracic Doppler echocardiography was done to assess for cardiac abnormalities. Blood pressure was measured using a calibrated sphygmomanometer. The study was done by taking two independent blood pressure measurements with 5 min pause after a rest of 5 min in a sitting position. In current analysis the mean of two measurements was taken. The blood pressure was classified according to the guidelines of Seventh Joint National Committee (JNC 7). All the patients were subjected to Electrocardiography (ECG) using machine of Mortara ELI 250. A twelve lead ECG including 3 bipolar limb leads, 3 unipolar limb leads and 6 unipolar precordial leads was performed. All necessary precautions desired in ECG were observed. Various ECG parameters like rate, axis deviation, P-wave changes, QRS complex, T-wave changes, ST changes were observed. The axis of P-value and QRS complex was calculated by hexaxial reference system. All patients were then subjected to transthoracic Doppler echocardiography using machine of Philips iE33 with a multi frequency probe of 2- 4.3 MHz to assess for, right side chamber size, left ventricle function, valvular status and pulmonary artery systolic function according to American Society for Echocardiography (ASE) guidelines. Tricuspid regurgitant flow was identified by color flow Doppler technique and the maximum jet velocity was measured by continuous wave Doppler without the use of intravenous contrast. In the absence of right ventricular outflow obstruction the pulmonary artery systolic pressure equals the right ventricular systolic pressure (RVSP) in echocardiography. The Modified Bernoulli equation (?p=4V2) was used, where ?p is the pressure gradient between the right ventricle and right atrium and v is the velocity of the tricuspid regurgitant jet. Right ventricular systolic pressure was calculated as: right ventricular systolic pressure = 4TRV2 + RAP where v is the velocity of the tricuspid regurgitant jet and RAP the right atrial pressure. Right atrial pressure was estimated from the inferior vena cava imaged with two-dimensional echocardiography. RAP was estimated to be 5, 10, or 15 mmHg based on the variation in the size of inferior vena cava with inspiration as follows: complete collapse, RAP = 5 mmHg; partial collapse, RAP = 10 mmHg; and no collapse, RAP = 15 mmHg28. Pulmonary hypertension (PH) was defined in this study as Pulmonary Artery Systolic Pressure (PASP) ≥ 30 mmHg28. This value was chosen according to the definition of pulmonary hypertension. Pulmonary hypertension was classified into mild, moderate, and severe category as PASP 30–50, 50–70, >70 mmHg, respectively. STATISICAL METHOD SPSS version 19.0 (IBM SPSS, US) was used to analyze the data. The quantitative variables have been described as mean ± SD or Frequency analysis with numbers and percentage. The study was statistically analyzed by Pearson Chi- square test. Value of p< 0.05 was considered significant. RESULTS In a total of 44 patients with COPD enrolled in the study 42(95.5%) were males and 2(4.5%) were females. The minimum age observed was 42 years and maximum 79 years. The mean age group in our study was 61.25 with a standard deviation of 8.662. The distribution of patients with severity staging of COPD on the basis of GOLD guidelines described in Table 2 The ECG changes observed in our study were right axis deviation, p pulmonale, t wave inversion in V1 and V2 was dominant r wave in V1 lead, persistent S wave in V5 and V6. The changes of right axis deviation was seen in 11(25.0%) of which 5(45.5%) and 6(54.5%) was severe and very severe COPD respectively (p value 0.005). The presence of P pulmonale was observed in 19(43.2%) patients of which 2(10.5%), 10(52.6%), 7(36.8%) were moderate, severe and very severe COPD respectively (p value 0.004). The changes of T wave inversion in V1 and V2 lead was observed in 5(11.4%) of which 2(40.0%) and 3(60.0%) was severe and very severe COPD respectively. The changes of dominant R wave in V1 lead was seen in 12(27.3%) of which 1(8.3%), 4(33.3%) and 7(58.3%) was moderate, severe and very severe COPD respectively (p value0.003). The changes of persistent S wave in V5 and V6 lead seen in 11(25.0%) of which 4(36.4%) and 7(63.6%) was severe and very severe COPD respectively (p value 0.001). The echocardiography findings seen in our study were right atrium and ventricle dilatation, left ventricular dysfunction, tricuspid regurgitation, regional wall motion abnormality and increase in Pulmonary artery systolic pressure (PASP). The changes of right atrium and ventricle dilatation was seen in 18(40.9%) of which 1(5.6%), 10(55.6%) and 7(38.9%) was moderate, severe and very severe COPD respectively (p value 0.001). There was left ventricular dysfunction in 13(29.5%) of which 6(46.15%) and 7(53.85%) was severe and very severe COPD respectively (p value 0.001). The changes of tricuspid regurgitation was seen in 24(54.5%) of which 4(16.7%), 12(50.0%) and 8(33.3%) was moderate, severe and very severe COPD respectively (p value 0.003). The presence of regional wall motion abnormality was seen in 8(18.2%) of which 3(37.5%) and 5(62.5%) was severe and very severe COPD respectively (p value 0.013). The Pulmonary artery systolic pressure (PASP) observed were mild (30-50mmHg), moderate (50-70 mmHg) and severe (>70 mmHg) in 26(59.09%), 13(29.55%) and 5(11.36%) of patients respectively. The distribution of PASP on the basis of severity staging of COPD is depicted in Figure 1 The assessment of blood pressure in our study showed distribution in all stages as depicted in Figure 2. The correlation of blood pressure with severity staging of COPD is depicted in Table3. DISCUSSION There are various cardiac manifestations in COPD which complicate its clinical course. In patients with COPD with associated cardiovascular diseases the morbidity and mortality is seen to be increased as shown in various studies29-31. COPD and cardiovascular diseases has various common risk factors, including smoking and aging. The presence of pro inflammatory mechanism and oxidative stress is seen in both diseases32-35. The sedentary lifestyle in COPD may also contribute to risk of developing cardiovascular diseases36. Among the 44 cases in our study all patients had ECG changes. The changes of right axis deviation in ECG were present in only severe and very severe COPD in our study. In a study by Padmavati et al the observation of right axis deviation in ECG of COPD patients were found to be 80%37. In concordance with our results, a study by D Holtzman et al reported high prevalence of right axis deviation inECG in COPD patients, increasing with severity of the disease38. P pulmonale is diagnosed when the amplitude of P wave in Lead II, III, and/or aVF is more than 2.5 mm. In a study by D.H Spodicks et al39, p pulmonale was observed in 13.9% of COPD patients. F. I Carid et al40 found the incidence of p pulmonale in 15.5% while R.C Scott et al41 and Pinto et al42 done a study on COPD patients showing the incidence of p pulmonale of 32.7%. In an Indian study by Aggarwal et al43 the incidence of p pulmonale was found to be 35.7%. In our study the p pulmonale was observed more in severe COPD 10(52.6%). However in our study the T wave inversion in V1 and V2 leads were not statistically significant but was seen in 2(40.0%) and 3(60.0%) patients of severe and very severe COPD respectively. Our study showed statistically significant changes in ECG like dominant R wave in V1 lead and persistent S wave in V5 and V6 increasing with the severity of COPD. The observed data shows that the features suggesting right ventricular hypertrophy increases with severity of COPD with more number of cases reported in severe and very severe stages of COPD. In our study echocardiography changes of right atrium and ventricle dilatation were seen increasing in severe cases of COPD. Soriano et al23 the overall prevalence of heart failure in COPD was observed as 7%. It was corresponding to the severity of airflow limitation. In a study by Higham M.A et al in which the presence of tricuspid regurgitation (TR) was observed in 56(77%) out of 73 COPD patients44. We also observed a significant number of patients in severe and very severe COPD with this abnormality. Our study showed that a significant number of patients also had regional wall motion abnormality and left ventricular dysfunction. In a study the prevalence of chronic obstructive pulmonary disease in patients with catheter diagnosed coronary artery disease by Ahmed A.H et al has shown that more than 1 in 4 patients with coronary artery disease had concomitant COPD45. In a study by Reed R.M et al prevalence of angiographically proven coronary artery disease in COPD was 59%46. Pulmonary hypertension (PH) was defined in this study as Pulmonary Artery Systolic Pressure (PASP) ≥ 30 mmHg28. This value was chosen according to the definition of pulmonary hypertension. Pulmonary hypertension was classified into mild, moderate, and severe category as PASP 30–50, 50–70, >70 mmHg, respectively. In our study the following was the distribution as depicted in Table4 In another study by M.A Higham et al the pulmonary artery systolic pressure was increased in 25%, 43%, and 68% of patients with mild, moderate, and severe COPD, respectively44. There is evidence suggesting that elevation of pulmonary arterial pressure is reported to occur in twenty to ninety percent of patients of COPD47-50. The presence of Cor pulmonale was seen in approximately 25% patients with COPD51. An autopsy study showed Cor pulmonale in 40% patients with COPD49,52. The Correlation of blood pressure with severity staging of COPD in our study is depicted in Table 5. In a study by Engstrom et al it was found that lung function was inversely associated with future blood pressure increase53. Our study also showed that the mean distribution of patients with increased blood pressure were more in advance stages of COPD. The study has some limitations. First the sample size was less. Second, the absence of a control group limits a definite assessment of the role of COPD in the pathogenesis of cardiac disorders. Thirdly, the study had a cross-sectional design, so no causal relationships with clinical outcomes could be established. Studies with larger sample size with a longer duration will be required to assess the outcome. The other co morbidities in COPD should have to be taken for study with considering the individual as whole. The study indicates that COPD is associated with a higher risk for cardiovascular diseases and the risk of cardiovascular diseases increases with the severity of COPD. CONCLUSION The study showed that cardiac disorders are highly prevalent in patients with severe-to-very severe COPD. All COPD patients must be evaluated for cardiac co- morbidities, since it might help establish adequate treatment that may potentially improve patient prognosis. ACKNOWLEDGEMENT Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to author/editors/publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Authors also acknowledge all the teaching and non teaching faculties and fellow postgraduates of Mahatma Gandhi Medical College, Pondicherry who have helped in the completion of this study. Source of funding- No funding received Conflict of interest- The authors do not have any conflicts of interest to disclose. 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Hansell AL, Walk JA, Soriano JB. What do chronic obstructive pulmonary disease patients die from? A multiple cause coding analysis. Eur Respir J. 2003;22:809-14. 26. Huiart L, Erns P, Suissa S. Cardiovascular morbidity and mortality in COPD. Chest. 2005;128:2640-6. 27. Hole J, Watt GC, Davey-Smith, Hart CL, Gillis CR, Hawthorne VM. Impaired lung function and mortality risk in men and women: findings from the Renfrew and Paisley prospective population study. BMJ. 1996;313:711-5. 28. Rappaport E. Cor pulmonale. In: Murray JJ, Nadel JA, Mason RM, Boushey H, editors. Textbook of respiratory medicine. 4th Edition. Philadelphia: W.B. Saunders; 2000. pp. 1631–48. 29. Dankner R, Goldbourt U, Boyko V, et al. Predictors of cardiac and noncardiac mortality among 14,097 patients with coronary heart disease: BIP Study Group. Am J Cardiol 2003; 91:121- 127. 30. Behar S, Panosh A, Reicher-Reiss H, et al. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcarePARASITIC WORMS FOUND IN STOMACH WHILE DOING UPPER GASTROINTESTINAL ENDOSCOPY AND STUDY OF THE DIFFERENCES BETWEEN ADULT HOOKWORMS AND LARVA OF ANISAKIS SIMPLEX INFECTING STOMACH English3438Govindarajalu GanesanEnglishObjective: To diagnose parasitic worms found in stomach while doing upper gastro-intestinal endoscopy in our patients. There have not been many studies in India which discuss about the presence and the type of parasitic worms present in stomach while doing upper gastro-intestinal endoscopy. Hence this present study was carried out to study about the presence and the type of parasitic worms present in stomach while doing upper gastro-intestinal endoscopy in our institute. Methods: A study of 707 patients who had undergone upper gastro-intestinal endoscopy for a period of two years and eight months from May 2009 to December 2011 was carried out in our institute. In each of the 707 patients, the stomach was carefully examined to find out the presence of parasitic worms. The results were found as given below. Results: Of the 707 patients, one patient was found to have hookworm in stomach instead of its usual site in duodenum while doing upper gastro-intestinal endoscopy. Conclusion: Hence upper gastro-intestinal endoscopy is a very useful investigation to diagnose parasitic infection like hookworm infection of stomach . Hence it is extremely important to carefully look for the presence of parasitic worms like hookworms in stomach while doing upper gastro-intestinal endoscopy. EnglishHookworms, Stomach, Upper gastro-intestinal endoscopyINTRODUCTION Hookworms are commonly reported to occur in duodenum while doing upper gastro-intestinal endoscopy especially in tropical and sub tropical countries (1to11). But it is extremely rare to find hookworms in stomach while doing upper gastro-intestinal endoscopy( 12,13). Hence an extremely rare and interesting report of hookworm found in stomach instead of its usual site in duodenum while doing upper gastro-intestinal endoscopy is given here. Other parasitic worms like the larva of anisakis simplex are also reported to occur in stomach especially in oriental patients after eating raw fish(14to17). Since both the adult hookworms and the larva of anisakis simplex can occur in the stomach of human beings, the important differences between the adult hookworms and the larva of anisakis simplex are also highlighted in this article. MATERIALS AND METHODS This study was conducted in the department of general surgery, Aarupadai Veedu Medical College and Hospital, Puducherry. A study of 707 patients who had undergone upper gastro-intestinal endoscopy for a period of two years and eight months from May 2009 to December 2011 was carried out in our institute. In each of the 707 patients, the stomach was carefully examined to find out the presence of parasitic worms. The results were found as given below. RESULTS Of the 707 patients, one patient was found to have hookworm in stomach instead of its usual site in duodenum while doing upper gastro-intestinal endoscopy. A 30 year old male patient presented with persistent epigastric pain for one month and hence was subjected to upper gastro-intestinal endoscopy. Very interestingly and unexpectedly a single hookworm was found in the antrum of the stomach of the patient [fig 1,2,3] instead of its usual site in duodenum . Small erosions in the gastric antrum were also found near the hookworm [fig 3]. The patient was also found to have bile reflux from duodenum to stomach(duodeno-gastric reflux) [fig 1,2]. The refluxed bile from duodenum to stomach is the most probable cause of shift of hookworm from duodenum to antrum of stomach in this patient. The patient was treated with a single dose of 400mg of albendazole and his symptoms resolved. Hookworms occurring in stomach Of all the intestinal worms adult hookworm measuring about ½ inch long is the worm most commonly found in duodenum and hence named as ancylostoma duodenale. But there has been only very few reports of finding hookworms in stomach while doing upper gastro-intestinal endoscopy (12,13) . In both these reports duodeno-gastric reflux[bile reflux from duodenum to stomach] was attributed to the ectopic localisation of hookworm in the antrum of the stomach (12,13) . Our patient was also found to have bile reflux from duodenum to stomach which is the most probable cause of the ectopic localisation of hookworm in the antrum of the stomach in this patient. DISCUSSION Hookworms occur commonly in the duodenum but can also occur rarely in the stomach of human beings. Other parasitic worms occurring in stomach(anisakis simplex) The finding of worms attached to human gastric mucosa is exceptional because of the hostile atmosphere due to gastric acid pH (14). Howewer other parasitic worms like the larva of anisakis simplex are also reported to occur in stomach especially in oriental patients after eating raw fish (14to17). The parasite [larva of anisakis simplex] has a protective layer against gastric acid and survives burrowed into the gastric wall. The larva of anisakis simplex develops into a reproducing adult only in marine mammals. In humans it cannot survive and dies within a few weeks. But the short time that it lives, it causes stomach pain and nausea. The larva of anisakis simplex is about 2 cm long Gastric anisakiasis Diagnosis of anisakiasis is made by gastroscopy which allows removal of the worms and cures the patients (18). A case of acute angina like chest pain due to gastric anisakiasis has also been reported in whom the larvae of anisakis simplex in the gastric mucosa were found and extracted endoscopically (19). Hence gastric anisakiasis should be included in the differential diagnosis of acute chest pain (19). Endoscopic extraction of larva is the most effective procedure in dealing with acute gastric anisakiasis (15) . But on the other hand adult hookworms infecting the duodenum and rarely of stomach can easily be treated with a single dose of 400mg of albendazole and endoscopic extraction is not necessary. Hence upper gastro-intestinal endoscopy is a very useful investigation to diagnose parasitic infection like hookworm infection of duodenum and stomach and gastric infection by the larva of anisakis simplex . Differences between adult hookworms and larva of anisakis simplex Since both the adult hookworms and the larva of anisakis simplex can occur in the stomach of human beings, both are of almost of the same size and both are parasitic nematodes or roundworms belonging to the phylum nemathelminthes, the important differences between the adult hookworms and the larva of anisakis simplex are highlighted below. Adult hookworms [ancylostoma duodenale/necator americanus]. 1. Infection occurs because of walking barefoot. 2. Infection is very common in India. 3. Only adult hookworms are found in the duodenum and rarely in the stomach of human beings. The larvae of hookworms do not occur in the duodenum and in the stomach of human beings. 4. Adult hookworms are most commonly found in the duodenum of human beings. 5. Adult hookworms measure 0.8to1.3 cm in length and are smaller than the larva of anisakis simplex. 6. Hookworm infection of stomach does not present acutely or with severe acute symptoms like severe chest pain or severe abdominal pain. 7. Hookworm infection can easily be treated with a single dose of 400mg of albendazole and endoscopic extraction is not necessary. The larva of anisakis simplex. 1. Infection occurs because of eating raw fish. 2. Infection is not common in India and is common only in oriental countries where people eat raw fish. 3. Only larva of anisakis simplex is found in the stomach of human beings. The larval stage dies in human beings without reaching the adult stage. Larval anisakis simplex develops into a reproducing adult only in marine mammals. 4. The larva of anisakis simplex is found most commonly in the stomach of human beings and hence the resulting infection is called as gastric anisakiasis. 5. The larva of anisakis simplex measures 2cm in length and is larger than the adult hookworms. 6. Gastric anisakiasis commonly presents acutely or with severe acute symptoms like severe chest pain or severe abdominal pain. 7. Albendazole is not effective in relieving the acute symptoms and endoscopic extraction of the larva of anisakis simplex from the stomach of human beings is the best treatment. CONCLUSION Hence upper gastro-intestinal endoscopy is a very useful investigation to diagnose parasitic infection like hookworm infection of stomach and gastric infection by the larva of anisakis simplex . ACKNOWLEDGEMENT The author sincerely thanks the staff nurses Shenbaghaprabha, Nithya and A.K. Selvi who were assisting the author while doing endoscopy and 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=456http://ijcrr.com/article_html.php?did=4561. Hyun HJ, Kim EM, Park SY, Jung JO, Chai JY, Hong ST. A case of severe anemia by Necator americanus infection in Korea. J Korean Med Sci. 2010 Dec;25(12):1802-4. 2. 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 3. Kibiki GS, Thielman NM, Maro VP, Sam NE, Dolmans WM, Crump JA. Hookworm infection of the duodenum associated with dyspepsia and diagnosed by oesophagoduodenoscopy: case report. East Afr Med J. 2006 Dec;83(12):689-92. 4. 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. 5. 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 6. Zaher, T. I., Emara, M. H., Darweish, E., Abdul-Fattah, M., Bihery, A. S., Refaey, M. M., and Radwan, M. I. Detection of Parasites During Upper Gastrointestinal Endoscopic Procedures. Afro-Egypt J Infect Endem Dis 2012; 2 (2): 62-68. 7. Anjum Saeed, Huma Arshad Cheema, Arshad Alvi, Hassan Suleman. Hookworm infestation in children presenting with malena-case series Pak J Med Res Oct - Dec 2008;47(4) ):98- 100 8. Mahadeva S, Qua C-S, Yusoff W, et al. Repeat endoscopy for recurrent iron deficiency anemia: an (un)expected finding from Southeast Asia. Dig Dis Sci 2007;52:523–525 9. Reddy SC, Vega KJ. Endoscopic diagnosis of chronic severe upper GI bleeding due to helminthic infection. Gastrointest Endosc May 2008;67(6) 990-992 10. Nakagawa Y, Nagai T, Okawara H, Nakashima H, Tasaki T, Soma W, et al. Comparison of magnified endoscopic images of Ancylostoma duodenale (hookworm) and Anisakis simplex.Endoscopy 2009;41(Suppl. 2):E189 11. LEE, T.-H., YANG, J.-c., LIN, J.-T., LU, S.-C. and WANG, T.- H. Hookworm Infection Diagnosed by Upper Gastrointestinal Endoscopy: —Report of Two Cases with Review of the Literature- Digestive Endoscopy, 1994 6(1): 66–72 12. Thomas V, Jose T, Harish K, Kumar S. Hookworm infestation of antrum of stomach. Indian J Gastroenterol 2006 MayJun;25(3):154 13. Dumont A, Seferian V, Barbier P.Endoscopic discovery and capture of Necator Americanus in the stomach. Endoscopy. 1983 Mar;15(2):65-6. 14. Muñoz-Navas M, Macías E, García-Villarreal L, Val J, Angós R. Endoscopic diagnosis and extraction of gastric parasites Endoscopy. 1993 Sep; 25(7):491 15. Akasaka Y, Kizu M, Aoike A et al.: Endoscopic management of acute gastric anisakiasis. Endoscopy 1979 may;11 /[2}/: 158- 162 16. Deardorff TL, Fukumura T, Raybourne RB: Invasive anisakiasis. A case report from Hawaii. Gastroenterology 1986april; 90[4}/: 1047-1050. 17. Hsiu JG, Gamsey AJ, Ives CE et al.: Gastric anisakiasis: report of a case with clinical, endoscopic and histological findings. Am. J. Gastroenterol. 1986dec/; 81[12}/: 1185-1187 18. Bouree P1, Paugam A, Petithory JC Anisakidosis: report of 25 cases and review of the literature Comp Immunol Microbiol Infect Dis. 1995 Feb;18(2):75-84. 19. García García JM1, Romero Arauzo MJ Angina-like chest pain due to gastric anisakiasis]. An Med Interna. 2004 Apr;21(4):185- 6

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcarePARASITIC WORMS FOUND IN THE COLON WHILE DOING COLONOSCOPY AND STUDY OF THE DIFFERENCES BETWEEN HOOKWORMS AND WHIPWORMS English3944Govindarajalu GanesanEnglishObjective: To diagnose parasitic worms during colonoscopy in our patients. There have not been many studies in India which discuss about the presence and the type of parasitic worms present in the colon while doing colonoscopy. Hence this present study was carried out to study about the presence and the type of parasitic worms present in the colon while doing colonoscopy in our institute. Methods: A study of 72 patients who had undergone colonoscopy in our institute for a period of 5 years from November 2009 to October 2014 was carried out in order to find out the presence of parasitic worms during colonoscopy in these patients. Results: Out of these 72 patients, parasitic worm was found in the colon in only one patient. But the stool examination of the patient was negative for ova or cyst. The parasitic worm found in this patient was identified as whipworm or trichuris trichiura by its characteristic whip like shape. In this patient, the tail or the posterior end of the whipworm is straight and bluntly round without any coil or corkscrew shape and hence can be identified as the female whipworm. The tail or the posterior end is highly curved and coiled like a corkscrew only in the male whipworm. Thus, while doing colonoscopy we can easily distinguish between male and female whipworm by looking at the tail or posterior end of the whipworm. But unlike hookworms which suck blood from the small intestinal wall and is red in colour, whipworms do not feed on blood and is white in colour as it feeds only on the tissue secretions of the large intestinal wall. Thus the whipworm in this patient was white in colour. Conclusion: Whipworms are the most common nematodes or roundworms found in the large intestine of human beings while doing colonoscopy. Our patient was also found to have whipworm in the colon while doing colonoscopy. The patient who had whipworm in our study had negative stool examination for ova or cyst. Hence colonoscopy is a very useful investigation to diagnose whipworm infection especially when the stool examination is negative for its eggs. EnglishAdult whipworm, Trichuris trichiura, ColonoscopyINTRODUCTION Hookworms are the most common nematodes or roundworms found in the duodenum of human beings while doing upper gastro-intestinal endoscopy. Similarly whipworms are the most common nematodes or roundworms found in the large intestine of human beings while doing colonoscopy. Our patient was also found to have whipworm in the colon while doing colonoscopy. There have also been reports of finding whipworm in the large intestine of human beings while doing colonoscopy in many parts of the world. (1 to 9,11 to 15). Usually whipworms are most commonly found in the caecum and in the right colon (2, 4). Only rarely whipworms are found in the left colon ( 4 ). But in our patient whipworm was found in the sigmoid colon which is the rare site to find the whipworm. The important differences between the hookworms inhabiting the small intestine and the whipworms inhabiting the large intestine of human beings are also highlighted in this article. MATERIALS AND METHODS This study was conducted in the department of general surgery, Aarupadai Veedu Medical College and Hospital, Puducherry. A study of 72 patients who had undergone colonos copy in our institute for a period of 5 years from November 2009 to October 2014 was carried out in order to find out the presence of parasitic worms during colonoscopy in these patients. In each of these patients, presence of any parasitic worm was carefully looked for during the procedure of colonoscopy and the colonoscopic pictures of each patient were carefully studied and analysed. RESULTS Out of these 72 patients, parasitic worm was found in only one patient. The parasitic worm found in this patient was identified as whipworm or trichuris trichiura by its characteristic whip like shape. This patient was an eighty year old male patient. In one study, the patient with whipworm in the colon was a 84 year old female (16) and in another study the patient with whipworm in colonoscopy was a 75 year old male (12). Our patient presented with history of lower abdominal pain for 1week, constipation for 2 days and vomiting for 1day. On abdominal examination, his abdomen was soft, mildly distended and mild tenderness was present in the hypogastric region. His haemoglobin was 14.4g%, white blood cell count was 10,900 and his differential white blood cell count was polymorphs 80%, lymphocytes 16% and eosinophils 4% . His stool examination was negative for ova or cyst. His X-ray abdomen and ultrasound abdomen showed gas filled bowel loops and was diagnosed as having mild subacute intestinal obstruction .When he was subjected to diagnostic colonoscopy, one adult whipworm was found in the sigmoid colon while doing colonoscopy despite negative stool examination for ova or cyst. The patient was treated with a single dose of 400mg of albendazole and started showing clinical improvement. 1. Absence of anaemia in whipworm infection In our patient anaemia was not present (haemoglobin 14.4 g%). In another study also (5), all the three patients with whipworm in colonoscopy did not have anaemia (haemoglobin 13.7 g %, 14.1 g%, 13.9 g%). 2. Absence of eosinophilia in whipworm infection In our patient, eosinophilia was not present. Eosinophilia was also not found in whipworm infection in various other studies (5, 7,12,16). 3. Negative stool examination in whipworm infection In our patient, stool examination was negative for ova or cyst. In various other studies also, adult whipworms were found while doing colonoscopy even when the stool examination is negative for its eggs (2, 3,5,6,7,14). 4. Site of whipworm in the colon Usually whipworms are most commonly found in the caecum and in the right colon (2, 4). Only rarely whipworms are found in the left colon (4). But in our patient whipworm was found in the sigmoid colon which is the rare site to find the whipworm. The worm can be overlooked particularly if colon preparation is imperfect ( 1) . Only in one more study, adult whipworms were found in the sigmoid colon and also in the rectum while doing colonoscopy (15). In another study, whipworm was found in the left colon in one patient (4). In all the other studies, adult whipworms were found in the caecum ( 2,3,4,5,7,13,14,16)or in the ascending (right) colon ( 2,3,5,12,13) while doing colonoscopy 5. Number of whipworms and gender of the whipworm found in the colon In our patient, only a single whipworm was found in the colon while doing colonoscopy and it was identified as female whipworm since the tail or the thicker posterior end of the whipworm is straight and bluntly round without any coil or corkscrew shape (fig 2). In one more study, single whipworm was found in the colon while doing colonoscopy (3) but this whipworm was identified as male whipworm since its tail or the posterior end is highly curved and coiled like a corkscrew. Thus, while doing colonoscopy we can easily distinguish between male and female whipworm by looking at the tail or the thicker posterior end of the whipworm. Few other studies have also shown single whipworm in the colon while doing colonoscopy (5,14). Many studies have shown the presence of multiple whipworms in the colon while doing colonoscopy (7,9,13,15,16). 6. Lower abdominal pain and tenderness in whipworm infection Our patient presented with lower abdominal pain for 1week and mild tenderness in the lower abdomen . In various other studies also, patients have presented with lower abdominal pain and tenderness in the lower abdomen (2to5 ,12to14). 7. Constipation or dysentery in whipworm infection Our patient presented with constipation for 2 days. Only in one study, a 75 year old male patient presented with constipation (12). But in many studies, patients have presented with diarrhea ( 2,5,13 )or with dysentery causing anaemia (Trichuris dysentery syndrome) which is common in children when there is a heavy load of whipworms ( 4,7,9,15). 8. Intestinal obstruction in whipworm infection Our patient presented with vomiting for 1day, constipation, mild abdominal distention and thus with mild subacute intestinal obstruction which was relieved with conservative man-agement, enema and anti worm treatment. Heavy whipworm or trichuris trichiura infection can lead to colonic obstruction producing vomiting, constipation and abdominal distention (16) and when very severe due to very heavy load of whipworms may require surgical resection of the right colon (16). 9. Mild, moderate and severe whipworm infection a. Mild whipworm infection Whipworm infection is clinically silent in the vast majority of cases, since the worm load tends to be low (14 ) and these patients require only anti worm treatment. Our study and also some other studies ( 3,5,14) have shown only a single whipworm in the colon while doing colonoscopy which represents the least load of whipworms and very mild whipworm infection in these fortunate patients. b. Moderate whipworm infection Howewer, when worm load approaches 50 to 150 worms, clinical disease becomes evident with either chronic or acute symptoms (14). Most patients exhibit chronic nonspecific disease (14). Many studies referred in this article (1,2,6,7,11,12,13) had patients only with few or moderate number of worms and hence these patients did not have any serious complications and could be treated only with supportive and anti worm treatment. c. Severe whipworm infection Fortunately, only very few number of patients –especially only poorly nourished children and very old people living in unhygienic conditions-have a very heavy load of whipworms and present with serious complications like Trichuris dysentery syndrome (4,9,15) causing anaemia requiring intensive medical treatment and prolonged antiworm treatment. Colonic obstruction and perforation occur especially in very old people living in very bad conditions (16) requiring surgical resection of the right colon. DISCUSSION 1. Parasitic worms occurring in the large intestine of human beings Various studies from many parts of the world have also clearly shown that whipworms are the most common nematodes or roundworms found in the large intestine of human beings while doing colonoscopy( 1to9,11to15). Our study has also shown the presence of whipworm in the sigmoid colon of a patient while doing colonoscopy. In almost all the studies, whipworm or trichuris trichiura was almost the only intestinal helminth or roundworm found in the large intestine of human beings while doing colonoscopy (1,3to9,11to15). Only rarely intestinal helminths other than whipworm or trichuris trichiura were found in the large intestine of human beings while doing colonoscopy such as ascaric lumbricoides and enterobius vermicularis ( 2). Very rarely anisakis simplex larva can be found in the large intestine of human beings while doing colonoscopy (2). But only stomach is the commonest site of infection by anisakiasis (2). Colonic anisakiasis is a very rare condition (2). Hookworms were also rarely found in the large intestine of human beings while doing colonoscopy(17, 18). 2. Blood loss and anaemia in whipworm and hookworm infection Unlike hookworm which sucks blood from the small intestinal mucosa, whipworm (trichuris trichiura) does not suck blood and causes only minimal oozing of blood at the site of its attachment to the colonic mucosa. Hence in trichuris infection, the daily blood loss is only 0.005 ml per worm per day which only accounts for about 10-15% from the blood loss due to Necator americanus and only 2-3% of that attributed to Ancylostoma duodenale. Also most people in endemic areas of Trichuris trichiura infections are colonized only by a small number of worms (usually less than 15) unlike large number of hookworms present commonly in hookworm infection. Hence severe anaemia is not common in whipworm infection, but is common in hookworm Infection. Our patient also did not have any severe anaemia (haemoglobin 14.4 g%). 3. Eosinophilia in whipworm and hookworm infection Eosinophilia is also not common in whipworm infection (5, 7,12,16), but is common in hookworm infection. 4. Whipworm eggs in the treatment of crohns disease Helminthic Infection like whipworm infection is known to decrease the incidence of inflammatory bowel disease like crohns disease (8,10) and ulcerative colitis (10). Crohns disease involves overactive Th 1 pathways and helminthes blunt Th 1 responses ( 8). Treatment with trichuris suis ova or pig whipworm eggs is shown to be effective in the treatment of active crohns disease (8,10) and to a lesser extent, ulcerative colitis (10) . 5. Shape of whipworm and its extremely long, thin oesophagus(stichosome) Whipworm has a short posterior thick part resembling the short handle of the whip and a long, thin anterior part resembling the distal long, thin part of the whip. The short posterior thick part of the whipworm constitutes 1/3rd part and thelong anterior thin part constitutes 2/3rd part of the whipworm. The short posterior thick part is occupied by intestine and reproductive organs and the long anterior thin part is occupied almost entirely by oesophagus and a very small mouth. Hence its oesophagus is an extremely long and thin tube occupying 2/3d of the body length. The anterior portion of the oesophagus is a thin walled muscular tube and its posterior portion is a thin tube surrounded by a column of unicellular glandular cells termed stichocytes. The entire oesophagus is termed as stichosome (16). 6. Size of whipworm and its life cycle The head or the anterior part of the whipworm having the esophagus needs to be narrow so that it can easily burrow through the tissue of the intestine (15) while the larger tail end having the reproductive organs ensures that the worm can still produce many eggs. The male whipworm is 3to 4.5cm and the female whipworm is 3.5 to 5cm in length (12 ). Adults can live for years and deposit thousands of eggs per day (8). Infective eggs are ingested form eating contaminated soil (8,14). Upon ingestion the eggs hatch into larvae in the small intestine (8,12,14,15) .The larvae eventually migrate to the large intestine and complete maturation to adult worms in 1to3 months (8,12,14,15). 7. White colour of whipworm and red colour of hookworm Unlike the hookworms which suck blood from the small intestinal wall , whipworms do not feed on blood and feeds only on the tissue secretions of the large intestinal wall. Hookworm appears red coloured immediately after sucking blood. But the whipworm is always whitish in colour (5) (fig 1) as it does not feed on blood. 8. Only a very small portion of the long anterior part of whipworm seen during colonoscopy We can see only the short posterior thick part or the tail entirely in the lumen of the large intestine (14,15) but only a very small portion of the long ,thin anterior part while doing colonoscopy since most of the anterior part penetrates into the large intestinal wall in order to feed on the tissue secretions of the large intestinal wall (14,15) . Hence in fig 1, we can see only the short posterior thick part or the tail of the whitish coloured whipworm entirely in the lumen of the sigmoid colon but only a very small portion of the long, thin anterior part since most of the anterior part penetrates into the large intestinal wall for feeding purpose. But in the highly magnified view in fig 2, we can see clearly both the short posterior thick part or the tail and also the anterior thin part clearly due to the higher magnification. 9. Tail or the posterior end of male and female whipworm The tail or the posterior end of the male whipworm is highly curved and coiled and has corkscrew shape. Its corkscrew tail has a single spicule for copulation. But the tail of the female whipworm is straight and bluntly round without any coil and is not corkscrew shaped (5). In fig 2, we can see clearly that the tail or the posterior end of the whipworm is straight and bluntly round without any coil or corkscrew shape and hence can be identified as the female whipworm. Thus, while doing colonoscopy we can easily distinguish between male and female whipworm by looking at the tail or posterior end of the whipworm. 10. Mouth and oesophagus of whipworm In whipworm the esophagus in the anterior end is extremely long and thin in order to penetrate into the wall of the large intestine in order to feed on the tissue secretions of the large intestinal wall. Hence only a very small portion of the long, thin esophagus can be seen while doing colonoscopy (fig 1) since most of the esophagus burrows through the tissue of the large intestine for feeding purpose. The extremely small mouth of the whipworm has a minute spear which helps to suck the tissue secretions of the large intestinal wall. CONCLUSION 1. Hence colonoscopy is a very useful investigation to diagnose whipworm infection especially when the stool examination is negative for its eggs. 2. Whipworm has a short posterior thick part resembling the short handle of the whip and a long, thin anterior part resembling the distal long, thin part of the whip. 3. But we can see only the short posterior thick part entirely in the lumen of the large intestine but only a very small portion of the long ,thin anterior part while doing colonoscopy since most of the anterior part or esophagus penetrates into the large intestinal wall in order to feed on the tissue secretions of the large intestinal wall. 4. We can also easily identify between the male and female whipworm by looking at its tail or its posterior end which is highly curved and coiled only in the male whipworm .In the female whipworm, the tail or its posterior end is straight and bluntly round without any coil or corkscrew shape. ACKNOWLEDGEMENT The author sincerely thanks the staff nurse Nithya who was assisting while doing endoscopy and for her 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=457http://ijcrr.com/article_html.php?did=4571. Joo JH, Ryu KH, Lee YH, Park CW, Cho JY, Kim YS, Lee JS, Lee MS, Hwang SG, Shim CS. Colonoscopic diagnosis of whipworm infection Hepatogastroenterology. 1998 NovDec;45(24):2105-9. 2. Do KR1, Cho YS, Kim HK, Hwang BH, Shin EJ, Jeong HB, Kim SS, Chae HS, Choi MG Intestinal helminthic infections diagnosed by colonoscopy in a regional hospital during 2001- 2008. Korean J Parasitol. 2010 Mar;48(1):75-8. 3. Yoshida M, Kutsumi H, Ogawa M, Soga T, Nishimura K, Tomita S, Kawabata K, Kinoshita Y, Chiba T, Fujimoto S. A case of Trichuris trichiura infection diagnosed by colonoscopy. Am J Gastroenterol. 1996 Jan;91(1):161-2. 4. Khuroo MS, Khuroo MS, Khuroo NS Trichuris dysentery syndrome: a common cause of chronic iron deficiency anemia in adults in an endemic area (with videos). Gastrointest Endosc. 2010 Jan;71(1):200-4. 5. Ok KS1, Kim YS, Song JH, Lee JH, Ryu SH, Lee JH, Moon JS, Whang DH, Lee HK Trichuris trichiura infection diagnosed by colonoscopy: case reports and review of literature. Korean J Parasitol. 2009 Sep;47(3):275-80. 6. Wang DD, Wang XL, Wang XL, Wang S, An CL Trichuriasis diagnosed by colonoscopy: case report and review of the literature spanning 22 years in mainland China. Int J Infect Dis. 2013 Nov;17(11): e1073-5. 7. Tuan Sharif SE, Ewe Seng C, Mustaffa N, Mohd Shah NA, Mohamed Z Chronic Trichuris trichiura Infection Presenting as Ileocecal Valve Swelling Mimicking Malignancy. ISRN Gastroenterol. 2011;2011:105178. doi: 10.5402/2011/105178. Epub 2010 Oct 31. 8. Chang CW, Chang WH, Shih SC, Wang TE, Lin SC, Bair MJ Accidental diagnosis of Trichuris trichiura by colonoscopy. Gastrointest Endosc. 2008 Jul;68(1):154. 9. Diniz-Santos DR, Jambeiro J, Mascarenhas RR, Silva LR. Massive Trichuris trichiura infection as a cause of chronic bloody diarrhea in a child. J Trop Pediatr. 2006 Feb;52(1):66-8. 10. Büning J, Homann N, von Smolinski D, Borcherding F, Noack F, Stolte M, Kohl M, Lehnert H, Ludwig D Helminths as governors of inflammatory bowel disease. Gut. 2008 Aug;57(8):1182- 3 11. Lorenzetti R1, Campo SM, Stella F, Hassan C, Zullo A, Morini S An unusual endoscopic finding: Trichuris trichiura. Case report and review of the literature. Dig Liver Dis. 2003 Nov;35(11):811- 3. 12. Tokmak, N., Koc, Z., Ulusan, S., Koltas, I. S., and Bal, N. Computed tomographic findings of trichuriasis World Journal of Gastroenterology, 2006; 12(26), 4270 13. Lee, S. H., Kwon, J. E., and Cheong, Y. S. Two cases of Trichuris trichiura infection diagnosed by colonoscopy. Korean Journal of Family Medicine, 2010; 31(8), 622-629. 14. Herman, M. A., Ukawa, K., and Sugawa, C. CASE REPORT: Diagnosis and Removal of Cecal Whipworm Infection. Digestive diseases and sciences, 2000; 45(8), 1639-1643 15. Azira, M. S., and Zeehaida, M Severe chronic iron deficiency anaemia secondary to Trichuris dysentery syndrome-a case report. Trop Biomed, 2012; 29(4), 626-631. 16. Bahon, J., Poirriez, J., Creusy, C., Edriss, A. N., Laget, J. P., and Dei Cas, E Colonic obstruction and perforation related to heavy Trichuris trichiura infestation. Journal of clinical pathology, 1997; 50(7), 615-616 17. Thomas, V., Harish, K., Tony, J., Sunilkumar, R., Ramachandran, T. M., and Anitha, P. M. (2005). Colitis due to Ancylostoma duodenale. Indian J Gastroenterol 2006; 25(4), 210-211. 18. Wang, C. H., Lee, S. C., Huang, S. S., and Chang, L. C. Hookworm infection in a healthy adult that manifested as severe eosinphilia and diarrhea. Journal of Microbiology, Immunology and Infection, 2011 6(44), 484-487.

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcareHISTOPATHOLOGICAL STUDY OF SALIVARY GLAND LESIONS English4551Dave P.N.English Parikh U.R.English Goswami H.M.English Jobanputra G.P.English Panchal N.V.English Shah A.M.EnglishObjective: The aim of the present study is to determine the incidence of Parotid gland lesions and study their morphology. Material and Method: A study of 60 cases of Parotid gland tumors from January 2012 to December 2014 was carried out in pathology department of our hospital. A tissue bit was taken after detailed clinical history and physical examination. After routine tissue processing and H and E staining, histopathological diagnosis was made. Results: Prevalence of salivary gland tumors in our study was 0.47 %. Benign salivary gland tumors comprised 71.6 % of all parotid gland tumors and malignant tumors accounted for 28.4 %. Pleomorphic adenoma was 46.67% and Mucoepidermoid carcinoma was11.67% of all Parotid gland neoplasms. Most of the benign neoplasms occurred in 3rd decade, while the malignant neoplasms more common in 5th decade. Males were more commonly affected than females. Conclusion: Parotid gland tumors are relatively less common and they exhibit a wide variety of microscopic appearances even within one particular lesion. Accurate diagnosis is essential as parotid gland neoplasms have diverse clinical and prognostic outcomes. EnglishSalivary gland, Pleomorphic adenoma, Warthin tumourINTRODUCTION Parotid gland is the site of origin of many non neoplastic and neoplastic lesions. Parotid gland tumors are a morphologically and clinically diverse group of neoplasm, which may present significant diagnostic and management challenges because of their relative frequency, the limited amount of pretreatment information available and wide variety of biological behavior with different pathological lesions.1 Although accounting for less than 5% of all neoplasms, parotid gland tumors are of importance because of similar presentation i.e. swelling of particular gland whether lesion is neoplastic and non neoplastic.1 They can show striking range of morphologic diversity between different tumor types and sometimes within an individual tumor mass. In addition, hybrid tumors, dedifferentiation and propensity for some benign tumors to progress to malignancy can confound histopathological interpretation. Parotid gland tumors are rare, with overall incidence in the world of approximately 2.5 to 3 cases per 1, 00,000 per year. Malignant parotid gland tumors account for more than 0.5% of all malignancies and approximately 3 to 5% of all head and neck cancers.2 Most patients with malignant parotid gland tumors present in the sixth or seventh decade of life with mean age for malignant lesions is 55 to 65 years while benign lesions typically develop at least a decade earlier at mean age of 45 years.2 The parotid gland is most common location of salivary gland neoplasms which accounts for 75-80% of cases. Benign tumors are much more frequent than malignant ones, benign tumors constitute (54-79%) as compared to malignant tumors (21-46%). Most frequently encountered tumor is Pleomorphic Adenoma and Mucoepidermoid Carcinoma being the most common malignant tumor. Little is known about the etiology of parotid gland tumors and high risk populations have not been identified. An in creased incidence of benign mixed tumors and other neoplasms has been observed following childhood therapeutic irradiation. There are no reliable criteria to differentiate on clinical grounds the benign from malignant lesions, so morphological evaluation is necessary. The first attempt at classification came in 1841 in the form of thesis by A. Agrwal.3 In 1859 Billorth published valuable articles describing parotid tumors histologically. AIMS AND OBJECTIVES • To study prevalence of Parotid gland tumors during period of 3 years. • To study age, sex distribution of various parotid gland tumors and compare with findings of other workers. • To study histomorphological (gross and microscopic) aspect and record the spectrum of morphological features of these lesions. • To correlate clinical diagnosis with that of histological features. • To differentiate benign from malignant conditions. MATERIALS AND METHODS A study of 60 cases of Parotid gland tumors from January 2012 to December 2014 was carried out in pathology department of our hospital. This study includes neoplastic lesions of the parotid glands. The specimens consisted of open biopsies, superficial parotidectomies and total parotidectomies with or without draininig lymph nodes. After detail history and clinical examination were noted from the original request forms, specimens were fixed in formalin and sections were taken from the lesion, its margins, surrounding tissue and lymph nodes if any. Sections were processed in automated tissue processor and embedded in paraffin after gross examination. The paraffin blocks were cut and stained with hematoxylin and eosin and in selected cases special stains like PAS was done. These slides were examined under low power and high power magnification. The details of cellular architecture, encapsulation, perineural and vascular patterns and surrounding areas were studied. The tumors were classified according to (WHO) World Health Organisation’s histological typing of salivary gland tumors. Data acquired from examination of each specimen was processed in systematic manner. The collected data were analyzed statistically and results obtained are compared with existing studies in the literature. RESULTS During the period of January, 2012 to December 2014; a total of 12587 specimens received for histopathological examination. Out of which 60 specimens were of salivary gland tumors, representing 0.47 %. Thus, the Prevalence of salivary gland tumors in our study was 0.47%.In each case, detailed clinical history, physical examination and gross examination was recorded. Out of 60 cases 43 (71.6%) were benign while 17 (28.4%) were malignant (Table I and Graph I). In case of benign tumors pleomorphic adenoma (46.67 %) was the most common followed by warthin’s tumor (16.67%) while in case of malignant tumors Mucoepidermoid carcinoma (28.4 %) was the most common (Table II and Graph II). The parotid gland neoplasm presented over a wide range of age from 8 years to 79 years. From age wise distribution, benign tumors were noted in age range from 8 to 71 years with mean age of 39.5 years and mostly common in 4thdecade of life. Our youngest patient was 8 year old while the eldest patient was 71 year of age. Malignant tumors were noted in age range of 18 to 79 years with mean age of 48.5 years and common from 5th decade onwards (Table III). In our study, male preponderance is seen for all parotid gland tumors with M: F ratio of 1.14:1. For malignant neoplastic lesions M:F ratio is 1.42:1, for benign neoplastic lesions M:F ratio is 1.04:1 (Table IV). The most common symptom encountered during the study was swelling at the angle of the mandible (100%). The disparity between the total number of cases and the total number of symptoms and signs is because many patients presented with more than one signs and symptoms. Pain and tenderness, rapid enlargement of the mass, palpable cervical lymph nodes and skin ulceration were the other clinical features noticed. No facial paralysis was seen in our study (Table V). DISCUSSION This present study was conducted over a period of 3 years from January 2012 to December 2014 in one of the tertiary care teaching hospital. Study of 60 cases was done with respect to incidence, age, sex and clinical presentation, gross and microscopic features. The results obtained were compared with those of previous studies of well known workers in this study and the significant differences and similarities in results are discussed below. In our study, among benign tumors, Pleomorphic adenoma was the most common benign tumor and Mucoepidermoid carcinoma was the most common among malignant tumors as comparable to G C Fernandes et al. The total number of biopsies received during the study period was 12587. Thus, parotid gland tumors were quite rare as compared to the other tumors located over other sites in the body. Prevalence in our study is lower as compared to the incidence observed by Solange et al4 (2005) and Amos et al5 (2007). The benign tumors were more common than malignant tumors in our study. All authors agreed the same. In terms of relative proportions, present study correlates with other studies (Table 6) Ito et al6 , Edda et al7 , Ahmed et al8 and Nagarkar et al9 (Table VI). Benign tumors are seen at lower age compared to malignant tumors. Present study correlates with Edda et al7 and Ahmed et al8 . In our study, M:F ratio in all parotid gland tumors is 1.14:1 suggesting slight male preponderance. These findings are consistent with Erik G et al10and Ahmed et al8 . In case of benign lesions there is equal sex distribution while in case of malignant lesions male predominance is noted. Our study is comparable with Mohd ayub11. In our study, Pleomorphic adenoma is the commonest benign tumor involving the parotid gland while in case of malignant tumours, Mucoepidermoid carcinoma is the most common, which is also comparable to other studies (Table VII). SUMMARY AND CONCLUSION • Parotid gland tumors are relatively less common and they exhibit a wide variety of microscopic appearances even within one particular lesion. Accurate diagnosis is essential as parotid gland neoplasms have diverse clinical and prognostic outcomes. • Prevalence of salivary gland tumors in our study was 0.47 %. • Benign tumors were common than malignant tumors. • Benign salivary gland tumors comprised 71.6 % of all parotid gland tumors and malignant tumors accounted for 28.4 %. • Pleomorphic adenoma was the commonest and accounted for 46.67%of all Parotid gland neoplasms. • Mucoepidermoid carcinoma was the commonest malignant tumor accounted for 11.67% of all parotid gland tumors followed by Adenoid cystic carcinoma comprising of 3.33% of all parotid gland tumors. • Most of the benign neoplasms occurred in 3rd decade, while the malignant neoplasms more common in 5th decade. • Males were more commonly affected than females. For all parotid gland tumors M: F ratio was of 1.14:1. For malignant neoplastic lesions M: F ratio was 1.42:1, for benign neoplastic lesions M:F ratio was 1.04:1. Englishhttp://ijcrr.com/abstract.php?article_id=458http://ijcrr.com/article_html.php?did=4581. Chapter in book: Juan Rosai. Chapter-12 In : Rosai and Ackerman’s Surgical Pathology, Tenth Edition, Volume I, Major and Minor Salivary gland; Mosby; Elsevier; 2011: 817-842. 2. Chapter in book: Stephen Sternberg. Chapter- 20 In : Diagnostic Surgical Pathology, Sixth Edition, Volume I, Salivary gland; Lippincott Williams and Wilkins; Philadelphia; 2015: 906-946. 3. Agrwal RV, Solanki BR, Junnakar RV. Salivary Gland tumor. Ind J cancer 1967;4:209-213. 4. Solange SL, Andrea FS, Rivadaxia FB, Roseana DA. Epidemiologic profile of salivary gland neoplasms: analysis of 245 cases. Rev Bras Otorhinolaryngo 2005: 71(3): 335-340. 5. Amos B, Philip WM, William MC. Relative frequency of intraoral minor salivary gland tumors: a study of 380 cases from Northern California and comparison to reports from other parts of the world. J Oral Pathol Med 2007:36(4): 207-214. 6. F A Ito, P A Vargas, O P de Almeid and M A Lopes, Salivary Gland tumors in Brazilian population: a retrospective study of 496 cases. International journal of oral and maxillofacial surg 2005; 34(5):533-536. 7. Edda A M vahahula, Salivary Gland tumors in Uganda: Clinical Pathological Study. African health sciences. April 2004; 4(1):15-23. 8. Shafkat Ahmed, Mohmmad Lateef, Rouf Ahmad. Clinicopathological study of primary salivary gland tumors in Kashmir. JK Practitioner 2002;9(4):231-233. 9. Nagarkar M Nitin, Bansal Sandeep, Dass Arjun, Singhal k Surinder, Mohan harsh. Salivary Gland tumors: Our experience. Indian J Otolaryngol Head and Neck Surg 2004; 56(1):31-34. 10. Erik G. Kohen, MD; Snehal G Patel, MD; Oscar Lin, MD; Jay O. Boyle, MD; Dennis H.Kraus, MD. Fine needle aspiration biopsy of Salivary Gland lesions in selected patient population; Arch Otolaryngol Head Neck Surg.2004;130-773-778. 11. Mohhmed Ayub Musain, Zahid Sohail, Abbas Zafar and Shoukat Malik, Morphological pattern of Parotid tumors. Journal of the College of Physicians and Surgeons 2008;18 (5):274-277. 12. Kornevs Eglis, Tars Juris, Lauskis Gunars. Treatment of Parotid Gland tumors in Latvian Oncological Center Stomatologija, Baltic Dental and Maxillofacial Journal 2005;7:110-114. 13. Das K Dilip, Petkar A Mahir, Al Mane M Nadra, Sheik A Zaffar and Malik K Mrinmay. Role of Fine Needle aspiration cytology in the diagnosis of swellings in the salivary gland regions: A study of 712 cases. Med Princ Pract 2004; 13: 95-106. 14. Ethundan M, Pratt CA, Macpherson DW. Changing frequency of Parotid Gland Neoplasms: analysis of 560 tumors treated in a district general hospital. Ann R Coll Surg Eng 2002;84:1-6. 15. Schoeman BJ and Clifford SD. The incidence of malignancy in salivary gland neoplasms. South Afr J Surg.2007; 45(4):134- 135

Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcareABO, RHESUS BLOOD GROUP AND ALLELE FREQUENCY IN AND AROUND RAIPUR (CHATTISGARH STATE), INDIA English5258Shruti ShrivastavaEnglish Renuka GahineEnglish Vijay KapseEnglishAim: ABO blood group system is shared by all human populations; but frequencies of distribution differ. Variation in distribution of ABO and Rhesus phenotype between ethnic and geographic population is a well documented fact. Blood groups are genetically determined and exhibit polymorphism in different populations. Present study was conducted with an aim to determine prevalence of ABO and Rhesus blood groups and allele frequency among people in and around Raipur. Subject and Method: Study conducted over a period of 2 1/2 years included 46,444 persons( recipients and donors ) attending blood bank of Dr. B R A M hospital associated with Pt JNM Medical College Raipur. Blood groups were determined by standard methods. Calculations for allelic frequency were based on Hardy Weinberg equilibrium. Result: The most prevalent blood group was B (35.42%) closely followed by group O (33.55%) and group A (22.17%). Least prevalent blood group was AB (8.17%) Rh D positive prevalence was 96.85% and 3.15% persons were Rh negative. Breakup of Rh negatives showed that 1.24% were group B, 1.00% were group O, 0.66% were group A and 0.20% were group AB. Allelic frequency calculations showed O allele to be most common. Conclusion: In present study blood group B was the commonest, closely followed by group O. More than 95% population is Rh positive. Distribution of ABO and Rh blood group is close to that seen in northern parts of India, Rajasthan, adjoining Pakistan, and Bangladesh. EnglishABO, Rhesus, Blood groups, Allele frequency, ChhattisgarhINTRODUCTION Variation in distribution of ABO and Rhesus phenotype between ethnic and geographic population is a well documented fact. Blood groups are genetically determined and exhibit polymorphism in different populations. Blood group ABO was identified by Karl Landsteiner in 1900[1]. Blood group AB was identified 2 years later by des Castillo and Struli in 1902[2]. Since then a total of 30 blood group systems have been recognized by International Society of Blood Transfusion including Rhesus (Rh) system, which was identified by Landsteiner and Weiner in 1941[3,4]. But ABO and Rh blood grouping is still the most important test performed in Blood Banks to avoid mortality and morbidity [5]. Apart from the importance of ABO and Rh blood groups in transfusion practice, they are also important in organ transplantation, anthropological studies, and have medico legal importance [6, 7]. ABO blood group system is shared by all human populations; but frequencies of distribution differ. ABO blood group distribution studies are available from various parts of India and world. To the best of our knowledge there is no recent published study available on the ABO and Rh blood group distribution among general population in Chhattisgarh state. So with an aim to know the blood group distribution and blood group allele frequency among people in and around Raipur (Chhattisgarh state), and to compare the results with distribution among other populations, this study was conducted among blood donors and recipients in the blood bank of a tertiary care hospital of Raipur . MATERIAL AND METHOD The study was performed over a period of two and half years from January 2009 to June 2011 in the largest Blood Bank of Chhattisgarh state. The study group included 46,444 persons including blood donors and recipients. Donors were taken randomly (not patient directed). For grouping 2ml Blood samples were collected in EDTA vial. Grouping was carried out by standard tube technique. For grouping commercially available monoclonal anti sera anti A, Anti B, and anti AB manufactured by Tulip Diagnostics (P) Ltd and SPAN Diagnostics Ltd were used. All reagents were subjected to quality control test and had a minimum titre of 1: 256. For reverse grouping, known cell preparations of A, B, and O blood group cells, pooled from three different known donor samples were used. On each day of use, known cells for reverse grouping were prepared fresh and known samples were run as controls. Special care was taken to avoid repetition of persons by double checking each entry. RESULTS The study conducted over a period of 2 1/2 years from Jan 09 to June2011 in blood bank of Dr. B.R.A.M. Hospital Raipur involved 46,444 persons. Results are presented in Table 1. Among general population of Chhattisgarh Blood group B showed highest prevalence with 16452 (35.42%) persons. It was closely followed by group O with 15583(33.55%) persons. Group A and AB were in 10612 ( 22.17%) and 3797 (8.17)persons respectively. Inclusive of all ABO blood groups, Rh D positive prevalence was 96.05% (44,994). Least prevalent blood group was AB-ve with 0.20% prevalence. Calculations for allelic frequency were based on Hardy Weinberg equilibrium law that says that at equilibrium (p + q + r) 2 = p2 + q2 + r2 + 2pq + 2rp + 2qr = 1, where p2 is the probability of IAI A and 2pr is the probability of IAi (thus probability of type A = p2 + 2pr), q2 is the probability of IBIB and 2qr is the probability of IBi(thus probability of type B = q2 + 2qr), r 2 is the probability of ii (thus probability of type O = r2 ), and 2pq is the probability of IAIB(thus probability of type AB = 2pq). Preliminary estimates were calculated manually as: p = 1 - √B+O, q = 1 - √A+O, r = √O (p, q, r denote allele frequencies and A, B, O denote observed frequencies of blood groups A, B and O.) Assumptions for the Hardy–Weinberg equilibrium law are - The organism under study is diploid, - There is sexual reproduction , - Non overlapping generations, - Random sampling study, - Trait is determined by three alleles of a single gene namely A, B, and O, - Co dominance of A and B and dominance of both over O. Static allele frequencies in a population across generations assume that:- - Migration is negligible - Mutation can be ignored - Random mating - Population size is very large Calculation of allelic frequencies:- The calculated gene frequencies are .1716 for IA (P), .2512 for IB (q) and .5792 for IO. In population from Chhattisgarh O (r) recorded the maximum frequency followed by B (q), and A (p). The Chi Square test for Goodness to fit between the observed and expected phenotype in case of ABO blood group was .0077 and the result is not significant at p=≤0.05. In case of Rh (D) group the calculated frequency for I (D) (v) was .8234 and that for Id (v) was .1766. For statistical calculations and confirmation of manually calculated gene frequencies S2ABO estimator by Silva Square was used. S2 ABO estimator by Silva Square is a program to estimate the allele frequencies of the ABO blood group system, and perform a couple of statistical tests on the data, particularly to compare simple heuristic estimates of the allele frequencies, to show the EM algorithm in action, to obtain maximum likelihood (ML) estimates of the allele frequencies and to perform goodness-of-fit tests of the HardyWeinberg assumption. DISCUSSION The Present study on ABO and Rh prevalence among people in and around Raipur included 46,444 individuals and we observed predominance of blood group B and allele O. Precursor substance for ABO blood group is antigen H, present on the surface of membrane of red cells and most of the epithelial and endothelial cells. The A allele codes for an enzyme that adds an N-acetyl galactosamine to the H antigen. The B allele, which differs from the former by four amino acid changes, codes for an enzyme that adds a D-galactose. The O allele occurs most frequently in modern humans and carries a human-specific inactivating mutation which produces a nonfunctional enzyme, and thus the H antigen remains without further modification on the surface of the cells.[8] As ABO blood group system is of autosomal inheritance controlled by a single gene at chromosome 9q34 , the frequency of blood groups is not different in both sexes[9], so we have not divided study group on the basis of male and female. An individual has the same blood group throughout his life; therefore no categorization of donors according to age was done. However few reports are there that an individual’s blood group changes through addition or suppression of an antigen in malignancy or in autoimmune disease. [10] Results of ABO blood group distribution among people of Chhattisgarh were close to studies from Northern India, Rajasthan, neighboring Pakistan and Bangladesh with B group predominance but O group followed closely behind. We can say that in these areas B ≥ O>A>AB [Table-2]. State of Chhattisgarh is having a different population base as compared to rest of India with 31.76% of “Tribal population”[11]. A higher tribal population base is not causing much difference in distribution of blood groups as compared to northern parts of India. Studies from Kashmir and Southern part of India showed a pattern of O>B>A>AB[Table-2]. Agarwal A et al showed O blood group predominance from central part of India. Chattisgarh is also from central part of India and their findings are in variance with the present study[24]. This difference may be due to larger population base of present study. Behra Rajshre also showed blood group B predominance from central India[14]. Blood group A predominance has been shown by Naidu and Veeraju in Brahmin community, by Datta et al in Lodha tribes of West Bengal and by Vokendra and Devi among selective tribes of Arunachal Pradesh[25,26,27]. This difference in distribution of blood groups represents multiethnic and anthropologically different origins of population. Among countries surrounding India, A group predominance has been reported from Nepal and B group predominance from Pakistan and Bangladesh.[Table-2] Allele O was most common in present study followed by allele B and A. these findings are in concordance with Agarwal A et al [24]. When data across the world is compared blood group distribution frequencies for A, B, O and AB blood group vary among different parts of the world [Table-3]. Although blood group B is most common blood group in present study, allele B is least common allele among world population with only 22% prevalence. Blood group B has its highest frequency in northern India and central Asia. Comparison of results of present study with that of some other populations is shown in Table 3. Blood group O is the most common phenotype globally with parts of Africa and Australia showing highest frequency. Blood group A is most common in northern and central Europe. Several theories have been proposed as reason for this difference in distribution and one of them is evolutionary selection based on pathogen driven blood group antigen changes [34 ]. Distribution of Rh phenotype in present study is shown in Fig-1 and in different parts of India and Neighboring Countries in table-4. There are opposing schools of thought for irrelevance or association between blood groups and diseases. Association of blood group A with gastric cancer is already proven. Some newer studies are suggesting association between blood group O and hemorrhage of upper gastrointestinal tract [35], between incidence of endometrioses and A+ve blood group[36,37]. An association of blood group AB with severe Dengue disease with reverse secondary infections has been suggested[38]. There are suggestions that A and B antigens serve as co-receptors in P falciparum rosetting, and selective digestion of A antigen from the uninfected red blood cell surface totally abolishes the preference of the parasite to form rosetting with these red blood cells. Thus persons with blood group O have lesser chances of developing severe P falciparum malaria as compared to persons with other blood groups.[39,40] Other recently suggested associations are of breast cancer in females with blood group A[41] and of myocardial infarction with blood group B [42]. Association of blood group A with stomach cancer has been established again in recent studies while blood group O people present with a higher risk of development of peptic ulcer [43]. Narendra Kumar et al have stated that the expression of certain blood group antigens on the surface of cancer cells can be regarded as an end product of tumour progression that can be used as a useful prognostic and diagnostic preclinical markers.[44] CONCLUSION We conclude that blood group B is most common among people in and around Raipur, with blood group O following closely behind. A higher tribal population base is not causing much difference in distribution of blood groups as compared to northern parts of India. Present study was conducted in blood bank of largest tertiary referral centre of Chattisgarh, which receives patients and blood donors from all over the state , representing general population of Chattisgarh. So we can say that the present study represents blood group distribution frequency among general population of Chattisgarh. As this study included a large number of individuals data obtained from present study may serve as reference for other studies in Chattisgarh state . We suggest a large population base and inclusion of other blood group antigens for prevalence of blood group studies that would further aid in the planning for better management of Blood bank inventory and improvement of transfusion services. Further studies for evaluation of blood groups as a preclinical marker can also be undertaken. ACKNOWLEDGEMENT Authors acknowledge the immense help received from the scholars 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=459http://ijcrr.com/article_html.php?did=4591. Garraty G, Dzik W, Issitt PD, lublin DM, Reid ME, Zelinski T. 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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241717EnglishN2015September11HealthcareEMPOWERMENT AND ENGAGEMENT OF SHE WOMEN AGAINST VIOLENCE DURING SEX INTIMACY: AN INTERVENTION STUDY FROM KARNATAKA, INDIA English5965Manoj Kumar GuptaEnglish Veena R.EnglishObjective: To empower and engage the Self Help Groups (SHGs) women against violence during sex/intimacy with the use of IEC strategy so that they can act as change agents for other women in the community. Methods: This was a ‘Multi-centric Action Research Demonstration Study’. As an intervention, series of workshops were conducted with the help of pre-developed IEC material. Results: The intervention was found effective in the form of a significant change in level of perception among SHG women that violence during sex or intimacy is abnormal, improvement in awareness about women’s right to decline to the partner from having sex while encountering violence from him and significant reduction in their experience of facing violence during intimacy or sex in last one year. Conclusion: This study provides experience of the feasibility; efficacy and impact of health education interventions and an insight into the development and implementation of effective interventions against violence during sex or intimacy in India. EnglishHealth education, Sexual violence, IEC, Self help group (SHG)INTRODUCTION Domestic violence is manifested through physical, sexual, psychological and economic abuse (Domestic violence against women and girls 2000). The “protection of women from Domestic Violence Act, 2005” says that any act, conduct, omission or commission that harms or injures or has the potential to harm or injure will be considered domestic violence by the law. Even a single act of omission or commission may constitute domestic violence (Kaur R, 2008; the protection of women from domestic violence act, 2005). However, even in the presence of this act, there is a gloomy picture. In depth analysis of National Family Health Survey-3 (NFHS-3) (2006-2007) showed that the prevalence of physical violence among Indian women is as high as 31% and that of sexual violence is also as high as 8.3% (Kimuna SR, 2013). Sexual abuse and rape by an intimate partner is not considered a crime in most countries, and women in many societies do not consider forced sex as rape if they are married to, or cohabiting with, the perpetrator. The assumption is that once a woman enters into a contract of marriage, the husband has the right to unlimited sexual access to his wife. In Zimbabwe women were told that the use of force by a husband is “a part of life”. In Nicaragua and Haiti, it is believed that women do not have the right to refuse sex if they do not feel like it and that in some circumstances men are justified to beat their wives (Population council, 2004). More than two decades of research has shown that sexual violence and intimate partner violence within or outside marriage are major public health problems with serious longterm physical and mental health consequences, as well as significant social and public health costs (Breiding MJ, 2008; Logan TK, 2007; Randall T, 1990; WHO, 2002). An expanding and persuasive body of evidence from diverse settings has documented the connection between sexual violence and reproductive and sexual health risks (Koenig M, 2004; Kishor S, 2004; Parish WL, 2004; Martin SL, 1999; Caceres CF, 2000; WHO, 2005). Many studies are of the view that violence by intimate partner most likely undermines the sexual and reproductive health of the women. This extensive violence has significant harmful effects like unwanted pregnancy (Khan ME, 1996),gynecological disorders (Golding JM, 1996) and physical injuries to private parts (Stark E, 1979). Internationally, one in three women have been beaten, coerced into sex or abused in their lifetime by a member of her own family (Heise L, 1999). Looking at the domestic front, staring from Vedic age to twenty first century, women in India perhaps have never experienced equal rights and freedom compared to their male counterparts. Underdevelopment, lack of economic opportunities for both sexes, and entrenched inequalities in the distribution of power, resources, and responsibilities between men and women (gender inequalities) create a risk environment that supports high levels of intimate-partner violence (Mane P, 1994; Gupta GR, 2002; Garcia-Moreno C 2000). In many developing countries women “believe” that the use of force is a man’s “right” and submission is the only way to avoid pain and ensure security in the marital home. Young women from various settings in South Asia said or were told: “I had feelings of discomfort but I had to accept my husband’s wishes.”“If you won’t give him then he will force you and you would have pain” (George A, 2003). A few studies in South Asia have explored the various coping strategies used by young married women to avoid situations of high personal risk for sexual violence. These studies revealed that young married women try to avoid unwanted sex with their husbands by threatening to scream, in order to endanger the husband’s prestige, threatening to commit suicide, waking up young children, and feigning menstruation (Santhya KG, 2005; Puri M, 2007; Puri M, 2010; Women’s Rehabilitation Centre, 2002; Khan ME, 2002; George A, 2002). Alternatively, some women try to develop a greater intimacy with their husbands, communicate sexual desire, and participate more equally in sex-related decision making to avoid unwanted sexual experiences (Khan ME, 2002; George A, 2002; Joshi AM, 2001). It has been proved that, if the women are given an intervention (life cycle education) regarding the sexual violence at the beginning of their sexual life then there might be a long term impact on reduction in incidence and prevalence of sexual violence. However, in a conservative society like India, talking about sex and other gynecological problems of women is a taboo. Across all strata of the society, these issues are not discussed with the girls before marriage (George A, 2003; Alaudin M, 1999). Even teachers and parents hesitate in talking sexual health issues with the young girls and boys. In this regard a ‘culture of silence’ prevails that inhibits women from revealing their private problems to others due to various social factors. In order to develop effective intervention programme and policy for sustained behavioural change, which is a longdrawn process, it is vital to know the attitude and perception of the women towards the issue in-depth. Communication strategies at the community level by integrating Information, Education and Communication (IEC) tools into public health programs may have great role to influence the change in attitudes, perceptions and behavior of people in the community. Development and use of IEC material along with active participation by the community ensures delivery of appropriate information and knowledge to people which in turn empowers them to make informed decisions about their life. IEC involves building social networks and communicating the information through appropriate channels and methods in a manner that is culturally accepted by the community. Health care workers in rural areas act as change agents and are trained to communicate the information contained in these materials to the community. Studies have proved that education can be a protective factor towards sexual violence by empowering women (Kimuna SR, 2013). With this background the present study was designed to empower and engage the SHG women against violence during sex/intimacy by creating awareness and sustaining interest through lesson plans in the IEC material so that they can act as change agents for other women in the community. METHODS A ‘Multi-centric Action Research Demonstration Study’ (Karnataka, Rajasthan and Chhattisgarh) was conducted to sensitize and engage Self Help Groups (SHGs) women through community mobilization. These women were sensitized and empowered and empowered to take care of their reproductive health including cervical cancer. Besides that it was expected that those SHG women will act as change agent for other women in the community. This study was conducted from May 2012 to October 2013. In the preparatory phase of this study (three months), extensive literature search was done, tools were designed and finalized, IEC materials were developed and baseline data was collected through household survey (HHs) and focus group discussions (FGDs). In the intervention phase (one year), a series of workshops were conducted for the SHG women to meet the objectives. In those workshops the pre-developed IEC materials were used to increase the awareness of SHG women. After that, an end-line data was collected through HHs and FGDs. The data was analyzed and report was prepared and submitted to fun ding agency. This paper has taken data from that original study. The primary study site was Kolar District of Karnataka state. From five taluks of Kolar district, Bangarpet taluk was selected as intervention taluk by applying simple random sam-pling. With the help of purposive sampling the nearby taluk, Malur was selected for adequate counter-factual which has socio-demographic, climatic, developmental and health indicators similar to Bangarpet taluk. In both these taluks HHs and FGDs were conducted to collect quantitative and qualitative information, respectively both during baseline and endline. During intervention phase, fifteen 3-day workshops were conducted targeting 75-80 SHGs in Bangarpet taluk. The local NGOs working in intervention site were involved in those sensitization workshops. In Dharwad, Koppala, Jaipur and Raipur districts only qualitative evaluation using FGDs were done, and only two workshops, each consisting three days, were conducted. Only quantitative data analysis of intervention district of Karnataka has been included in the present article. Sample size: As per the literature search and by assuming the minimum prevalence (50%) about correct perception of SHG women regarding violence during sex/intimacy and considering 10% permissible level of error in the estimated prevalence, the sample size was calculated using the formula n= z2 pq/L2 . The calculated sample size (384) was rounded up and fixed to 400 and decided to interview 200 SHG women from Bangarpet and 200 from Malur taluks during baseline and end-line each. Selection of Households: There are 3 Community Mobilization Research Centers (CMRCs) in Bangarpet taluk (Kamsamudra, Toppanahalli and Budikote) and 2 CMRCs in Malur taluk (Thoralakki and Dinnahalli). From each CMRC, 6 villages were selected by simple random sampling method. Thus a total of 30 villages were selected for the study. In the selected villages total enumeration of SHG women was done to prepare a sampling frame. The required study subjects for each taluk were selected adopting probability proportion to size (PPS) sampling technique. In order to get required study subjects, simple random sampling was done. SPSS v16.0 software was used to analyze the generated data. For statistical inference chi-square test was applied. The statistical significance was decided based on the p value. A p value of Englishhttp://ijcrr.com/abstract.php?article_id=460http://ijcrr.com/article_html.php?did=4601. Alaudin M, Maclaren L. Reaching newlywed and married adolescent. In Focus: Focus on young adults 1999 July; 1-7. Available at: http://www.pathfinder.org/publications-tools/pdfs/Reaching-Newlywed-and-Married-Adolescents.pdf (Last accessed on 07/9/2014). 2. 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