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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareBACTERIOLOGICAL PROFILE AND ANTIMICROBIAL SUSCEPTIBILITY PATTERN OF ISOLATES OF NEONATAL SEPTICEMIA IN A TERTIARY CARE HOSPITAL
English0105Ronni Mol P.English Aparna Y. TakpereEnglish P.R. ShahapurEnglishObjectives: Neonatal sepsis is one of the major causes of morbidity and mortality in the newborn. Early diagnosis and appropriate treatment of blood stream infections would minimise the risk besides reducing emergence of multidrug resistant organisms. Therefore the present study was done to know the etiological agents of neonatal sepsis, and their antimicrobial susceptibility pattern.
Methods: All neonates with signs and symptoms of neonatal septicaemia were enrolled in the study. Blood culture was done by conventional method. Any growth was identified by colony characteristics and standard biochemical tests. Antimicrobial susceptibility tests was done by Kirby Bauer Disc Diffusion method according to National Committee for Clinical Laboratory Standards (NCCLS) guidelines.
Results: 115 cases were enrolled in the study . Out of them early onset sepsis occurred in 76(66.08%)and late onset sepsis in 39 (39%) neonates. Rates of infection was high in males (60%) as compared to females(40%). Culture proven sepsis was seen in 45(39.13%) cases. Common isolated pathogen was Klebsiella pneumonia 13(29%) which was sensitive to Cotrimoxazole( 69.2%) , Sparfloxacin(15.3%) and Amikacin(15%) . Second most common organism was Pseudomonas aeruginosa 9(20%) which was sensitive to Amikacin(88.8%), Ciprofloxacin(77.7%) and Piperacillin/Tazobactum(77.7%). Among the Gram positive organisms, Coagulase Negative Staphylococcus 7(15.5%) was predominant isolate which was sensitive to Linezolid (100%) and Piperacillin/Tazobactum (71.42%).
Conclusions: Blood culture, antibiotic susceptibility surveillance and rational antibiotic use will reduce the rate of neonatal septicaemia and ensure therapeutic success.
EnglishSepsis, Culture, Isolates, Sensitive.INTRODUCTION
Neonatal sepsis is one of the major causes of morbidity and mortality in the newborn.1 In India, neonatal septicemia is responsible for one-fourth to nearly half of the neonatal deaths next to perinatal hypoxia.2 Prior to the antibiotic era, the mortality from septicemia was 90%. But with presently available antimicrobial agents, it may be treated successfully and mortality from septicemia in neonates has declined to 24.58%.3 Medical achievements of the last twenty years have increased the survival rate of neonates but these babies with low immunity, always need prolonged hospitalization which is a factor contributing to the high risk of post-infectious complications.4 Early diagnosis and appropriate treatment of blood stream infections would minimise the risk besides reducing emergence of multidrug resistant organisms.5 Therefore the present study was done to know the etiological agents of neonatal sepsis, and their antimicrobial susceptibility pattern.
MATERIALS AND METHODS
A prospective study was undertaken from May 2013 to Mar 2014.All neonates with signs and symptoms of neonatal septicaemia admitted to Neonatal Intensive Care Unit of Department of Paediatrics at Shri B M Patil Medical College, Bijapur were enrolled in this studyC Ethical clearance was obtained from Shri B M Patil Medical College, Bijapur. 115 cases were included in this study. Blood culture sample was collected from peripheral vein by aseptic conditions. Local site was cleansed with alcohol(70%) and povidone iodine (1%), and again by alcohol (70%). Blood culture was done by conventional method with 1:5 dilution of BHI broth with sodium polyanethol sulphonate. Any growth was identified by colony characteristics and standard biochemical tests. If there was no growth observed on the plates by the next day, subcultures were repeated on day 4 and day 7.6 Antimicrobial susceptibility testing was performed for all blood culture isolates by Kirby–Bauer disc diffusion method as recommended in the National Committee for Clinical Laboratory Standards (NCCLS) guidelines. The drugs for disc diffusion testing were: Ampicillin (10 μg), cloxacillin (1 μg), lomefloxacin (10 μg), amoxiclav (20/10 μg), cephalexin (30 μg), cefuroxime (30 μg), ciprofloxacin (5 μg), erythromycin (15 μg), gentamicin (10 μg), (30 μg), penicillin (10 units), co-trimoxazole (1?25 μg trimethoprim/23?75 μg sulfamethoxazole), amikacin (30 μg), ofloxacin (5 μg), sparfloxacin (5 μg), pefloxacin (5 μg), cefoperazone+ sulbactum (75 μg/30 μg), netilmicin (30 μg), piperacillin/tazobactam (100/10 μg), norfloxacin (10 μg), carbenicillin (100 μg), azithromycin (15 μg), and linezolid (30 μg). The discs were obtained from Himedia (India) Laboratories.
RESULTS
115 cases were enrolled in the study. Out of them Early onset sepsis occurred in 76(66.08%) and Late onset sepsis in 39 (39%) neonates, as shown in Graph-1. Rates of infection was high in males (60%) as compared to females(40%). Culture proven sepsis was seen in 45(39.13%) cases. Out of them Gram negative bacteria were 31(68.8%) and Gram positive bacteria were 14(31.1%), as shown in Table-1. Common isolated pathogen was Klebsiella pneumoniae 13(29%) which was sensitive to Cotrimoxazole (69.2%). Second most common organism was Pseudomonas aeruginosa 9(20%) which was sensitive to Amikacin (88.8%), Ciprofloxacin (77.7%) and Piperacillin/Tazobactum (77.7%). Among gram positive organisms Coagulase Negative Staphylococcus 7(15.5%) was most coomon organism which was sensitive to Linezolid (100%) and Piperacillin/Tazobactum (71.42%). Distribution of the isolated organisms and their antibiotic susceptibility pattern is shown in Table - 2,3,4 and 5.
DISCUSSION
The varying microbial pattern of sepsis warrants the need for ongoing review of causative organisms and their antibiotic sensitivity pattern. In our study male neonates (60%) were affected more than females (40%) which was similar to Pais M et al.7 A male predominance with male-to-female ratio of 1.5:1 was found in our study, which agrees with previous reports. This might be because of the importance given to the male infants and also because of more number of male infants born compared to female infants born.8 In this study, blood culture-positivity rate is 39.13%. This finding is comparable with other reports. A low blood culture isolation rate could be due to administration of antibiotic before blood collection from the primary centers or the possibility of infection with anaerobes. A negative blood culture does not exclude sepsis and about 26% of all neonatal sepsis could be due to anaerobes.9 In our study, the most frequent isolate was Klebsiella pneumoniae (29%) which was in accordance with Roy and colleagues.10 Even the report of the National Neonatal – Perinatal database showed Klebsiella as the predominant organism(29%).11 Common isolated pathogen in our study was Klebsiella pneumonia 13(29%) which was sensitive to Cotrimoxazole(69.2%), Sparfloxacin(15.3%) and Amikacin(15%). Second most common organism was Pseudomonas aeruginosa 9(20%) which was sensitive to Amikacin(89%), Ciprofloxacin(78%) and Piperacillin/Tazobactum(78%). Among the Gram positive organisms, Coagulase Negative Staphylococcus 7(15.5%) was predominant isolate which was sensitive to Linezolid (100%) and Piperacillin/Tazobactum (71.42%). Other isolates were Streptococcus species which was also sensitive to above antibotics and Enterococcus species which was sensitive to Linezolid(100%)and Pefloxacin(33.3%). The antimicrobial sensitivity pattern differs in different studies as well as at different times in the same hospital. This is because of emergence of resistant strains as a result of indiscriminate use of antibiotics.
CONCLUSION
It is evident from this study that Klebsiella pneumoniae, Pseudomonas aeruginosa and Coagulase Negative Staphylococcus are the leading cause of neonatal sepsis. Depending on the antibiotic sensitivity patterns of isolates, antibiotics should be used in the hospitals.
In view of the above facts, we conclude that for effective management of neonatal septicaemia cases, study of bacteriological profile and regular antibiotic surveillance and evaluation, and enforcement and periodic review of antibiotic policy should be implemented in all the hospitals.
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.
Englishhttp://ijcrr.com/abstract.php?article_id=461http://ijcrr.com/article_html.php?did=4611. Betty chacko et al. Early Onset Sepsis.Ind J Paed. 2005, 72(1):23-26
2. Adams-Chapman I, Stoll BJ. Prevention of nosocomial infections in the neonatal intensive care unit. Curr Opin Pediatr, 2002; 14:157-64.
3. Sima BK, Disha PA, Praveg G, Kiran P, Gurudutt J. Bacteriological profile and antibiogram of neonatal septicemia. Nat J CoM Med. 2012 , 3(2).
4. Madhu Sharma, Sarita Yadav, Uma Chaudhary. J Lab Physicians. 2010 Jan-Jun; 2(1): 14–16.
5. Joshi et al. Neonatal Gram Negative Bacteremia. Ind J Paed 2000; 67:27-32.
6. Deching sehring et al,Extended Spectrum Beta-lactamase Detection in Gram-negative Bacilli of Nosocomial Origin. J Glob Infect Dis. 2009 Jul-Dec; 1(2): 87–92.
7. Pais M et al. Neonatal Sepsis, bacterial isolates and antibiotic susceptibility patterns among neonates. Nurs J India. 2012;103(1):18-20.
8. Mathur M, Shah H, Dixit K, Khambadkone S, Chakrapani A, Irani S. Bacteriological profile of neonatal septicemia cases. J Postgrad Med. 1994, 40: 18- 20.
9. Shrestha P, Das BK, Bhatta NK, Jha DK, Das B, Setia A, et al. Clinical and bacteriological profiles of blood culture positive sepsis in newborns. J Nepal Paediatr Soc. 2008;27:64–7.
10. Roy I, Jain A, Kumar M, Agarwal SK. Bacteriology of neonatal septicemia in a tertiary care hospital of northern India. Indian J Med Microbiol. 2002;20:156–9.
11. Neonatal morbidity and mortality; report of the National Neonatal-Perinatal Database. Indian Pediatr. 1997;34:1039–42.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareDOUBLE FORAMEN TRANSVERSARIUM-A CASE REPORT
English0608Nilofer Gausmohiyuddin MullaEnglish Sunil J. PundgeEnglishAim: To report a case of bilateral accessory foramen transversarium in lower cervical vertebrae.
Case Report: In the present case we observed two abnormal foramina in transverse process of C7 and probably C6 cervical vertebrae. Rest of cervical vertebrae were normal.
Discussion: The reasons for the presence of accessory foramen transversarium can be developmental or vascular. The presence of accessory foramen can alter the course of vertebral artery and even lead to compression of vertebral artery. This can lead to symptoms like headache, migraine and fainting attacks.
Conclusion: The study of these variations is important to radiologists in interpreting CT and MRI scans.
EnglishCervical vertebra, Foramen transversarium, DoubleINTRODUCTION
Foramen transversarium (FT) is a unique feature which is present in the transverse process of cervical vertebrae. The transverse process is morphologically composite around the foramen transversarium [1]. It has a dorsal and ventral bar, which terminates laterally as corresponding tubercles. These tubercles are connected, lateral to the foramen, by the costal (or, intertubercular) lamella. In upper six vertebrae foramen transversarium normally transmits vertebral artery, vertebral vein and a branch from cervicothoracic ganglion (vertebral nerve) [1]. In the seventh cervical vertebra it transmits only accessory vertebral veins and each is often divided by a bony spicule [1]. These foramina are known to exhibit variations and their etiology may be related to variations of the course of vertebral artery and is developmental [2]. The foramen transversarium is a result of the special formation of cervical vertebra. It is formed by vestigial coastal element fused to the body and the originally true transverse process of the vertebra. The vertebral vessels and nerve plexus are caught between the bony parts [3]. The deformation and variations of this foramen may affect the anatomical course of vascular and neural structures, and consequently may cause pathological conditions like vertebrobasilar insufficiency [4]. We noted abnormal foramina in the transverse process of C7 and probably C6 vertebrae.
CASE REPORT
During the routine osteology demonstration classes of cervical vertebrae in anatomy department, we notice two abnormal foramina in the transverse process of C7 and probably C6 vertebrae. The foramina were smaller, bilaterally present and posterior to the normal foramen transversarium. The foramina were complete and separated from the main foramen by a thin bar of bone. There was no other abnormality in the bone and remaining cervical vertebrae were normal.
DISCUSSION
Double foramen transversarium may be unilateral or bilateral depending on the course of vertebral artery. The reasons for the presence of accessory F.T can be developmental or vascular. It might be due to double rib bone element on the same side fusing to the original transverse process resulting in unusual number of FT [5].The association of double FTand duplication of vertebral artery is also possible but it is not a rule. The lack of foramen transversarium may indicate bypassing the vertebra by the vertebral artery. These have been confirmed by radiological studies [6]. Taitz et al studied 480 vertebrae from various populations and reported double foramen transversarium in 34 cases i.e.in 7% of vertebrae and only one vertebra manifested three transverse foramina unilaterally [3]. In contrast Das et al has reported duplicated foramen transversarium in two cases out of 132 cases he examined [2]. El Shaaray et al reported accessory foramen transversarium were most common in lower cervical vertebrae (C5, C6 and C7) which goes well with the present case [7]. Murlimanju et al studied 363 vertebrae and reported accessory foramen in 1.6% cases (only in 6 vertebrae) out of which 5 vertebrae showed double foramen and all the foramen were observed in lower vertebrae (C6 and C7) [8]. The vertebral vessels are a factor in the formation of the FT, thus it is assumed that variations in the presence and course of the vessels will be manifested in changes of the FT. Conversely, variations of the FT can be useful for estimating changes or variations of the vessels and accompanying nerve structures. Similar correlation may be suggested for double FT [3].
CONCLUSION
The knowledge of these variations helps in determining a more accurate approach to the removal of osteophytes or spurs compressing the vertebral arteries or in other interventions in the area. The surgical anatomy of foramen transversarium and vertebral artery are important to neurophysicians and radiologists in interpretation of radiographic films, angiograms and CT scans.
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=462http://ijcrr.com/article_html.php?did=4621. Standring S, 40th ed. Gray’s anatomy-The anatomical Basis of Clinical Practice. Spain: Churchill Livingstone Elsevier. 2005:718-721.
2. Das S, Suri R, Kapur V. Double foramen transversaria: An osteological study with clinical implications. Int Med J. 2005; 12:311-313.
3. Taitz C, Nathan H, Arensburg B. Anatomical observations of the foramina transversaria. Journal of Neurology, Neurosurgery and Psychiatry 1978; 41:170–176.
4. Mishra GP, Kumari S, Bhatnagar S, Singh B. Sixth cervical vertebra with bilateral double foramen transversarium and nonbifid spine: a rare case. Int J Res Med Sci. 2015; 3(1): 352-353.
5. Veeramani and Shankar. An unusual origin of the right vertebral artery from the thyrocervical trunk- a case report. International Journal of Basic Medical Sciences. (2011); 2(4).
6. Jarostaw Wysocki, Mariusz Bubrowski, Jerzy Reymond, Jan Kwiatkowski. Anatomical variants of the cervical vertebrae and the first thoracic vertebra in man. Via Medica, (2003); 62:357- 363.
7. El Shaarawy EAA, Sabry SM, El Gammaroy T, Nasr LE. Morphology and morphometry of the foramina transversaria of cervical vertebrae: A correlation with the position of the vertebral artery. Kasr El Aini Medical Journal [serial online] June 2010. Accessed December 10, 2010
8. MurlImanju BV, Prabhu LV, Shilpa K, Rai R, Dhananjaya KVN, Jiji PJ. Accessory transverse foramina in the cervical spine: incidence, embryology basis, morphology and surgical importance. Turkish Neurosurgery.2011; 21(3):384-387.
9. Cloward R. B. The anterior approach for removal of ruptured cervical discs. Journal of Neurosurgery. (1958); 15:607-617.
10. Caovilla HH, Gananca MM, Munhoz MS, Silva ML. Sindrome cervical. Quadros Clinicos Otoneurologicos Mais Comuns. Atheneu, Sao Paulo.2000; 3(11):95-100.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareHEPATITIS C VIRUS: SCREENING, DIAGNOSIS, AND INTERPRETATION OF LABORATORY ASSAYS
English0913Amit H. AgravatEnglish Mital J. GamitEnglish Gauravi A. DhruvaEnglish Kaushal R. BhojaniEnglish Krupal M. PujaraEnglishBackground: All blood and blood products should be tested for Hepatitis C virus (HCV) before transfusion to decrease prevalence
of HCV.
Aim and Objective: The aim of present study is to determine the prevalence of hepatitis c virus (HCV) and to check the accuracy
of our laboratory analysis used for HCV testing of blood donors in our blood bank.
Material and Methods: The duration of this study is of 2 year since April 2013 to March 2015. All donors are screened during
counselling. The blood sample of Total Donor 26,789 including voluntary and replacement were tested for anti HCV antibody by
3 rd generation ELISA (QUALISA).Samples which are reactive or in gray zone were retested by ELISA and also confirmed by
rapid HCV card.
Results: From total donor 26,789, positive for the HCV were 45 (0.16%). Out of 45, 42 (93.3%) were male, 3(6.6 %,) were female
positive. 25 (55.5%) were voluntary and 20 (44.4%) were replacement. Maximum donors come under the age group of
21-30 and 31 -40 and 22 (48.8%) were B RhD positive subjects found.
Conclusion: The prevalence of HCV infection is mild (0.16 %) in blood donors in blood bank of PDU medical college and hospital,
Rajkot. The prevalence is equal in voluntary and replacement donors. Males are more infective than female.
EnglishHCV infection, Anti HCV antibody, Blood donorsINTRODUCTION
Hepatitis C was first detected in 19891 , and it has been described as a significant causative agent of post transfusion non A non B chronic hepatitis². HCV may remain latent or become activated, leading to persistent infections and in some case cirrhosis and hepatocellular carcinoma ³. HCV is most commonly transmitted through direct contact with infected blood4 .Other routs of transmission include unsafe injection practice, mother to child transfer injection drug use5 . The impact of this infection is emerging in India. The mainstay in diagnosing infection with HCV is to initially screen high risk groups for antibodies to HCV (anti-HCV). Virological diagnosis of HCV infection is based on two categories of laboratory tests, namely serologic assays detecting specific antibody to HCV (anti-HCV) (indirect tests) and assays that can detect, quantify, or characterize the components of HCV viral particles, such as HCV RNA and core antigen (direct tests). This article aims to give overview of emerging infection in India discussing the screening, diagnosis and interpretation of available assay.
MATERIAL AND METHOD
This study was conducted at department of pathology, PDU medical college and Rajkot. The duration of this study is of 2 year since April 2013 to March 2015 .Total donors during this period were 26,789. A blood donor is offered an option to know his TTI status at the time of registration for blood donation after due counseling and give consent for the same. After blood donation blood sample is collected in plain vaccutte at the end of phlebotomy for pre transfusion testing .The sample is allowed to clot to separate serum. The test is done by using 3 rd generation ELISA kit( QULISA, manufactured by Tulip diagnostic pvt.ltd.) and manufacturer’s instructions were strictly followed while performing each assay samples found reactive or in gray zone were retested by the same kit and also confirmed by the rapid HCV card(RECKON, manufactured by reckon diagnostic pvt.ltd.)
RESULT
From total donor 26789, positive for the HCV were 45 (0.16%),out of 45, 42 (93.3%) were male, 3(6.6%,) were female.25 (55.5%) were voluntary and 20 (44.4%) were replacement. Maximum donors come under the age group of 21-30 and 31-40. Out of 45, 22 (48.8%) were B RhD positive.
DISCUSSION
In our study, 45 donors were HCV positive out of 26,789. Comparison of our study with the study done in different part of Gujarat is given below: It is observed that male donors are more positive than female as same study done at Ambrose Ali University, Ekpoma, NiWe found that there is no major difference between voluntary and replacement donor. In in study of Nigeria6 replacement donors were more frequent (63%) than voluntary donors. In our study HCV positive largest age group is 31-40 year while in study of Nigeria largest age group found was 21-30 year. In a study conducted in Germany,7 it was observed that HCV-infected women were significantly more often Rhesusnegative than men. On the other hand, a more recent study in the United States of America.8 found no association between blood groups and HCV. The previous study found that antiHCV results correlated with age and sex whereas the latter study did not find any significant association of HCV with either age or sex. In study of Nigeria most of positive donor were HCV positive as shown below table. In our study most of the B positive donors are HCV positive.
CONCLUSION
Screening of blood donors for HCV can efficiently exclude those donors who are persistent low level carrier, those in the window period of acute infection. The study suggests that despite testing of bloo
Englishhttp://ijcrr.com/abstract.php?article_id=463http://ijcrr.com/article_html.php?did=4631. Choo Q-L, Kuo G, Weiner AJ. Isolation of a DNA clonederived from a blood borne non A, non B viral hepatitis genome. Science 1989; 244: 362-4.
2. Alberti A, Chemello L, Benvegnu L. Natural history of hepatitis C. J Hepatol 1999; 31 (Suppl 1); 17-24.
3. Naoumov NV, Chokshi S, Metivier E, et al. Hepatitis C virus infection in the development of hepatocellular carcinoma in cirrhosis. J Hepatol 1997: 27: 331-6.
4. Burnouf T, Radosevich M. Reducing the risk of infection from plasma products: specific preventive strategies. Blood Rev 2000; 14: 94-110.
5. Okamoto M, Nagata I, Murakami J, Kaji, et al. Prospective reevaluation of risk factors in mother-to-child transmission of hepatitis C virus: high virus load, vaginal delivery and negative anti-NS4 antibody. J Infect Dis 2000; 182: 1151-4.
6. Zaccheaus Awortu Jeremiah, Baribefe Koate1, Fiekumo Buseri, Felix, et al. Prevalence of antibodies to hepatitis C virus in apparently healthyPort Harcourt blood donors and association with blood groupsand other risk indicators. Blood Transfusion 2008; 6:150-155.
7. Caspari G, Gerlich WH, Bever J, Schmitt H. Non specific and specific anti HCV results correlated to age, sex, transaminase, Rhesus blood group and follow up in blood donors. Arch Virol 1997; 142: 473-89.
8. Busch MP, Glynn SA, Stramer SL, et al. Correlates of hepatitis C virus (HCV) RNA negativity among HCV seropositive blood donors. Transfusion 2006: 46: 469-75.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareA STUDY OF ANAMOLOUS ORIGIN OF GLUTEAL ARTERIES
English1416Amudalapalli Siva NarayanaEnglish M. Pramila PadminiEnglishAim: The present study has been taken up to observe the branching pattern of internal iliac artery and its importance for the clinicians in their respective fields.
Methodology: 45 pelvic halves were studied from dissected cadavers. The branches of gluteal arteries were traced carefully by separating the connective tissue surrounding the arteries.
Result: In 4 cadavers, inferior gluteal artery was given off in the gluteal region, in 1 case it is given off from posterior division of internal iliac artery. In 1 case superior gluteal arose in common with internal pudendal artery.
Conclusion: Vascular variations in the gluteal region are important for surgeons and anatomists.
EnglishInternal iliac artery, Gluteal arteries, Pelvic region, Internal pudendal arteryINTRODUCTION
Each internal iliac artery is about 4 cm long and begins at the common iliac bifurcation level with the intervertebral disc between L5 and S1 vertebrae and anterior to the sacroiliac joint. As it passes downward across the brim of the pelvis it is separated from the psoas major by the external iliac vein and has the internal iliac vein lying somewhat to its posterolateral side. Inferior gluteal artery is the larger terminal branch of anterior division of internal iliac artery and principally supplies the buttock and the thigh.
MATERIALS AND METHODS
A total of 45 pelvic halves had been studied, of which study on 12 pelvis were also included (i.e., 24 pelvic halves) and the remaining 21 being single sides. The study was done on adult cadavers, procured for dissection for undergraduate students Dr. Pinnamaneni Siddhartha Medical College, Gannavaram and Gitam Medical College, Andhra Pradesh. The study was carried out in the dissection hall of the above college. The Common Iliac Artery was identified and the branches were carefully cleared till the terminal bifurcation which were External Iliac and Internal Iliac Arteries(IIA). The tributaries of internal iliac vein along with the main trunk were discarded to visualize the branches of IIA. Connective tissue surrounding the IIA was cleared. Parietal and visceral branches were traced. Some of the branches of IIA were traced till their exit from the pelvic cavity and are called parietal branches. The other branches were traced till they reached the specific pelvic organs and are named as visceral branches.
OBSERVATION
The length of common iliac artery is about 1.5cm long (figure:1). The actual length of common iliac artery is 4cm. Normally the division occurs between the fifth lumbar vertebra and the upper border of the sacrum. In the present study its division occurred above the level of L5. In 1 specimen the inferior gluteal artery was arising from the posterior division of internal iliac artery (figure: 2). In 1 pevic half , a common trunk from IIA has given superior gluteal artery and internal pudendal artery and inferior gluteal artery was arising from the anterior division of internal iliac artery separately (figure: 3). In 4 specimens the inferior gluteal artery and internal pudendal artery were arising from a common stem which has been given off in the gluteal region (figure:4)
DISCUSSION
The inferior gluteal artery may be doubled or form a common trunk with superior gluteal artery (Bergman RA et al19881 ). In a study by Gabrielli et al2 . the inferior gluteal artery or one of its branches pierced the sciatic nerve in 22.5% of cases (Ga-brielli et al 19972 ). In the present study inferior glutel artery arose from the posterior division of internal iliac artery. Variations of gluteal vessels is importance to the orthopedic surgeons dealing with the fractures and dislocations of the hip. In a study by Surekha D Shetty et al 20123 , there was complete absence of inferior gluteal artery. Inferior gluteal artery may form a common trunk with the superior gluteal (Bergman RA et al 19881 ). In study of Kawanishi Y et al4 , the IPA originates together with the superior and inferior gluteal artery within 1 cm of each other. In a study of Pavan Pet al 20145 , inferior gluteal artery took origin from anterior division in 42 specimens (84%),from posterior division in 3 specimens(6%) and was found to be absent in 5 specimens(10%). In the present study inferior gluteal artery arose from posterior division of internal iliac artery in one specimen, in another specimen superior gluteal artery and internal pudendal artery arose as a common trunk and in four specimens inferior gluteal artery arose from a common trunk along with internal pudendal artery in the gluteal region.
CONCLUSION
The knowledge of internal iliac artery and gluteal arteries are very important in pelvic surgeries , hysterectomies and orthopedic surgeries related to hip joint.
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=464http://ijcrr.com/article_html.php?did=4641. Bergman RA, Thomson SA, Afifi AK, Saadesh FA. Compendium of Human Anatomic Variations. Baltimore, Munich, Urban and Schwarzenberg. 1988; 84.
2. Gabrielli C, Olave E, Sarmento A, Mizusaki C, Prates JC. Abnormal extra pelvic course of the inferior gluteal artery. Surg Radiol Anat. 1997; 19: 139–142.
3. Surekha D SHETTY, Abhinitha P, Sapna MARPALLI, Satheesha NAYAK B Total replacement of inferior gluteal artery by a branch of superior gluteal artery Int J Anat Var (IJAV). 2012; 5: 85–86.
4. Kawanishi Y, Muguruma H, Sugiyama H, Kagawa J, Tanimoto S,Yamanaka M, et al. Variations of the internal pudendal artery as a congenital contributing factor to age at onset of erectile dysfunction in Japanese. BJU Int 2008;102(2):259.
5. Pavan P Havaldar , Sameen Taz , Angadi A.V , Shaik Hussain Saheb Study Of Variations In Anterior Division Of Internal IliacArtery int j anat res 2014, vol 2(2):363-68. Issn 2321- 4287.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareCOMPARISON BETWEEN EFFECT OF PURSED LIP BREATHING AND MOUTH TAPING ON DYSPNOEA: A CROSS SECTIONAL STUDY
English1721Gaurav Maind PTEnglish Raziya Nagarwala PTEnglish Seemi Retharekar PTEnglish Supriya Gondane PTEnglish Nilima Bedekar PTEnglish Ashok ShyamEnglish Parag SanchetiEnglishBackground and purpose of the study was to compare Pursed-lip breathing and Mouth taping for relieving dyspnoea and analyse their effectiveness.
Method: Subjects of age group 18-34 years and normal BMI were randomly divided into two groups, group A (n= 40) for PLB technique and group B (n= 40) for MT technique. Each subject’s Heart rate, Respiratory rate, Blood pressure, Treadmill walking time and level of dyspnoea according to Modified Borg CR10 scale was assessed before and after the intervention.
Results: Both the techniques showed significant improvement by virtue of an increased treadmill walking time, the subject’s dyspnoea status during the treadmill walking and lesser time for recovery to baseline vital parameters. Significant reduction in post-test RR after PLB (p=0.030) and MT (p=0.012) respectively were seen. Although, when compared to each other, MT and PLB techniques showed no significant differences with respect to the dyspnoea relieving time(p=0.08)and treadmill walking time(p=0.2).
Conclusion: MT and PLB both have proved themselves to be equally effective in improving the response to exercise in terms of increased treadmill walking time and post-test dyspnoea status and recovery of vital parameters, without any significant differences between the two techniques.
EnglishTreadmill walking time, Dyspnoea reliefINTRODUCTION
Dyspnoea’ or ‘shortness of breath’ or ‘breathlessness’ is perceived as difficulty in breathing or painful breathing that a patient is aware of. It is an unpleasant sensation of laboured breathing. Normal breathing is an unconscious act but when respiration becomes disturbed, an individual may become acutely aware of discomfort or distress associated with breathing1 . Dyspnoea may be considered as a part of the warning system for humans to recognize when they are at a risk due to variations in intensity of exertion/exercises which may lead to inadequate ventilation. Dyspnoea has always been a frequent cause of emergency room visits and has proven itself to be an independent predictor of mortality2 . The workshop by The National Institute of Health on pulmonary rehabilitation also suggested ‘Dyspnoea’ as the most frequent symptom reported by patients with chronic respiratory disease3 . A statement from American Thoracic Society offered the following definition of dyspnoea, “Experience of dyspnoea derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses4 ”. It is especially very important when it interferes with activiIties of daily living, important consequence being profound reduction in activity. The subsequent sedentary lifestyle may contribute to muscular deconditioning leading to greater breathlessness. Therapies for relieving dyspnoea include pharmacological and non-pharmacological treatments with the aim of modifying a specific cause or rather a general symptomatic management5 . Non-pharmacological treatment includes ventilator support like BiPAP, relaxation techniques, counselling, facial cooling by icing, application of cold air by sitting near an open window, doing pursed lip breathing in a relaxed posture, music therapy, dyspnoea relieving positions, etc. Pursed Lip Breathing (PLB) is a very popular and excellent “Rescue” technique for acute dyspnoea resulting from COPD, Emphysema and Asthma. It simply imposes a slight obstruction to expiratory air flow at the mouth which generates back pressure throughout the airway causing stenting effect which helps prop open the airways and assists exhalation and thereby, better lung emptying6 Mouth taping is a technique which simply mimics pursed lip breathing, modification here is the application of tape around and over the lips with a small opening at the centre, creating acentral aperture. Mouth taping may appear to be an unconventional approach; but there is no evidence that the practice may be harmful. With no published research about the physiological effects of mouth taping there is a need to investigate this area. The need of this study was to observe whether the effect of mouth taping technique would be similar to the beneficial effects of pursed lip breathing.
MATERIALS AND METHODOLOGY
Institutional Ethical committee approval was obtained for the cross sectional study design. By purposive sampling, 80 healthy subjects fulfilling our selection criteria were fully explained the nature of the study and a written informed consent was obtained from them. Baseline parameters-HR, RR, BP and level of dyspnoea according to Modified Borg’s scale (CR-10) were documented. Before the test, subjects were instructed to stand on treadmill with hands loosely holding the handrails. All were subjected twice to the Bruce’s protocol with a rest period of 3 days as a wash out period in between the tests. At each stage of Bruce’s protocol, subjects graded their dyspnoea status. Test was terminated either when the subject reported “maximal” on the CR-10orwhen the subject stopped due to any reason other than dyspnoea (e.g. leg cramps, giddiness). All the vital parameters were reassessed immediately after and until recovery to baseline values. Time required for recovery to pre-test parameters was noted. This denoted time for dyspnoea relief, Researcher one carried out Bruce’s protocol on all the 80 subjects. These 80 were divided by simple random sampling into two groups. Group A- Mouth taping (Before starting the Bruce’s protocol), subjects’ mouth were taped with the help of micropore tape, only central aperture, i.e., only 1/4th of the total lip length was kept open. Subjects were asked to demonstrate breathing pattern like pursed lip breathing after the tape was applied. After the confirmation of the breathing pattern, subjects were asked to walk on treadmill and advised to inhale from nose and exhale through the mouth right from beginning of the test.
Group B- Purse lip breathing (Subjects were instructed to purse their lips while walking on treadmill and advised to inhale from nose and exhale through pursedlips) Researcher two carried out the Bruce’s protocol for both these groups.
RESULTS
Statistical analysis
The data was analysed using SPSS software. The level of significance was set at p Englishhttp://ijcrr.com/abstract.php?article_id=465http://ijcrr.com/article_html.php?did=4651. AJ Fedullo, AJ Swinburne, C McGuire-Dunn. Complaints of breathlessness in the emergency department. NY State J Med 1986; 86:4–6
2. GT O’Connor, KM Anderson , WB Kannel, et al. Prevalence and prognosis of dyspnea in the Framingham Study Chest 1987; (suppl 2):90-92
3. D Mahler, A Harver. Pulmonary rehabilitation-Alfred Fishman, C Dyspnea, 1st ed, Marcel Dekker. New York. Pg. no.97-116.
4. B Mark. Parshall, M Richard, Schwartzstein, A Lewis, B Banzett, L Harold. BJ Manning, M Peter. AG Calverley. M. Meek et al; American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnoea on behalf of the ATS Committee on Dyspnoea October, 2011).
5. Deanna Douglas – Session II Palliative treatment of dyspnoea. (www.lifeproject.org).
6. GFaager, A Stahle, FF Larsen. Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe COPD. J clinical rehabilitation 2008, vol.22, no.8, 675-678.
7. MA Nield, GW SooHoo, J Roper, S Santiago. Efficacy of pursed-lips breathing: a breathing pattern retraining strategy for dyspnoea reduction. J Cardiopulm Rehabil Prev. 2007; 27:237- 244.
8. MR Wolfson, T Shaffer . Cardiopulmonary physical therapy- A guide to practice. Scot Irwin. 4th ed, Mosby, 2004.pg no. 39-81.
9. Gigliotti F, Romagnoli I, Scano G; chest wall kinematics and breathlessness during pursed lip breathing in patients with COPD. Chest 2004 125: pg no.459-465
10. D Frownfelter, M Massery. Cardio vascular and pulmonary physical therapy- Donna Frownfelter, 4th ed. Mosby, 2006, pg no.363-403.
11. Campbell, Agostoni, news on Davis and L Lloyd Respiratory muscle: mechanics and neural control-2nd ed, by London. pg no.348, 1970.
12. DO Rodenstein, DC Stanescuetal.Absence of nasal air flow during pursed lips breathing. The soft palate mechanisms. Am Rev Respir Dis. 1998; 128:716-718.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareIMPORTANCE OF CLINICAL HISTORY AND ENDOMETRIAL HISTOMORPHOLOGY IN TREATMENT DYSFUNCTIONAL UTERINE BLEEDING
English2229Panchal Nirav S.English Baxi Seema N.EnglishIntroduction: Dysfunctional Uterine Bleeding (DUB) seen in 10-15% of women attending gynaecological clinic has variations in endometrial patterns. Modern treatment depends upon physiology and morphological pattern.
Aims: This study was undertaken to analyse types, frequencies and histomorphology of DUB in a part of India where this was the first study of its kind, to analyse hormonal effects and to evaluate percentage of hyperplasia and pre-neoplastic features as per WHO 2008 and Endometrial Intraepithelial Neoplasia (EIN) criteria.
Method: 237 curettage and 126 hysterectomy samples of DUB patients were assessed between July 2012 - July 2013 in a tertiary care teaching hospital.
Results: DUB was common between 31-50 years. Adolescents were not seen to have DUB. Early menopause at 40 years was seen in 14.3% cases. Ovulatory cases comprised 34.7% and anovulatory 50.5%. Hyperplasia comprised 5.5% and 1.7% had malignancy. One case of simple hyperplasia had EIN. Tuberculous endometritis is not common in our district though pulmonary tuberculosis is rampant.
Conclusion: Regional differences in age of presentation and socioeconomic differences in organic pathologies are noted in different parts of India. Different treatment options make it essential to differentiate DUB into ovulatory/anovulatory, disordered proliferative endometrium or hyperplasia.
EnglishDysfunctional uterine bleeding, Exogenous hormones induced endometrial changes, Endometrial intraepithelial neoplasia, Endometrial hyperplasia, Disordered proliferative endometriumINTRODUCTION
Endometrium being a hormonally sensitive tissue continuously undergoes rhythmic changes during reproductive life. Normal menstruation occurs as bleeding from a secretory endometrium and does not exceed 5 days (ovulatory cycle). Any bleeding outside this criteria is known as Abnormal Uterine Bleeding (AUB). AUB in absence of any organic pathology is called Dysfunctional Uterine Bleeding (DUB). DUB is one of the common complaint seen in 10-15% of women attending a gynaecological clinic.[1] Since it is associated most commonly with anovulatory menstrual cycles perimenopausal and to a lesser extent adolescent women are particularly vulnerable. DUB also occurs in ovulatory cycles. Post menopausal bleeding is also included in DUB.[1] DUB has great variation in the endometrial patterns and treatment depends upon ovulation physiology and morphological pattern. Freely prescribed hormonal treatment by gynaecologists as well as by general practitioners and easily available oral contraceptive pills cause various abnormalities in histology of endometrium. However, the history of such hormone intake is not available to the pathologist in most cases. It adds to the dilemma of the reporting pathologists. The present study was undertaken to analyse types, frequencies and histomorphology of DUB in a part of India where this was the first study of its kind, to analyse hormonal effects and to evaluate percentage of hyperplasia and pre-neoplastic features as per WHO 2008 and Endometrial Intraepithelial Neoplasia (EIN) criteria. [2,3,4,5]
MATERIALS AND METHODS
The study was conducted on patients of Dysfunctional Uterine Bleeding attending Gynecology OPD during the period of July 2012 to July 2013 of a district level tertiary medical care hospital of Bhavnagar, Gujarat state. Clinical colleagues were asked to give precise history for this study undertaken by pathology resident. Institutional review board (IRB) permission was taken. The study included both curettage and hysterectomy specimens of DUB patients. The uterus of a patient already curetted was not considered as a new case.\
Inclusion criteria were patients with history of
• Dysfunctional uterine bleeding at any age
• Post menopausal bleeding
Exclusion Criteria were patients known to have
• Acute Pelvic Inflammatory Disease
• In situ intrauterine contraceptive device
• Systemic Bleeding disorders
The bleeding patterns and LMP were recorded from the requisition slips. The morphological histopathology evaluation of slides was done by a single experienced senior consultant. Cases with morphology of hormonal treatment were requestioned before final diagnosis. WHO classification of 2008 of hyperplasia were strictly followed. Cases of hyperplasia were further evaluated for Endometrial Intraepithelial Neoplasia in relation to Endometrial Intraepithelial Neoplasia diagnostic criteria.[2,5] .
RESULTS
A total of 237 curettage and 126 hysterectomy specimen were studied during this study. Figure 1 shows age wise distribution of patients having DUB in our study and figure 2 shows age wise histomorphological spectrum. Menorrhagia and polymenorrhoea were found in 85% and 10% respectively equally in 21-30 and 31-40 years age group. Polymenorrhoea and metrorrhagia respectively occupied around 60% and 70% in 41-50 years age group. When continuous bleeding (24.2%) and DUB were mentioned as type of bleeding they were clubbed with menorrhagia for facilitation of comparison with other studies. 15% cases in 31-40 year group presented with post menopausal bleeding. Proliferative pattern was the commonest endometrial pattern in all ages seen in 196 out of 363(54%) cases across all bleeding types. Out of these 196 cases of proliferative pattern, 31.6% were true proliferative phase as per last menstrual period (LMP) and rest 68.4% were proliferative phase of anovulatory cycles and showed morphology of weak proliferation and persistent estrogen effect.[Fig. 3A] Atrophic and isthmic endometrium were seen in 3.6% and 0.6% respectively.[Fig. 3 B,C] Secretory phase was seen only in the age groups between 31-40 years and 41-50 years where it comprised – 3.03% and 2.20% respectively. Progestin pill effects were seen in 1.9%.[Fig. 3D] In PMB group (35 cases) only 17.1% cases were due to malignancy and 57.1% due to hyperplasia. Rest belonged to non-neoplastic category. Few organic pathologies came up unsuspected in this study of DUB. Figure 4 shows percentage distribution of organic pathologies. Hyperplasia were seen in only 5.5% cases. Surprisingly menorrhagia was the commonest presenting bleeding pattern of hyperplasia. 70% of the Hyperplasia cases were Simple Typical hyperplasia and most of them were seen in the age between 31-50years. Disordered proliferative endometrium was seen in 3.6% of total cases. (Fig. 5 A,B,C) The 20 cases of Hyperplasia were evaluated for Endometrial Intraepithelial Neoplasia. One case met all the criteria of Endometrial Intraepithelial Neoplasia (EIN). (Fig. 5 D) 6 cases of malignancy were detected, all were postmenopausal and above 55 years. 3 cases had Endometrial adenocarcinoma one of which showed secretory variant, 2 had Endometrial adenocarcinoma with benign squamous component (Endometrial Adenoacanthoma) and one had poorly differentiated Endometrial stromal sarcoma.(Fig. 6 A,B,C,D) 3 hysterectomy patients had associated ovarian tumors. A 52 year patient had functioning Granulosa cell tumor of ovary. Two other cases were associated with non functional Granulosa cell tumor and non functional Brenner’s tumor in 55 and 58 year patient respectively. 10.2% curettage specimens were inconclusive. The predominant reasons were pre analytical (66.7% were due to scanty material, 20.8% due to haemorrhage and 12.5% due to uninterpreteble morphology). Thus in the entire study ovulatory DUB comprised 34.7%, anovulatory DUB 50.5%, organic pathologies 7.7 and inconclusive 7.1%.
DISCUSSION
The bleeding pattern mentioned in requisition slip did not match with ovulatory or anovulatory bleeding pattern seen on morphology in many cases. It shows that terminologies were not fastidiously used despite the fact this ongoing study was known to the clinicians. The terminology menorrhagia should be used only for heavy cyclical bleeding and metrorrhagia for intermenstrual bleeding. Continuous bleeding is an ovulatory bleeding and usually seen in hyperplasias. However in our study most common bleeding pattern in hyperplasia appear to be menorrhagia. Oligomenorrhoea seen in perimenopausal anovulatory bleeds was never mentioned in requisition slips. However, the terminology DUB was used frequently. Due to mismatches the final decision of ovulatory or anovulatory bleeds was based on LMP and morphological pattern with an advice to correlate clinically. Literature states that 10-15% of women of reproductive age suffer from DUB [1] of which 20% are adolescent and 50% are in between 40-50 years.[6] However, in our study we found no DUB patients in adolescents. This is in concordance with another study from the same state and a very low % in two other studies from Karnataka[7] and New Delhi.[8] In our study the % of patients in 21-30 years was also only 5% compared to 20-25% in other studies.[7,8] The reasons for these regional differences were beyond the scope of this study. Proliferative pattern was the most common endometrial pattern found in our study group of which 34.7% were ovulatory and 50.5% were anovulatory. Most studies have not classified patients clearly into ovulatory or anovulatory bleeding which is the basis of determining treatment modality in association with prostaglandin E2 , F2 , I2 and anti fibrinolytic levels in the patients of DUB. Incidence of endometrium with progesterone effect in our study is comparable with Jairajpuri et. al.[8] but five times less compared to Dadhania et. al.[10] This could be due to rampant use of progesterone rich hormonal treatment in the area of the study of the latter. Atrophic endometrium was diagnosed in our study when glands were lined by flat cuboidal cells and stroma was sparse. It was seen in post menopausal cases. More stromal cellularity and low columnar glands are seen in weak proliferative phase which are features of classical proliferative phase but lesser in intensity. Estrogen excess effect which shows weak proliferative phase or atrophic like endometrium in long standing cases usually gets classified as proliferative phase. Only a strong suspicion and elicitation of detailed history brings to notice such cases as patients may have been inadvertently treated by older generation general practitioners, gynaecologists and orthopedicians(Hormone replacement therapy) with predominant estrogen pills. Occassionaly curettage has not gone deep enough into uterine cavity and only the lower uterine segment is scrapped showing morphology of isthmic endometrium. This especially happens in teaching hospitals where new residents take over curetting. The diagnosis of isthmic, atrophic or weak proliferative phase can be very confusing. They usually get tagged as proliferative phase to the novice and also due to lack of history and surity of the curettage procedure. Disordered proliferative endometrium (DPE) is an exaggeration of the normal proliferative phase.[5] DPE lies at the lower end of the spectrum extending from hyperplasia to endometrial carcinoma[8] and usually gets overdiagnosed (hyperplasia) if strict diagnostic criteria of hyperplasia are not applied. Though other studies have taken into consideration this category, the % of hyperplasias in their studies though are still high.[7,9,10,11] Endometritis is occasionally a direct cause of AUB.[11] Chronic endometritis is diagnosed on the basis of presence of plasma cells and can occur as a result of intra uterine contraceptive device (IUCD), pregnancy or incomplete abortion[8] in addition to other infectious etiology. Chronic endometritis of tuberculous origin was found in 7.7% in Jairajpuri et. al.[8] However, in our study there were no cases despite pulmonary and extra pulmonary tuberculosis being common in our population. Incidence of hyperplasia in our study is comparable with Jairajpuri et. al.[8] but in comparison to all other studies[7,9,10,11] it is much lower which could be due to strict adherence to the WHO diagnostic criteria for hyperplasia or true regional genetic differences. Most patients presented with lower degrees of Hyperplasia (Simple typical > Simple atypical > Complex typical). Hyperplasias were common in perimenopausal age group in concordance with literature. One case of hyperplasia met all the criteria of Endometrial Intraepithelial Neoplasia (EIN) but only focally. EIN diagnostic criteria used are described in table 2. Such cases should be followed up with PTEN marker immediately or sonography or curettage every 3 to 6 months as these are at high risk to develop adenocarcinoma. The presence of small focus of EIN in a case of simple typical hyperplasia indicates that all cases of hyperplasia should be evaluated for EIN. The percentage of endometrial primary malignancy in our study was 1.7% which is similar to other studies. In our study metastatic etiology of DUB was not found. Over all percentage of ovulatory and anovulatory bleeding in our study were 34.7% and 50.5% respectively. This data is not available in our comparison studies. History of drugs which affect dopamine levels eg. tri cyclic anti depressants, phenothiazines, risperidone and olanzapine, hypothyroid status, obesity, Von Willebrand factor deficiency, hyperprolactinemic and androgenic states, functional ovarian tumors will be of help to the reporting pathologist. [12]
Ovulatory bleeding can be controlled in 20-40% cases by cyclo oxygenase inhibitors in patients having increased PG E2 and I2 levels, 50% cases by tranexamic acid in patients having enhanced endometrial fibrinolysis and 80-90% cases by IUD with levonorgestral. They can also be given trial of non resecting radiofrequency endometrial ablation. Most anovulatory cases respond to cyclical luteal phase progestins and weight reduction in obese patients. Trials of combined contraceptive pills may be effective in both ovulatory and anovulatory cycle.[12] Temporary to lasting effect of leuprolide acetate (GnRH agonist) can be achieved and offered to women who are contemplating hysterectomy but unfit due to low haematocrit. Acute bleeding in chronic DUB may be controlled medically. Hysterectomy is to be considered for DUB only when less invasive treatments fail or if patient refuses to accept these even after medical counselling. Hysterectomy can also be considered in patients with low grade hyperplasia who do not respond to medical treatment, higher grades of hyperplasia and EIN.[12] High percentage of curettage samples (10.2%) had pre analytic errors like scanty material and predominant haemorrhage. Endometrial biopsy is likely to give a better idea of the endometrium rather than crushed and shredded haemorrhagic curettage material.
CONCLUSION
Regional and socioeconomic variations in age of presentation and organic pathologies are noted in different parts of India. End stage estrogen therapy and mixed exogenous hormonal morphologies in endometrium are difficult to diagnose. Hyperplasia comprised only a small percentage in our study. Strict adherence to criteria for Hyperplasia are required to report endometrial material. Differentiating DUB into ovulatory and anovulatory etiology (34.7% and 50.5% respectively in our study) is important in giving appropriate and minimal medical and surgical treatment to the woman rather than subjecting all to hysterectomy as generally practised. For this differentiation fastidious use of bleeding pattern terminologies and precise clinical history is the need of the hour. It is high time for clinicians to use endometrial biopsy rather than curettage material for yielding better morphological diagnosis.
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=466http://ijcrr.com/article_html.php?did=4661. Padubidri VG, Shirish ND: Menorrhagia and dysfunctional uterine bleeding (DUB). Howkins and Bourne Shaw’s Text book of gynaecology:13th edition, New Delhi, Elsevier, 2004: 291-299.
2. Mutter GL. Diagnosis of Premalignant endometrial disease. J Clin Pathol: 2002: 55: 326-331.
3. Mehmet CS , Alp U , Kubra B, Kunter Y. Comparison of WHO and endometrial intraepithelial neoplasia classifications in predicting the presence of coexistent malignancy in endometrial hyperplasia. J Gynecol Oncol; 2010 June; 21(2):97-101.
4. Jonathan LH, Tan AI , Jan PA , Heather EB , Maryann WO, Mutter GL. Prediction of endometrial carcinoma by subjective endometrial intraepithelial neoplasia diagnosis. Modern Pathology;2005;18: 324–330.
5. Robboy SJ, Russell P, Anderson MC, Morse A. Endometrial Hyperplasia : Pathology of the female reproductive tract. Churchill Livingstone, 2002: 305–330.
6. Chabra S, Jaswal M, Nangia V. Uterine size, Endometrium Fertility in women with dysfunctional uterine haemorrhage. J. Obstet Gynaecol. 1992;42:692-694.
7. Patil R, Patil R K, Andola S, Laheru V, Bhandar M. Histopathological spectrum of endometrium in dysfuctional uterine bleeding: Int J Biol Med Res. 2013; 4(1): 2798-2801.
8. Jairajpuri Z, Rana S, Jetley S. Atypical uterine bleeding-Histopathological audit of endometrium - A study of 638 cases: Al Ameen J Med Sci 2013; 6 (1):21-28.
9. Pilli et. al. Dysfunctional Uterine Bleeding; J Obstet Gynecol India. 2000;52(3):87-89.
10. Dadhania B, Dhruva G, Agravat A , Pujara K. Histopathological study of endometrium in dysfunctional uterine bleeding ;Int J Res Med. 2013; 2(1);20-24.
11. Anvikar A, Ramteerthakar N, Sulhyan K. Abnormal uterine bleeding – A clinopathological study of 160 cases: Asian J Med Res ; Jan-Mar 2013; 2, Issue 1.
12. Minkin M J, Miller C E, Munro M G, Zurawin R K. Chronic dysfunctional uterine bleeding – Identifying patients and helping them understand their treatment options: Ob. Gyn. News.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareNATURAL RESISTANCE ASSOCIATED MACROPHAGE PROTEIN 1 POLYMORPHISM SUSCEPTIBILITY TO MULTI DRUG RESISTANCE TUBERCULOSIS IN SOUTH INDIAN POPULATION: A CASE –CONTROL
STUDY
English3033Rooth Vasantha M.English G. SudhakarEnglish S. SrideviEnglishAim: To know the association of NRAMP1 gene polymorphisms in MDR-TB Patients.
Methodology: Studies on NRAMP1 (Natural Resistance Associated Macrophage Protein1 or SLC11A1 revealed its function on macrophage activation and its association with infectious diseases. A case-control study was carried out to find the association of NRAMP1 gene with MDR-TB belonging to Visakhapatnam district of Andhra Pradesh, India. Genetic polymorphisms of NRAMP1 gene 3’UTR and 274 CT were analysed using Polymerase Chain Reaction-Restriction Fragment Length Polymorphism
(PCR-RFLP).
Results: Significant statistical difference in the 3’UTR polymorphism between MDR-TB patients and healthy controls was observed. (P=0.001, OR=0.691,95%CI=0.077-6.208). But no significant association was found between the disease and 274 CT polymorphism (P>0.05).
Conclusion: Significant association of MDR-TB with 3’UTR polymorphism of NRAMP1 gene was identified, while no significant association was observed in 274CT polymorphism of NRAMP1 gene. Further study with large sample size is required to confirm the above results.
EnglishNRAMP1, 3’UTR, 274CT, MDR-TBINTRODUCTION
According to World Health Organisation Global Tuberculosis report 2014, nine million people developed TB in 2013 and 1.5 million died of the disease(WHO, 2014(1)). The number of people developing the disease is declining by an average of 1.5% a year. However the report underlines that many lives are being lost to a curable disease and confirms that TB is the second largest killer disease from single infectious agent-Mycobacterium tuberculosis. Although routine surveillance efforts are increased yet millions of people who fall ill from TB are missed by health system each year, because they are not diagnosed or they diagnosed but not reported. The association of tuberculosis with HIV and increasing multi-drug resistant tuberculosis (MDR-TB) frames a serious issue especially in the developing nations (WHO 2014(2)) Increase in population rate along with disorders, linked with several socio-economic factors are operational in India, than in any other developing country. The proportion of patients with MDR-TB is increasing day by day due to insufficient treatment facilities. The progression of molecular study up to gene level in research has attributed much to the identification of the individual strains of MTB. The reason that many TB patients who are in the course of anti-TB treatment are stopping to take medicines, is that after seven weeks of using the drug, major symptoms of TB reduce and the patients assume that their health has improved. Thus a man made public hazard has become prominent (3). Treatment of MDR-TB has become difficult as the MTB became resistant to two most powerful anti-TB drugs Rifampicin and Isoniazid. MDR-TB patients who are not responding to the treatment are a constant source of transmission of multi-drug resistant MTB. In India many people have the habit of spitting the sputum in public places. If patients with TB and MDR-TB cough and spit in public places then the infection is transmitted by air through droplets of sputum dispersed into the environment. The amount of germs in the phlegm is also massive. Molecular study on Tuberculosis affected patients reveals that acquisition of TB does not occur due to horizontal transfer of resistance bearing genetic elements, but due to mutations (nucleotide substitution, insertions, or deletions in specific resistance determining region of the genetic targets. In humans, drug-resistance mutation in MTB occurs mainly within the lung cavities, where high loads of bacteria are present. Here active mycobacterial replication and reduced exposure to host defence mechanism was reported. Chromosome 2q35 was mapped with NRAMP1 gene (4). Many polymorphisms in this gene alter its function.NRAMP1 controls the replication of intracellular parasites by altering the intra vacuolar environment of the microbe containing phagolysosome (5,6). Mutations in this gene may play an important role in rapid screening of drug resistance among MDR-TB patients and early treatment can be initiated.
MATERIALS AND METHODS
3 In patients diagnosed with multidrug resistant TB were taken into study. Diagnosis was based on clinical and laboratory data retrieved from the clinical records maintained by Chest and Tuberculosis Hospital in Visakhapatnam between the time periods of July 2012 to Dec 2012. Diagnosis of the patients was done within the hospital laboratory using Lowenstein Jensen (L-J) medium. All the patients were under Anti-TB therapy. Patients were identified to have MDRTB if they were resistant to both Isoniazid and Rifampicin anti TB drugs. Data of these patients on basis of age, gender, drug resistance, habitual smoking and drinking, irregular treatment, details of prior treatment with anti-TB medication were recorded. Among the 33 MDR-TB patients, 27 were males and 6 were females. 100 healthy contacts were taken as controls. Written consent was obtained from all individuals taken into study. This study was carried out only after getting ethical approval from Institutional ethical committee, Andhra University.
DNA extraction
Isolation of Genomic DNA using salting out procedure was done in the Human Genetics Department laboratory of Andhra University, Visakhapatnam. After quantity and quality analysis using spectrophotometer and Agarose Gel electrophoresis, the isolated DNA was stored at -4o c.
Molecular analysis
3’UTR and 274 CT genotype analysis of NRAMP1 gene was carried out using Thermocycler. Primers used for the detection of SNP’s were purchased from Thermo scientific, restriction enzymes Fok1(NEB) and Mnll (Thermo scientific). PCR was performed in a total volume of 20µl of a solution containing 2µl of genomic DNA, 2.0 µl of 10×PCR buffer, 0.8 µl dNTPs, 0.5 µl of recombinant Taq polymerase (Invitrogen), 1 µl of Forward primer, 1 µl of reverse primer and 12.7 µl of sterile water. PCR amplification was carried out by operating the thermal cycler for 3’UTR NRAMP1/SLC11A1 polymorphism using the following conditions. 95o c for 5 mins,30 cycles of 95 oc for 30s, 52 oc for 30s and 72 oc for 30 sec with a final extension at 72 oc for 10 min. Primer sequence for 3’UTR, Forward: GCA TCT CCC CA TTC ATG GT. Reverse: AAC TGT CCC ACT CTA TCC TGC (Rahayu Anggraini et al., 2010(7). A region of 240 bp was amplified and genotyping was performed using restriction fragment length polymorphism analysis. The amplified PCR product was digested at 37o c for 2 hours with Fok1. The digested products were run on 2% agarose gel which is stained with Ethidium bromide and visualised under UV transilluminator. Primer sequence for 274 CT of NRAMP1 gene Forward: TGC CAC CAT CCC TAT ACC CAG. Reverse: TCT CGA AAG TGT CCC ACT CAG (Rahayu Anggraini et al., 2010). A region of 167 base pairs was amplified with annealing temperature of 56o c for 30 sec. The amplified PCR product is then digested at 37o c for 2 hours with Mnll restriction enzymes. The digested products were then run on 2% agarose gel stained with Ethidium bromide and visualised under UV transilluminator.
RESULTS
The observed results in Agarose gel electrophoresis for 3’UTR show genotype TGTG++ at 211bp and 33bp;TGTG+/ del genotype at 244bp,211bp, and 33bp;genotype TGTG del/ del at 244bp. Here the normal allele is TGTG+ and the mutant allele is TGTG del. For 274 CT polymorphism CC genotype at 102bp, 65bp, 37bp, and 12bp; CT genotype at 167bp, 102bp, 65bp, 37bp and 12bp; TT genotype at 167bp, 37bp, and 12bp.Here C is the normal allele and T is the mutant allele. Some of the PCR samples did not get amplified due to unseen reasons, so the sample size decreased to 29 MDR-TB and 89 healthy controls. A significant difference between the genotype frequencies of 3’UTR polymorphism of NRAMP1 gene in patients with MDR-TB and those in control group was observed.
Among the MDR TB patients, about 83 percent are found to be homozygous for the genotype TGTG/TGTG for the 3’UTR region of NRAMP1gene. The frequency of heterozygous type (TGTG/TGTG del) is only 3 percent among MDR TB patients, The remaining 14 percent are homozygous for TGTG del/TGTG del type.(P= 0.001;Odds ratio0.691;95%CI=0.077-6.208)
Among the MDR TB patients, 79 percent are found to be homozygous for the genotype C/C for the 274 CT SNP of NRAMP1 gene. The frequency of heterozygous type (C/T) is 21 percent among MDR TB patients. The homozygous type T/T is not found in the present patient sample. (P=0.533;odds ratio=1.500;95%CI=0.505-4.451)
DISCUSSION
MDR-TB is a severe health problem in the world today. Nearly estimated 29% of the global tuberculosis cases come from India. Out of which 0.5% to 3.2% have MDR-TB. Gujarat state showed high rate of prevalence in India (8, 9, 10). The reason for MDR-TB emergence is due to drug discontinuation in middle of the treatment and the bacteria becoming susceptible to TB drugs. Hence Anti-TB drugs should be individually tailored for each MDR-TB patient as the standard treatment for drug-resistant TB is not known. And even after administering the treatment less percentage of cases showed favourable outcome. HIV is also expected to cause an increase in the percentage of MDR-TB (11, 12, 13) But HIV patients were not included in the present study. Natural mutation in NRAMP1 gene impairs early immunity to several intra cellular pathogens including mycobacterium. Increased frequency of specific NRAMP1 mutation among patients and control is observed in various studies. The distribution of NRAMP1 3’UTR polymorphism did not deviate from the Hardy Weinberg Equilibrium (P>0.05) the frequency of 3’UTR in MDR TB patients was 17.2% and that of controls is 5.7%. No significant association was found between MDR-TB patients and controls in 274 CT polymorphism of NRAMP1.3’UTR of NRAMP1 studies on Thais,(14) Chinese,(15) and Koreans(16) show significant difference in Pulmonary TB patients. Polymorphisms of SLC11A1 /NRAMP1 gene are known to influence phagolysosomal function of macrophages in iron transport, maintenance of acidity, and production of nitric oxide(NO)(17-20). The change in the phagolysosomal function of NRAMP1 gene may affect the viability of phagocytosed MTB leading to the development of drug resistant strains of MTB. Variations in 3’UTR leading to mutations could be one of the independent risk factor for MDR-TB and possible basis for drug penetration. This study suggests that NRAMP1/ SLC11A1 polymorphisms in part are associated with the emergence of multi drug resistance and extensive pulmonary involvement. Further study is necessary to confirm the association of 3’UTR of NRAMP1 gene with more number of MDR-TB patient samples.
CONCLUSION
The results obtained in the study suggest that variation in the NRAMP1/SLC11A1 gene is associated with the emergence of Susceptibility to multidrug resistance TB. Further study with larger sample size is required to confirm the association.
ACKNOWLEDGEMENTS
The authors are thankful for the UGC RGNF fellowship from the government of India, for funding of the research work. The author also acknowledges the published articles of the scientists and other dignitaries on Tuberculosis. Conflict of interest: The authors declared no conflict of interest
Englishhttp://ijcrr.com/abstract.php?article_id=467http://ijcrr.com/article_html.php?did=4671. WHO .2013.Global tuberculosis report.
2. WHO.2014.Multi Drug and Extensively drug-resistance TB 2014. Global Report on Surveillance and Response 2014.
3. Article on Tuberculosis in Hindu Newspaper Magazine dated March 15/2015.Pg:4
4. Blackwell J et al., 1995. Genomic Organisation and Sequence of the Human NRAMP gene: Identification and mapping of a promoter region polymorphism. Mol Med.1:194–205.
5. Gruenheid S et al., Natural resistance to infection with intracellular pathogens; the NRAMP1 protein is recruited to the membrane of the phagosome. J. Exp Med 1997; 4:717-30.
6. Hackam D et al., Host resistance to intracellular infection: mutation of natural resistance associated macrophage protein 1(Nramp1) impairs phagosomal acidification. J.Exp Med 1998; 188:351-64.
7. Rahayu Anggraini et al., 2010. Polymorphism of Natural-resistance-Associated Macrophage Protien1 (NRAMP1)D543N gene and expression of NRAMP1 on Lung Tuberculosis Patients and Nurses in Surabaya. Folia Medica Indonesiana.Vol.46 No.2:78- 87.
8. Mendez AP et al., Global Surveillance for anti tuberculosis dug resistance, 1994-1997.N.Eng J Med.1998; 338:1641-49.
9. Jawahar MS. Multi drug resistance tuberculosis. ICMR bull 1999. 29:10-11.
10. Ramachandran R, Balasubramanian R. Chemotherapy of Resistant tuberculosis; the tuberculosis research center experience over 40 years .Indian J Tub 2000;47:201-10.
11. H.S.Subhas et al., Clinical characteristics and treatment response among patients with multi drug resistant tuberculosis; A retrospective study. India chest Dis Allied Sci 2003, 45:97-103.
12. Gilad J,Borer A,Riesenberg K, Peled N,schlaeffer F. Epidemiology and ethnic distribution of multidrug resistant tuberculosis in southern Israel,1992-1997.Chest 2000;117:738-43.
13. Suchindran S, Brouwer ES, Van Rie A .2009.Is HIV Infection a Risk Factor for Multi-Drug Resistant Tuberculosis? A Systematic Review PLoS One 4 (5): e5561
14. Vejbaesya S, Chierakul N,Luangtrakool P,Sermduangprateep C.2007.NRAMPI and TNF-Alpha polymorphisms and susceptibility to tuberculosis in Thais. Respiratory.12:202-206.
15. W.Liu, W.C.Cao and et al.2004.VDR and NRAMP1 gene polymorphisms in susceptibility to pulmonary tuberculosis among the Chinese Han population: a case-control study. The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease. Vol: 8:428.
16. Ryu S et al., 2000. 3’UTR Polymorphisms in the NRAMP1 gene are associated with susceptibility to tuberculosis in Koreans. Int J Tuberc Lung Dis.4:577-580.
17. Govoni G, Gros P. Macrophage NRAMP1 and its role in resistance to microbial infections. Inflamm Res 1998.47:277–84.
18. Kuhn DE, et al., Iron transport into Mycobacterium aviumcontaining phagosomes from an Nramp1 (Gly169)- transfected RAW264.7 macrophage cell line. J Leukocyte Biol 2001.69:43– 9.
19. Hackam DJ et al., Host resistance to intracellular infection: mutation of natural resistance-associated macrophage protein 1(Nramp1) impairs phagosomal acidification. J Exp Med 1998.188:351–64.
20. Barton CH, Whitehead SH, Blackwell JM. Nramp transfection transfers Ity/Lsh/Bcg-related pleiotropic effects on macrophage activation: influence on oxidative burst and nitric oxide pathways. Mol Med 1995.1:267–79.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareEVALUATION OF ADOLESCENT FRIENDLY HEALTH SERVICES (AFHS): CLIENTS' PERSPECTIVES
English3448Dinesh KumarEnglish R.J. YadavEnglish Arvind PandeyEnglishContext: Adolescent period is hazardous for adolescent health due to absence of proper guidance and counseling, which have not received proper attention and guidance because of which the need of Adolescent Friendly Health Services (AFHS) is emphasized. Continuous monitoring and evaluation of established Adolescent Friendly Health Clinics (AFHC) is desirable.
Aim: Evaluation of selected Adolescent Friendly Health Services (AFHS) with clients’ perspectives.
Methods: Evaluation study was conducted at two health facilities during November 2012 to February, 2013. Existing patterns of Adolescent Friendly Health Services (AFHS) were evaluated based on clients’ exit interviews in selected health facilities. Exit interviews of adolescents (clients) from selected AFHC and other OPD were conducted. Evaluation of AFHC was done based on its desired characteristics of availability, accessibility, and acceptability.
Results: Majority of respondents were self motivated to attend these clinics. Maximum number of clients took 30-60 min to approach the health facility. The physical environment in terms of waiting area was reportedly good by 21.7% clients of AFHC. Reading material was available as reported by 56.5% AFHC clients and 43.4% found the material interesting. Friendly behavior of doctors was reported by 100% clients but only by 90.9% respondents attending other OPDs. Confidentiality was maintained in most of cases. Overall satisfaction rates were 78.0% for AFHC clients and 73.0% for other respondents and about 65.0% AFHC
clients were encouraged to recommend these services to their friend also. Suggestions regarding free services to be provided were given by 52.1% clients whereas 34.7% AFHC clients reported long waiting time. Majority of clients attending AFHC were in favor of separate discussion with doctors.
Conclusions: Study concludes that Adolescent Friendly Health Services (AYFHS) need some improvements to provide appropriate services to them to make them available, accessible, and acceptable. Existing services were found to be lacking in terms of maintaining privacy of clients. Adolescent Friendly Health Initiatives (AFHI) should be developed and monitored at different levels as ongoing efforts using newer methodology and evaluation techniques.
EnglishAdolescent friendly health services (AFHS), Adolescent friendly health initiatives (AFHI); Adolescent reproductive and sexual health (ARSH)INTRODUCTION
Adolescents are the most dynamic, creative, productive and enthusiastic group of population but also the most neglected groups by our society and policy makers. The World Health Organization (WHO) promotes Adolescent Friendly Health Services to address these issues and make it easier for adolescents to obtain the required services. Viewing adolescents as a specific group with their own needs is a relatively recent practice, especially in the developing world; India has identified adolescent reproductive and sexual health (ARSH) as a key strategy under the Reproductive and Child Health Programme Phase II (RCH-II) and the National Rural Health Mission (NRHM). Strategy for ARSH has been approved as part of the RCH-II. There are various programs available for adolescents and youths in different states. Initiative like “Adolescent Friendly Health Services (AFHS)” introduced in the schools is one of important efforts in this direction. Ministry of Health and Family Welfare (MoHFW) has de veloped guidelines and training package for operationalizing AFHS. Haryana is one of the first states in the country to have launched a distinct Adolescent Reproductive and Sexual Health (ARSH) program providing AFHS at government health facilities. The National Program Implementation plan of the RCH II has proposed to expand this program to 75 districts in the country. The AFHS project under RCH II in Haryana employs an “Adolescent Action Group” (AAG) to plan interventions with clear targets and roles and responsibilities. ARSH was implemented in Haryana in 2008 in nine districts with the objective of providing adolescent friendly health services through the existing public sector health facilities. Reproductive Health Services under the public sector are more oriented towards adult married women, while unmarried adolescents hesitate to seek health services due to the fear that these services are not confidential, inability to pay, requirement of parents’ approval and negative or insensitive attitude of health providers1 . For many adolescents who need sexual and reproductive health services, such as appropriate information, contraception and treatment for sexually transmitted infections, these are either not available or are provided in a way that makes adolescents feel unwelcome and embarrassed. Even married adolescent girls shy away from seeking healthcare due to sheer embarrassment and the taboo associated with reproductive and sexual health problems2 . This creates an “unmet need” for reproductive and sexual healthcare. This unmet need varies among married and unmarried adolescents Actions taken during adolescence can affect a person’s life opportunities, behavioral patterns and health. Adolescent period is hazardous for adolescent health due to absence of proper guidance and counseling, which have not received proper attention and guidance because of which the need of Adolescent Friendly Health Services (AFHS) is emphasized. AFHS provides a broad range of preventive, promotive and curative services under one roof can help to ensure improved availability, accessibility and utilization of health services. According to WHO3 , Adolescent-Friendly Health Services (AFHS) are accessible, acceptable and appropriate in terms of right place, at the right time, and affordable. WHO promotes Adolescent Friendly Health Services to address these issues. There are several AFHI’s undertaken by some NGOs in India such as Mamta, Nehru Yuva Kendra etc. MAMTA, an NGO to establish a model of AFHS through the public health system in villages of Delhi, runs the clinic, called Friends’ Clinic focusing the needs of the local youth population providing clinical and counseling services4 . Nehru Yuva Kendra acts as an health awareness unit through active participation of the young; Kishori Shakti Yojana is to improve the health and nutritional status of the girls; Balika Samridhi Yojana is to delay the age of marriage; Mahila Samakhya Programme - stresses on equal access to education facility for adolescent girls and young women; school age education. Yadav et al (2009)5 observed that proportion of adolescent girls visiting the AFHCs in Delhi and Kolkata was higher whereas the situation was reverse in Chandigarh. Present study was undertaken with an objective of evaluating selected Adolescent Friendly Health Clinics (AFHC) with clients’ perspectives.
MATERIAL AND METHODS
This study was undertaken during November 2012 to February, 2013 at two health facilities: Kamla Nehru Memorial Hospital Allahabad, Uttar Pradesh, India, Sarojini Naidu Children Hospital Allahabad, Uttar Pradesh, India attached with M.L.N. Medical College Allahabad and GMCH Chandigarh (UT) India. Existing patterns of Adolescent Friendly Health Services (AFHS) were evaluated based on clients’ exit interviews in selected health facilities. . Exit interviews of adolescents (clients) from selected AFHC and other OPD were conducted regarding their problems, services offered and satisfaction thereof. Evaluation of AFHC was done based on its desired characteristics of availability, accessibility, and acceptability. Prior permissions from concerned authorities were taken for conducting the study. Exist interviews were taken only of clients willing of participating in the study and confidentiality of their responses was ensured following Ethical Guidelines of ICMR. Because of some time, financial and other constraints, study could not be extended further in terms of inclusion of more AFHC’s in other cities.
RESULTS
A total of 23 adolescents attending AFHC and other OPD were studied. Some important findings are presented in Table-1. There were 13 (56.5%) boys and 10(43.4%) girls in the age group 11-19 years. There were 26.1% male clients 73.9% female clients in AFHC clients from while other OPD’s were only females as they were mainly selected from Gynecology OPD. Respondents were mostly Hindus belonging to general category all were unmarried mostly living with parents. There were 91.3 % clients studying while all respondents attending other OPD’s were studying. Out of all AFHC girl clients 9(52.9%) and out of all girls attending other OPD, 9 (81.1%) have attends menarche. Among these girls 44.4% AFHC client and 77.7% other attendees reported regular cycle. Majority of respondents were self motivated to attend these clinics. They attended the clinic with several health problems listed maximum number of clients took 30-60 min to approach the health facility. No prior appointments was found in most of the cases and mostly had to wait 30-60 min to consult the doctor. No counseling was done in the most of the cases and most of them were not availing contraceptive service. The physical environment in terms of waiting area was reportedly good by 21.7% and 54.5% respondents. Reading material was available as reported by 56.5% AFHC clients and 43.4% found the material interesting. Friendly behavior of doctors was reported by 100% clients but only by 90.9% respondents attending other OPDs. Doctors took about 10-15 min as reported by 47.8% AHFC clients and 18.1% other respondents. Confidentiality was maintained. They received all relevant information up to a satisfaction level. About 78.0% AFHC clients 73.0% other respondents were satisfied with overall services whereas 34.7% AFHC clients reported long waiting time. About 65.0% AFHC clients were encouraged to recommend these services to their friend also. Suggestions regarding free services to be provided were given by 52.1% clients. About 69.0% AFHC clients were of the opinion in favor of availing opportunities of separate discussions with doctors in privacy.
DISCUSSION
Addressing adolescents provide not only health benefits in terms of delaying age at marriage, reducing incidence of teenage pregnancy, prevention and management of obstetric complications including access to early and safe abortion services and reduction of unsafe sexual behavior etc. but also economic and other benefits due to improved productivity and will help in protection of human rights. Health services have to be sensitive to the needs and developmental attributes of adolescents to be able to attract them6 . More young people now need reproductive health care, especially prevention services. These arguments strongly advocate the need of establishing AFHC. It is a known fact that adolescents first approach their peers for advice on sexual or reproductive issues. In the present study, majority of respondents were self motivated to attend these clinics mostly without any prior appointment and mostly had to wait 30-60 min to consult the doctor. There may be several reasons why the present health services are not accepted well by adolescents such as lack of knowledge regarding availability and accessibility of services, cultural reasons, lack of confidentiality, long way away or expensive services, lack of friendliness services, poorly trained staff, physical or logistical restrictions, gender barriers, and peer pressure etc. as observed in the present study also. Seventy two percent girls and 56% boys reported health problems during survey. only 43% girls and 35% boys reported to the clinic voluntarily to seek help and only one fifth the amount of problems were reported at the clinic in comparison to the quantum of problems reported in survey, which probably reflects a poor health seeking behavior by Joshi et al (2006)7 . No counseling was done in the most of the cases and most of them were not availing contraceptive service as observed in the present evaluation. The physical environment in terms of waiting area was reportedly good only by 21.7% AFHC clients and 54.5% other OPD clients. They received all relevant information up to a satisfaction level. Confidentiality and the quality of care are major concerns among adolescents. Present study reported that confidentiality was also maintained in most of the cases. Utilization of AFHC could be improved by intensive information, education and communication (IEC) strategies raising awareness on reproductive health and gender related issues. Reading material was available as reported by 56.5% AFHC clients and only 43.4% found the material interesting. Overall satisfaction rates were found to be about 78.0% among AFHC clients and 73.0% among other respondents whereas 34.7% AFHC clients reported long waiting time. About 65.0% AFHC clients were encouraged to recommend these services to their friends also. About 52.0% AHHC clients desired free services to be provided which needs further considerations. Existing services were found to be lacking in terms of confidentiality/privacy as about 69.0% AFHC clients were of the opinion that there should be opportunity of separate discussions with doctors in privacy. No earlier study is available on evaluation of AFHC in Indian set-up5 .
Conclusions and Suggestions
Existing services were found to be lacking in terms of maintaining privacy of clients. Adolescents felt need some improvements in AFHC. More users friendly AFHS need to be established and extended with desired characteristics of availability, accessibility, and acceptability. Further insight should be given to understand problems of adolescents attending AFHC and for evaluation of AFHS in a better way. Adolescent Friendly Health Initiatives (AFHI) should be developed and monitored at different levels as ongoing efforts.
ACKNOWLEDGEMENTS
The present paper is based upon some work conducted during Short Term Fellowship/Training in Indian Institute under HRD Scheme of Department of Health Research (DHR), Ministry of Health and Family Welfare, Govt. of India. I owe my sincere thanks to the Department of Health Research, Ministry of Health and Family Welfare, Govt. of India for award of this Short Term Fellowship/Training. 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 are also grateful to Reviewers for their valuable comments and improvements suggested.
Englishhttp://ijcrr.com/abstract.php?article_id=468http://ijcrr.com/article_html.php?did=4681. Mamdani M. Adolsecent reproductive health: Experience of community based programmes. In: Pachauri S, editor. Implementing a reproductive health agenda in India: The Beginning. New York: Population Council; 1999.
2. Bang R, Bang A. A community Study of Gynaecological Diseases in Indian Villages. In Zeidenstein and Moore, editors. Learning about sexuality: A practical beginning. New York: The Population Council; 1989
3. Peter McIntyre. Adolescent Friendly Health Services —An Agenda for Change WHO, Oxford, UK 2002.
4. Agrawal D, Mehra S, Mishra RK, Pandey SP. Road Map for implementing youth friendly services in Indian public health system. Paper presented at International conference on “Investing in young people′s health and development: Research that improves policies and programs” held at Abuja, Nigeria from April 27-29, 2008.
5. R.J. Yadav, Rajesh Mehta, Arvind Pandey and Tulsi Adhikari. Evaluation Of Adolescent-Friendly Health Services In India.. Health and Population: Perspectives and Issues Vol. 32 (2), 96- 104, 2009.
6.http://www.searo.who.int/entity/child_adolescent/topics/adolescent_health/adolescent_sexual_reproductive/en/assessed on 26.07.2015.
7. B. N. Joshi, S.L. Chauhan, U.M. Donde, V.H. Tryambake, N.S. Gaikwad, V. Bhadoria Reproductive Health Problems and Help Seeking Behavior Among Adolescents in Urban India, Indian J Pediatr 2006; 73 (6) : 509-513.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareA DETAILED STUDY OF THE ROLE OF SERUM FERRITIN AS THE INDICATOR OF IRON STORES IN SEVERE HOOKWORM INFECTION DIAGNOSED BY DOING ENDOSCOPY
English4953Govindarajalu GanesanEnglishObjective: Severe anaemia is reported to occur in severe hookworm infection in many studies. But so far detailed study of the role of serum ferritin as the indicator of iron stores and iron status in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy was not done. Hence a detailed study of the role of serum ferritin as the indicator of iron stores and iron status in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy was done in our institute.
Methods: A study of 1259 patients who had undergone upper gastro-intestinal endoscopy for a period of 5 years from May 2009 to April 2014 was carried out in our institute. In each of these 1259 patients, the first and second part of duodenum were carefully examined to find out the presence of hookworms. In all the patients found to have hookworms in duodenum, investigations were done to know about the presence of anaemia except in the very few patients who were lost for follow up. In patients with severe anaemia [haemoglobin EnglishSevere anaemia, Hookworm infection, Serum ferritin, Iron stores, Upper gastro intestinal endoscopyINTRODUCTION
Severe anaemia is reported to occur in severe hookworm infection in many studies (1to17). But so far detailed study of the role of serum ferritin as the indicator of iron stores and iron status in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy was not done. Hence a detailed study of the role of serum ferritin as the indicator of iron stores and iron status in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy was done in our institute.
MATERIALS AND METHODS
This study was conducted in the department of general surgery, Aarupadai Veedu Medical College and Hospital, Puducherry. A study of 1259 patients who had undergone upper gastro-intestinal endoscopy in our institute for a period of 5 years from May 2009 to April 2014 was carried out. In each of these 1259 patients, the first and second part of duodenum were carefully examined to find out the presence of single or multiple hookworms. In all the patients found to have hookworms in duodenum, investigations were done to know about the presence of anaemia except in the very few patients who were lost for follow up. Anaemia is defined as haemoglobin < 12g/dl or 12g% in women and haemoglobin < 13g/dl or13g% in men. Severe anaemia is taken as haemoglobin 500 mg, which is the required minimum during pregnancy; 40% have iron stores of 100- 500 mg, and 40% have virtually no iron stores in another study conducted by Milman et al. in Scandinavia (24).
Third study conducted by Milman in Scandinavia.
42% of non-pregnant women have serum ferritin levels 70 microg/l corresponding to body iron of >or=500 mg. Non-pregnant women have a low iron status (25). Thus iron status and body iron can be monitored using serum ferritin(25) .
Fourth study conducted by Milman in Scandinavia.
Iron deficiency was defined by serum ferritin Englishhttp://ijcrr.com/abstract.php?article_id=469http://ijcrr.com/article_html.php?did=4691. 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. 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.
3. 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.
4. 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.
5. Basset D, Rullier P, Segalas F, Sasso M. Hookworm discovered in a patient presenting with severe iron-deficiency anemia Med Trop (Mars). 2010 Apr;70(2):203-4.
6. 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.
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. A Rodríguez, E Pozo, R Fernández, J Amo, T Nozal. Hookworm disease as a cause of iron deficiency anemia in the prison population Rev Esp Sanid Penit 2013; 15: 63-65.
9. Li ZS1, Liao Z, Ye P, Wu RP Dancing hookworm in the small bowel detected by capsule endoscopy: a synthesized video. Endoscopy. 2007 Feb;39 Suppl 1:E97. Epub 2007 Apr 18.
10. Kalli T1, Karamanolis G, Triantafyllou K Hookworm infection detected by capsule endoscopy in a young man with iron deficiency. Clin Gastroenterol Hepatol. 2011 Apr;9(4):e33.
11. Chen JM1, Zhang XM, Wang LJ, Chen Y, Du Q, Cai JT. Overt gastrointestinal bleeding because of hookworm infection. Asian Pac J Trop Med. 2012 Apr;5(4):331-2.
12. 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.
13. Govindarajalu Ganesan. A detailed study to know about the occurrence of chronic diarrhea in addition to severe anaemia and severe eosinophilia in patients having hookworms in duodenum while doing upper gastro-intestinal endoscopy in healthcare institute. IJCRR. 2014; 6(23): 54-58.
14. Yan SL, Chu YC. Hookworm infestation of the small intestine Endoscopy 2007; 39: E162±163. 15. Chao CC1, Ray ML. Education and imaging. Gastrointestinal: Hookworm diagnosed by capsule endoscopy. J Gastroenterol Hepatol. 2006 Nov;21(11):1754.
16. Christodoulou, D. K., Sigounas, D. E., Katsanos, K. H., Dimos, G., and Tsianos, E. V. Small bowel parasitosis as cause of obscure gastrointestinal bleeding diagnosed by capsule endoscopy. World journal of gastrointestinal endoscopy, 2(11), 2010: 369.
17. Genta RM, Woods KL. Endoscopic diagnosis of hookworm infection. Gastrointest Endosc 1991 July;37(4):476-8.
18. Stoltzfus RJ1, Albonico M, Chwaya HM, Savioli L, Tielsch J, Schulze K, Yip R. Hemoquant determination of hookworm-related blood loss and its role in iron deficiency in African children. Am J Trop Med Hyg. 1996 Oct;55(4):399-404.
19. Pritchard DI, Quinnell RJ, Keymer AE Hookworm (Necator americanus) infection and storage iron depletion Trans R Soc Trop Med Hyg 1991 Mar-Apr; 85(2):235-8.
20. Crompton DW, Whitehead RR. Hookworm infections and human iron metabolismParasitology. 1993;107 Suppl:S137-45.
21. Stoltzfus RJ1, Chwaya HM, Tielsch JM, Schulze KJ, Albonico M, Savioli L. Epidemiology of iron deficiency anemia in Zanzibari schoolchildren: the importance of hookworms Am J Clin Nutr. 1997 Jan;65(1):153-9.
22. R M Hopkins, M S Gracey, R P Hobbs, R M Spargo, M Yates, R C Thompson The prevalence of hookworm infection, iron deficiency and anaemia in an aboriginal community in north-west Australia Med J Aust. 1997 Mar 3;166 (5):241-4.
23. Milman N. Iron in pregnancy: How do we secure an appropriate iron status in the mother and child? Ann Nutr Metab. 2011;59(1):50-4.
24. Milman N1, Bergholt T, Byg KE, Eriksen L, Graudal N Iron status and iron balance during pregnancy. A critical reappraisal of iron supplementation. Acta Obstet Gynecol Scand. 1999 Oct;78(9):749-57.
25. Milman N Iron and pregnancy--a delicate balance. Ann Hematol. 2006 Sep;85(9):559-65. Epub 2006 May 12.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareA STUDY OF HISTOPATHOLOGICAL CHANGES IN FALLOPIAN TUBES IN ECTOPIC PREGNANCY
English5458Richa SharmaEnglish Dayanand S. BiligiEnglishAim: The study was conducted with the aim of studying histopathological changes in ectopic pregnancy in the fallopian tube and correlate them with clinical history.
Methodology: Fifty cases of tubal ectopic were studied retrospectively to compare the histopathological changes in the lining of fallopian tube. Routine haematoxylin and eosin stain with special stains were employed to study the sections. Ratio of ciliated to secretory cells was calculated. Associated inflammation and other pathology was also studied.
Results: Out of 50 cases studied majority of ectopics were on right side and presented at less than 8 weeks of gestation. Most common age group to be affected was between 28-32 yrs. Around 28 of cases had previous history of surgeries and 14% previous ectopic or abortions.
We also noted a significant degree of deciliation in the tubal lining with maximum number of cases showing deciliation in fimbrial ectopics. Significant number of cases showed association with salpingitis isthmica nodosa (22%) and inflammation was seen in three fourths of all cases.
Conclusion: The study highlights the association with deciliation in tubal ectopics and also the significant association with inflammation and abdominal interventions
EnglishEctopic, Deciliation, Fallopian tube, Salpingitis isthmica nodosaINTRODUCTION
Ectopic pregnancy is the term applied to implantation of the fetus in any site other than a normal intrauterine location. The most common site is within the fallopian tubes (~90%). Other sites include ovary, the abdominal cavity and intrauterine portion of the fallopian tube (cornual pregnancy). Ectopic pregnancy occur about once in every 150 pregnancies. (1) In a multicentric case control study in India, (ICMR Task Force Project, 1990) the incidence of ectopic pregnancy was 3.12 per 1000 pregnancies or 3.86 per 1000 live births. (2) While there has been about four fold increase in incidence over the couple of decades but the mortality has been slashed down to about 80%. (3)
AIMS
1. To study the changes in fallopian tube in tubal ectopic pregnancy
2. To correlate the changes with age group, medications, other medical conditions and previous surgical history.
METHODOLOGY
It was a retrospective study of fifty cases conducted in the Department of Pathology, Victoria Hospital, Bangalore medical college and research institute over the period from January 2010 to December 2010. Haematoxylin and eosin stain with special stains were done on all the sections. The pathological findings were correlated with clinical data like age distribution, parity, associated medical conditions, previous pregnancies and history of surgical procedures. Microscopically, ratio of ciliated to secretory cells was calculated. An area of 1x1 mm was screened and number of ciliated and secretory cells were counted. We also did mas son’s trichrome (fig 8) on the sections which clearly showed secretory cells with granules in them and cilia as well. Also additional findings of inflammation (acute, chronic, follicular ) and salpingitis isthmica nodosa were noted.
RESULTS
The study showed that maximum cases of ectopic were in the age group (fig 1) of 28 to 32 years ( 40.81 %) . Most of the women were multigravidae, maximum cases seen in gravida2 (fig 2). Primigravida presenting with ectopic constituted just 18% (fig 2) of all the cases. Most commonly women presented in less than 8 weeks gestation (74% cases - fig 3). There was a striking predominance of right sided ectopics ( more than 60% - fig 3). Over half of the cases presented with ruptured pregnancy (54% - fig 3).
Intra operatively the common site of ectopic was fimbriae (52.1%) followed by ampulla (39.13%) and 8.6% cases in cornua. There was also a significant association seen with previous surgeries. Six cases had previous history of ectopic pregnancy (12%) . Seven cases had previous history of abortions and medical termination of pregnancy (MTP). Six cases had previously undergone tubectomy/fimbriectomy and 8 cases had history of bilateral abdominal tubectomy. In the study, 6 cases had lower segment caesarean section (LSCS) in their previous pregnancies. One patient had history of tuboophorectomy in the past. Two cases were treated with Methotrexate but needed surgery owing to failure to respond to medical management. Histopathologically, majority ectopics were in ampulla(54%). Along with findings like tubal dilation, congestion, hemorrhage, trophoblastic tissue (fig 4) , presence of villi, ratio of ciliated to secretory cells (fig 6 and 7) were also calculated. The sections also showed concurrent presence of acute salpingitis (16%) , chronic salpingitis (56%) and follicular salpingitis (12%) (fig 9).
There was a significant association with salpingitis isthmica nodosa -22%(abbreviated as SIN in the graph above - fig 5) . Salpingitis isthmica nodosa (fig 10 and 11) is a known etiological factor for infertility and ectopic pregnancy. Another very significant finding noted in the study was marked deciliation in majority of cases. Around 20 cases were in fimbria and all of them showed marked deciliation ( fig 8) in tubal epithelium. Out of 27 cases of ampullary ectopic 18 showed features of decilaition and only 9 were normal. The 3 cornual ectopic showed 2 cases with reduced cilia and only 1 case showed normal cilia distribution.
DISCUSSION
Anatomy of fallopian tube : The Fallopian tubes are paired, tubular, seromuscular organs whose course runs medially from the cornua of the uterus toward the ovary laterally. Each tube is about 10 cm long with variations in length from 7 to 14 cm. The fallopian tube is shaped like an elongated funnel and is divided anatomically into four parts – infundibulum, ampulla, isthmus and interstitial part. (4) The tubal wall consists of three layers: the internal mucosa (endosalpinx), the intermediate muscular layer (myosalpinx), and the outer serosa, which is continuous with the peritoneum of the broad ligament and uterus, the upper margin of which is the mesosalpinx. The serosal layer and broad ligament have a lining of mesothelium. The muscular wall has two layers , an inner circular and outer longitudinal. (5) The inner aspect of the tube is lined by mucosa arranged in the shape of longitudinal, branching folds ( known as plicae) , which merge with the fimbriae. (6) Microscopically the epithelium is composed of three distinct cell types: secretory, ciliated and intercalated “(peg). (7) There are fewer ciliated cells in the isthmus than in the ampullary portion of the tube, whereas they are most prominent in the fimbriated infundibulum. Ciliation and deciliation is a continuous process throughout the menstrual cycle. Ciliation is maximum in the periovulatory period, particularly in the fimbria. Estrogen enhances the process of ciliation, whereas progesterone inhibits it, so significant deciliation occurs in atrophic postmenopausal tube. (8) Diagnosis of ectopic pregnancy is clinical. In tubal pregnancy the gestational sac is completely made up of tubal tissue, with no participation from the ovarian or intraligamentary tissues.(9) Hydropic changes and polar trophoblastic proliferation can occur; they should not be overdiagnosed as hydatiform mole.(10) Changes resembling atherosclerosis may be seen in tubal arteries at the site of implantation, analogous to those occurring in the uterus in orthotopic pregnancy. (9) The fallopian tube epithelium may undergo clear cell hyperplasia. (11) In a multicentric case control study in India, (ICMR Task Force Project, 1990) the incidence of ectopic pregnancy was 3.12 per 1000 pregnancies or 3.86 per 1000 live births. In our series the ectopic pregnancy rate is 7.06 per 1000 deliveries or in other terms 1 in every 141 deliveries. Tubal ectopic commonly seen in 28-32 years age group. Previous studies have shown a higher frequency in 25-28 years of age (Cole and Corelett (12)). Another study by Andersen et al (13) showed 1.4% of all pregnancies in young age group to 6.9% in older age groups. Murray et al (14) showed common gestational age at diagnosis to be 6 to 10 weeks. Our series of cases showed predominance in less than 8 weeks of gestation. Our study showed a predominance of ectopic gestation in parous women. Studies conducted by Hlavin et al (15) and De Cherney et al (16) showed highest incidence in those with two to three children. 62% cases were seen on right side. This is thought to be due to spread of infection from appendicitis. (17) Majhi et al (18) in the study had 72% cases presenting as ruptured ectopic. With a significant number of cases in our study too presenting with rupture explains why we consider ectopic a life threatening condition. Majhi et al(18) also noted ectopic in patients with history of tubectomy (14.4%), abortion (26.1%), previous caesarean section (11.1%). Our study also showed a similar association with tubectomy and other intraabdominal surgeries. Histopathologically, common site was ampulla (54%) then fimbria (40%) consistent with previous studies. Dahiya et al (19) estimated 79% cases in ampullary region and 16% in fimbria. Our study showed reduction in ciliated cells in affected fallopian tubes with all the fimbrial ectopics showing marked deciliation indicating that deciliation of the lining cells play a significant role in the pathogenesis of tubal ectopic. Our findings correlate with that of Vasquez et al (20). Dahiya et al showed incidence of 6% of salpingitis isthmica nodosa (SIN), while studies done by Homm et al (21) and Dubuisson et al (22) showed incidence of 45.9% and 36.4% respectively. Our study showed a significant association of 22% with SIN and very marked association with acute salpingitis or chronic or follicular salpingitis. These findings suggests that there is a indicative contribution of inflammation in causation of ectopics.
CONCLUSION
The study highlights the association of deciliation with ectopic pregnancy. The cilia of the fallopian tube physiologically helps in fertilisation and implantation of the embryo. Deciliation can happen for various reasons for example pelvic inflammatory disease and this predisposes for ectopic pregnancy. Ectopic pregnancy in theory can be prevented by preventing and timely management of conditions predisposing it.
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=470http://ijcrr.com/article_html.php?did=4701. Kumar Vinay, Abbas Abul K, Fausto Nelson, Aster Jon C. Robbins and Cotran Pathologic Basis of Disease. 8th edition. Elsevier. 1053-1054.
2. Vyas Priti S, Vaidya Pratibha. Epidemiology, diagnosis and management of ectopic pregnancy -an analysis of 196 cases. Bombay hospital journal.
3. Dutta DC. Textbook of Obstetrics. Edited by Hiralal Konar. 6thed.Central book agency .2004.179.
4. Young Barbara, Lowe James S, Stevens Alan, Heath John W. In: Wheater’s Functional histology. 5th ed. 367.
5. Young Barbara, Lowe James S, Stevens Alan, Heath John W. In: Wheater’s Functional histology. 5th ed. 368.
6. Rosai Juan. Female reproductive system. In: Rosai and Ackerman’s Surgical pathology. Vol 2. Ed.9. Elsevier Inc.2009.1636
7. Hendrickson MR, Kempson RL. Normal histology of the uterus and fallopian tubes. In : Sternberg S (ed): histology for pathologist, ed.2. Philadelphia, 1997; Lippincott-Raven: 879-928
8.http://www.gfmer.ch/International_activities_En/El_Mowafi/ Fallopian_tube.htm
9. Rosai Juan. Female reproductive system. In Rosai and Ackerman’s Surgical pathology. Vol 2. Ed.9. Elsevier Inc,2009: 1639
10. Burton JL, Lidbury EA, Gillespie AM, Tidy JA, Smith O, Lawry J, Hancock BW, Wells M. Over-diagnosis of hydatidiform mole in early tubal ectopic pregnancy. Histopathology 2001, 38: 409- 417.
11. Blaustein A, Shenker L, Vascular lesions of the uterine tube in ectopic pregnancy. Obstet Gynecol 1967, 30: 551-555.
12. Cole T, Corlett RC 1982. Chorionic ectopic pregnancy. Obstetrics and Gynecology 59: 63-68.
13. Nybo Anderson AM, Wohlfahrt J, Christens P, Olsen J, Melbye M.Maternal age and fetal loss:population based register linkage study. BMJ. 2000 Jun 24;320(7251):1708-12.
14. Heather Murray, Hanadi Baakdah, Trevor Bardell, Togas Tulandi. Diagnosis and treatment of ectopic pregnancy. CMAJ.2005 Oct11; vol173:no8: 905-12.
15. Hlavin GE, Ledoski LT, Bren JL.Ectopic pregnancy: an analysis of 153 patients. International Journal of Gynaecology and Obstetrics.1978;16:42-47.
16. De Cherney AH, Minkin MJ, Spangler S 1981a. Contemporary management of ectopic pregnancy. Journal of Reproductive Medicine 26:519-523.
17. F. Cunningham, Kenneth Leveno, Steven Bloom, John Hauth, Larry Gilstrap, Katharine Wenstrom. Williams Obstetrics. 22nd Edition. McGraw Hill Professional;2005:266.
18. Majhi AK, Roy N, Karmakar KS, Banerjee PK. Ectopic pregnancy – an analysis of 180 cases. J Indian Med Assoc.2007 Jun;105(6): 308, 310, 312.
19. Dhaiya N, Singh S, Kalra R, Sen R, Kumar S. Histopathological changes associated with ectopic tubal pregnancy. IJPSR,2011;Vol.2(4): 929-933.
20. Vasquez G, Winston RM, Brosens IA. Tubal mucosa and ectopic pregnancy. Br J Obstet Gynaecol. 1983 May;90(5): 468-74.
21. Homm RJ, Holtz G, Garvin AJ. Isthmic ectopic pregnancy and salpingitis isthmica nodosa. The American fertility society.1987;48: 756-60.
22. Dubuisson JB, Aubriot FX, Cardone V, Vaucher-Lavenu MC. Tubal causes of ectopic pregnancy. Fertil steril 1986; 46: 970-2.
26. Milman N1, Byg KE, Bergholt T, Eriksen L, Hvas AM. Body iron and individual iron prophylaxis in pregnancy--should the iron dose be adjusted according to serum ferritin? Ann Hematol. 2006 Sep;85(9):567-73. Epub 2006 May 30.
27. WHO. Iron deficiency anaemia: assessment, prevention, and control. A guide for programme managers. Geneva, Switzerland: World Health Organization, 2001. (WHO/NHD/01.3.)
28. Albonico M1, Stoltzfus RJ, Savioli L, Tielsch JM, Chwaya HM, Ercole E, Cancrini G. Epidemiological evidence for a differential effect of hookworm species, Ancylostoma duodenale or Necator americanus, on iron status of children. Int J Epidemiol. 1998 Jun;27(3):530-7.
29. Bakta, I. M., Wijana, D. P., and Sutisna, P. (1993). Hookworm infection and iron stores: a survey in a rural community in Bali, Indonesia. The Southeast Asian journal of tropical medicine and public health, 24(3), 501-504.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareSWEYER JAMES SYNDROME- A CASE REPORT
English5961Vishnukanth GovindarajEnglish Hariprasad KalpakkamEnglish Balla Nagamalli KumarEnglish Suryakala NarayanaswamyEnglish Manju R.English Dharm Prakash DwivediEnglishUnilateral hyperlucency on a chest x ray is not a uncommon occurrence. The causes vary from a simple rotation to a potentially life threatening pulmonary embolism. Sweyer James syndrome is one of the less known causes for unilateral hyperlucent lung which results as a sequlae to recurrent respiratory tract infections in childhood. We describe a patient with sweyer James syndrome who had no significant respiratory infections since childhood.
EnglishSwyer james syndrome, Unilateral hyperlucency, CT chestINTRODUCTION
Sweyer James syndrome was first described by Paul Robert Swyer and George C W James in the 1950s. Simultaneosly the condition was also described by English physician William Mathiseon Macleod, and by J Brett in France. Hence this syndrome is also referred to as Macleod syndrome, Brett syndrome and Janus syndrome.1,2 The syndrome is characterized by hyperlucency of one lung, lobe or part of a lobe due to pulmonary vascular abnormalities and alveolar over distension. The important pathological features of this syndrome include emphysema, bronchiectasis or bronchiolitis obliterans.3 The exact etiology of this syndrome is unknown but repeated episodes of respiratory tract infections particularly in the childhood is an important cause.4 Patients usually present in adult age and in many, a history of childhood respiratory infections is not obtained.
CASE DETAILS
A forty five year old agricultural labourer presented with symptoms of cough with minimal expectoration of ten days duration. He had similar symptoms atleast once a year for the last ten years. These symptoms subside with treatment. There was no seasonal aggravation of symptoms. He was not a smoker and had no past history of tuberculosis. Upon examination he had no clubbing or cyanosis. He maintained saturation at room air. His heart rate, pulse rate and blood pressure were within normal limits. His respiratory system examination was normal. He was treated as upper respiratory tract infection and advised symptomatic management. Patient returned a week later with persistence symptoms. He was subjected for chest x ray which showed hyperlucency of the left hemithorax. (fig 1)Differential diagnosis of left sided pneumothorax, polands syndrome, sweyer James syndrome, pulmonary embolism, congenital lobar emphysema were considered. There was no rotation on the chest x ray. Patient was examined thoroughly and polands syndrome and pneumothorax were ruled out. A possibility of pulmonary embolism (?Westermark sign) and Sweyer James Syndrome were considered. Patient was subjected to high resolution computed tomography and pulmonary angiography scan. High resolution computed tomography(HRCT) scan of the chest showed decreased attenuation and decreased vascularity of the left lung with hyperlucency and bronchiectatic changes(fig 2). The right lung had normal vascularity. Pulmonary angiography was done which revealed a hypoplastic left pulmonary artery with reduced bronchovascular markings in left lung which confirmed the diagnosis.(fig 3) The patient had no echocardiographic evidence of pulmonary hypertension and arterial blood gas estimation was normal.He is currently managed symptomatically and is on regular follow up.
DISCUSSION
Swyer-James syndrome(SJS) is usually suspected radiologically. On chest x ray there is hyperlucency of one lung field. Usually the left side is commonly affected 5. Childhood viral respiratory infections particularly with measles, bordetella pertussis, tuberculosis, Mycoplasma pneumonia, influenza A, adenovirus types 3, 7, and 21 most commonly lead to development of SJS later4 . The pathological process in SJS is obliterative broncholitis with concomitant vacsulitis. Following repeated viral infections the small bronchi and bronchioles are affected. A form of bronchiolitis obliterans develop which results in inflammation and fibrosis of the bronchiolar walls. As a result the lumen of the respiratory bronchioles are narrowed. The interalveolarseptae undergo fibrotic changes with obliteration of pulmonary capillary bed 6 . This causes diminished blood flow to the major pulmonary artery segments, resulting in hypoplastic arterial development. In addition, the reduction in ventilation causes a compensatory decrease in perfusion. Also consequent to bronchiolar obstruction the terminal air sacs expand which offers additional mechanical resistance to blood flow in the capillaries resulting in atrophy of vascular bed and hypoplasia of pulmonary artery 7 . The disease symptom can manifest in the early infancy and childhood. Children present with recurrent history of respiratory tract infections. Cough can be productive or non productive. Shortness of breath and chest pain may be associated. Haemoptysis can occur. The symptoms depend on associated bronchiectasis8 . Patients with no or minimal bronchiectasis are usually diagnosed in adult age by incidental chest radiography. The classical chest x ray finding is unilateral hyperlucency. There can be mediastinal shift during inspiration and expiration. A mediastinal shift toward the affected side may occur on inspiration. Expiratory radiograph may demonstrate air trapping or a shift of the mediastinum towards the normal side. Associated Bronchiectatic changes may be seen. Computed tomography(CT) is the investigation of choice in the diagnosis of this syndrome. On CT, Sweyer James syndrome appears as low attenuation hyperlucent areas due to decreased pulmonary perfusion of the lung with intervening areas of normal attenuation. Other findings include bronchiectasis, bronchiolectasis, atelectasis and scarring9 . Ventilation – perfusion scans can help in confirmation of the ventilation perfusion defect. Matched ventilation and perfusion defect can be seen10. Pulmonary angiography may reveal diminished size of the affected pulmonary artery. A number of other conditions can cause unilateral hyperlucency on chest x ray and they should be considered in the differential diagnosis of SJS. These include pneumothorax, pulmonary embolism, congenital lobar emphysema, polands syndrome, foreign body aspiration, post pneumonectomy, pulmonary agenesis. A few instances of misdiagnosis as pneumothorax with inadverdent intercostal tube placement are reported.8 There is no specific treatment for SJS. Treatment is usually supportive and is aimed at treating super added infections. Vaccination for influenza and pneumococci can be advised. Bronchodilators may be helpful in some patients. Prognosis depend on the underlying bronchiectasis 11. Long term oxygen may be needed in patients presenting with respiratory failure. Surgical treatment like lobectomy or pneumonectomy may be required in a few patients.
CONCLUSION
Sweyer James Syndrome is not an uncommon syndrome and has to be considered in the differential diagnosis of unilateral hyperlucency and when suspected a CT scan can help in establishing the diagnosis.
ACKNOWLEDGEMENT
The authors would like to thank Dr. Ravindra Chary, Junior resident in the department of Pulmonary medicine for his help in the preparation of this manuscript. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=471http://ijcrr.com/article_html.php?did=4711. www.radiopedia.org/articles/sweyer james syndrome. ACCESSED ON 1.5.2015.
2. Swyer PR, James GC. A case of unilateral pulmonary emphysema. Thorax 1953;8:133–136.
3. Kanwal Fatima Khalil and WaseemSaeed.Swyer-James-MacLeod Syndrome. Journal of the College of Physicians and Surgeons Pakistan 2008, Vol. 18 (3): 190-192.
4. Schlesinger C, Veeraraghavan S, Koss MN. Constructive (obliterative) bronchiolitis.CurrOpinPulm Med 1998;4:288–293.
5. Abba AA, Al-Mobeireek AF. Clinical spectrum of Swyer-JamesMacLeod syndrome in adults. Saudi Med J 2003; 24:195-8.
6. Schlesinger C, Meyer CA, Veeraraghavan S, Koss MN. Constrictive (obliterative) bronchiolitis: diagnosis, etiology, and a critical review of the literature. Ann Diagn Pathol 1998;2:321– 334.
7. Mathur S, Gupta SK, Sarda M, Jaipal U. Swyer-James-Macleod syndrome with emphysematous bulla. J Indian Med Assoc 1995;93:150–154.
8. Sulaiman A, Cavaille A, Vaunois B, Tiffet O. Swyer–James–MacLeod syndrome; repeated chest drainages in a patient misdiagnosed with pneumothorax. Interact Cardio Vasc Thorac Surg 2009;8:482–484.
9. Umesh C. Parashari, Ragini Singh, AnitParihar, Pallavi Aga, Rajesh Yadav. Diagnostic role of magnetic resonance angiography in Swyer James syndrome: Case series of two cases. Lung India. 2010 Jul-Sep; 27(3): 161–163.
10. Arslan N, Ilgan S, Ozkan M, Yuksekol I, Bulakbasi N, Pabuscu Y, et al. Utility of ventilation and perfusion scan in the diagnosis of young military recruits with an incidental finding of hyperlucent lung. Nucl Med Commun. 2001;22:525–30.
11. Gopinath A, Strigun D, Banyopadhyay T. Swyer-James syndrome. Conn Med 2005; 69:325-7.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareAN ANALYSIS OF THE ROLE OF UTERINE MALFORMATIONS IN PRIMARY INFERTILITY - AN OBSERVATIONAL STUDY
English6267A. JayashreeEnglish Udaya Kumar P.English V. PadmajaEnglish L. VinodiniEnglish K. Sudha RaniEnglishIntroduction: According to World Health Organization worldwide estimates 60-80 million couples suffer from infertility. Infertility or the inability of a female to conceive despite 12 months or more of unprotected coital exposure can be due to several factors including uterine anomalies, tubal anomalies, and hormonal imbalance among others.
Aims and Objectives: The scope of this study includes impact of Uterine Anomalies on primary infertility.
Materials and Methods: The study includes evaluation and investigation of 100 cases of infertile females and women with bad obstetric history over a period of 3 years from 2007 to 2009 in Gandhi Hospital, Secunderabad, Telangana. A detailed history for every complaint in all the cases was taken by the in charge gynaecologist.
Results: In the present study the bicornuate uterus predominates with 40% (4 cases out of 100). Septate uterus and uterus didelphys were observed in 2 cases each (20%), whereas arcuate uterus and unicornuate uterus were observed in 1 case each (10%).
Conclusion: It is pertinent to note that, a fairly high incidence of bicornuate uterus and uterus didelphys with poor reproductive outcome in the present study provokes a challenge in terms of management protocol on account of its morbidity and demands a meticulous antenatal surveillance. Considering the low socioeconomic and rural background in most of the cases in this study, it is worthwhile to investigate whether nutritional and environmental factors play a role in the genesis of the reproductive system.
EnglishUterine anomalies, Primary infertility, Bicornuate uterus, Uterus didelphys, Septate uterus, Arcuate uterus, Unicornuate uterusINTRODUCTION
This study attempts to explain the much established linkage between Uterine Anomalies and Infertility. The scope of this study includes impact of these anomalies on primary infertility. Primary infertility in this study is taken to imply females who have never previously conceived.
Normal anatomy and development
The uterus is a hollow, pear shaped, thick-walled and muscular organ, normally situated in the lesser pelvis between the urinary bladder and the rectum. The uterus is divided into two main regions – the body – corpus uteri – forms the upper two thirds, and the cervix – cervix uteri - forms the lower third. The uterine tubes are attached to the upper part of the body of uterus with their ostia opening into the lumen [1].
Development
The mullerian (paramesonephric) ducts form a major part of the vagina, cervix and uterine body. The ducts begin to develop as a linear invagination of coelomic epithelium on the lateral aspect of the mesonephric ridge near its cranial end. The Mullerian duct consists of vertical cranial and caudal parts and an intermediate horizontal region. The cranial part of the para mesonephric ducts forms the uterine tubes, and the original coelomic invagination remains as the pelvic opening of the tube. The caudal vertical parts of the two ducts fuse with each other to form the uterovaginal primordium. This gives rise to the lower part of uterus and, as it enlarges, it takes in the horizontal parts to form the fundus and most of the body of the adult uterus. The stroma of the endometrium and the uterine musculature develop from the surrounding mesenchyme [2]. Failure of fusion of the two paramesonephric ducts can lead to a range of anomalies of the uterus with varying degree of septation and also contribute to anomalies of vaginal development.
Classification of mullerian duct anomalies:
The main groups of deformities arise from three embryological imperfections are discussed below.
1. Defective canalization of the vagina could lead to the formation of transverse vaginal septum or absence of the vagina itself.
2. Also possible is the unilateral maturation of Mullerian duct along with incomplete or total absence of development of opposite duct. The defects in such cases lead to upper urinary tract anomalies.
3. Absence or imperfect midline fusion of mullerian ducts: Total absence of fusion could lead to two independent uteri, vaginas and cervices. Uterine septum could be formed due to incomplete resorption of tissue between the fused mullerian ducts.
MATERIALS AND METHODS
The study analyses the investigative observations procured from 100 cases of infertile women with bad obstetric history over a period of 3 years from 2007 to 2009 in Gandhi Hospital, Secunderabad, Andhra Pradesh. All cases were sourced from the hospital’s Gynaecology outpatient department. Prior informed consent was taken from the patient. A detailed history for every complaint in all the cases was taken by the in charge gynaecologist. For those effected by primary infertility, details such as duration of married life, age of the couple, previous usage of contraception, duration of the couple living together, Previous history of expose to sexually transmitted diseases, history of tuberculosis, operations such as appendicitis and other illness, detailed menstrual history, history of abortions were taken. Patients were subjected to a detailed gynaecological and general examination.
1. Gynaecological Examination: Per speculum examination was performed to determine whether cervix was normal or conical with a pin point os, small, elongated, or infected. Also, bimanual examination was done to find out whether uterus was normal sized or ill developed or malformed. Position and mobility of uterus was established. Fornices were examined to make out palpable adnexal pathology, if any.
2. General Examination: A comprehensive general examination was done, which included the stature of the patient, nutritional status, examination of the heart and lungs, any enlargement of thyroid gland and cervical lymph nodes.
Investigations: In the Females – Complete blood picture, Blood Grouping and Typing, Erythrocyte Sedimentation Rate, Random Blood Sugar, X-Ray Chest, Venereal disease research laboratory test, dilation and curettage, Ultra Sonography of Pelvis and Hystero Salpingo-graphy. In the Males – Venereal disease research laboratory test, Semen Analysis. From the above parameters, the information is collected and tabulated for the present study. The data under different investigative procedures like Hystero-salpingography, Ultrasonography, hysteroscopy, and laparoscopic findings were taken. Results were tabulated as per investigative procedures and compared with available literature.
RESULTS
The observations represent a total of 100 cases of primary infertility, between ages of 18 years and 35 years. Table No. I and Figure No. 7 specify the type of anomalies observed, where the bicornuate uterus predominates with 40% (4 cases out of 100). Septate uterus and uterus didelphys were observed in 2 cases each (20%), whereas arcuate uterus and unicornuate uterus were observed in 1 case each (10%).
DISCUSSION
A large number of uterine anomalies are detected routinely in reproductive medicine as practiced in current times. This increase is attributed more to availability of better imaging techniques for the uterus rather than increases in prevalence of such anomalies in the general female population. According to World Health Organization worldwide estimates 60-80 million couples suffer from infertility [3]. Infertility or the inability of a female to conceive despite 12 months or more of unprotected coital exposure can be due to several factors including uterine anomalies, tubal anomalies, and hormonal imbalance among others. In all probability, arcuate uterus has the least impact on reproductive capacity. Infact, recurrent miscarriages are common in cases of uterine septum. Also, surgical correction of uterine septum is less morbid and easy. Excessive preterm delivery, retained placenta, malpresentation and miscarriage rates are characteristic in bicornuate uterus cases. This anomaly therefore requires extensive surgical repair. Reevaluation of few studies has revealed that Didelphic uterus impacts reproductive outcomes. Apart from high miscarriage rates and preterm deliveries, cases of didelphic uterus run the risk of Cesarean section for dystocia, and malpresentation. Poorest reproductive outcomes are observed in unicornuate uterus cases. High rates of ectopics, miscarriage, pre term delivery are therefore common in patients with a unicornuate uterus. Malpresentation, low live-birth rates, and Cesarean section for dystocia are the risks associated with unicornuate uterus [4]. Various authors have put forward explanations for the mechanism of reproductive failure in infertility. Disorganization of uterine stroma along with high intrauterine pressure caused by an enlarging fetus could lead to cervical incompetence and insufficient uterine expansion [5]. Additionally, poor vascular arrangement in the anomalous uterine fundus, will in turn fail to provide necessary support to the growing fetus. These conditions could lead to their loss in late first trimester and second trimester. The association of primary infertility with uterine anomalies remains less clear. However, non-feasibility of fundal implantation in an abnormal uterus could lead to occurrence of lateral wall implantation or septal implantation. The subsequent alteration in vascular supply, myometrial and endometrial formation in this area, results in inadequate implantation. In the present analysis of 100 infertility cases, Mullerian anomalies accounted for 10%. Bicornuate uterus (Figure No. 1) tops the list with 40% of total number of cases with mullerian anomalies followed by the septate uterus (Figure No. 2) and uterus didelphys (Figure No. 3 and 4) with 20% each, while the arcuate uterus (Figure No. 5) and unicornuate (Figure No. 6) accounted for 10% each. In a review by Saravelos S.H. in 2008 [6] uterine anomalies were found in 16.7% among those with recurrent miscarriages while it accounted for 13% as observed by Grigoris F. Grimbizis et. al. in 2001 [7]. Braun P. et. al., in 2005 [18] found the frequency of malformations to be 10% which tallies with the findings in the present study. Surprisingly the works of Pedro Acién in 1993 [11], Francisco Raga et. al. in 1997 [14], and Bruseo G.F. et. al 2001 [15] found the incidence to be 6%, 6.3% and 7.62%, respectively. In the current study, bicornuate uterus takes the top slot with an incidence of 40% of total cases with anomalies. In a study reported by Grigoris F. Grimbizis et. al. in 2001 [7] the mean incidence of bicornuate uterus was 25% while it accounted for 13.6% in a retrospective study by Braun P. et. al. in 2005 [18]. Tulandi T. et. al.[8] in their evaluation of uterine anomalies in infertility in the year 1980 had 13 such cases, out of which 6 underwent metroplasty and 4 achieved term pregnancy after surgery. Pedro Acién’s [11] study in 1993 of 176 women found metroplasty and cerclage corrected infertility and increased live birth rate, but nevertheless found a poor pregnancy outcome. Pedro Acién and Maribel Acién in 2004 [12] also affirmed a higher reproductive loss, while in a study undertaken by A. M. Khalil et. al. in 1995 [13], it was observed that fetal wastage rate fell from a massive 93% prior to surgery to 16% after abdominal metroplasty was advocated for uterine unification. Operative outcome was not contemplated in the current study. Septate uterus accounted for 20% in the present study while it showed a higher incidence of 33.6% in a study undertaken by Francisco Raga et. al. in 1997 [14], and 35% was observed by Grigoris F. Grimbizis et. al. in 2001 [7]. According to Braun P. et. al. in 2005 [18] it was 24.3%, while Saravelos S.H. in his review in 2008 [[6] found the dominance of septate uterus in infertile women. Francisco Raga et. al. in 1997 [14] studied the impact of congenital Mullerian anomalies on women wanting to conceive, and they found that reproductive performance of the didelphys uterus was poor. Pui M.H. in 2004 [17] discussed the pros and cons of various diagnostic tools such as HSG, MRI, USG, hysteroscopy, and laparoscopy in management of anomalies. He inferred that diagnosis can be challenging, for instance complete uterine and vaginal septum can mimic uterus didelphys. Hence comprehensive evaluation has been mooted to pin point underlying anomaly. In the present study this malformation represents 20% of total anomalies. The arcuate uterus gets listed for its 10% share in the current study. Francisco Raga et. al. in 1997 [14] reported an incidence of 32.8% whereas it accounted for a mean incidence of 20% in a study by Grigoris F. Grimbizis et. al. in 2001[7], while a retrospective study by Braun P. et. al. in 2005 [18] took a high toll of 57.6%, which was reaffirmed by Saravelos S.H. in 2008 [6]. In 2002, Lin Paul et. al. [16] in their review opined that the arcuate uterus had minimal effect on reproduction, whereas Pedro Acién in 1993 [11] and again in 2004 with Maribel Acién [12] found greater reproductive loss in arcuate uterus when compared to septate. Closely following with a parallel incidence of 10% is the unicornuate uterus in the current analysis. In 1983, Heinonen P.K. and Pystynen P.P.[10] found that the unicornuate uterus accounted for 15% while Braun P. et. al., in 2005 [18] accounted it for 4.5%. Pentti K. Heinonenet. al. in 1982 [9] observed that unicornuate uterus had a fetal survival rate of 40%.
CONCLUSION
It is pertinent to note that, despite being a known cause for many years now, mullerian anomalies continue to attract academic interest and presents a formidable challenge for Obstetricians. Availability of better imaging techniques and associated therapeutic options has generated greater interest in this field. The current study has shown that bicornuate uterus accounted for 40% of the total number of patients with mullerian anomalies, while uterus didelphys and septate uterus accounted for 20% each. Unicornuate uterus and the arcuate uterus cornered 10% each. A fairly high incidence of bicornuate uterus and uterus didelphys with poor reproductive outcome in the present study provokes a challenge in terms of management protocol on account of its morbidity and demands a meticulous antenatal surveillance. Considering the low socioeconomic and rural background in most of the cases in this study, it is worthwhile to investigate whether nutritional and environmental factors play a role in the genesis of the reproductive system.
Competing Interests
The authors declare that we have no competing interests
Ethical Committee As this is only an observational study of the patients who attended the Gynaecoology and Obstetrics outpatient department and underwent treatment later on, in the respective department, permission from ethical committee was not considered in the present study. But prior informed consent was taken from the patient in their own vernacular.
Source of Funding
This is a self funded study.
ACKNOWLEDGEMENTS
Authors thank Dr. Seema Madan, Professor and Head of the Department of Anatomy Dr. Ashok Kumar, Professor of the Department of Anatomy for precious suggestions and practical guidance during the study. Authors are indebted to the patients who consented to be included in the study. 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=472http://ijcrr.com/article_html.php?did=4721. Susan Standring, PhD; Gray’s Anatomy, The Anatomical Basis of Clinical Practice; 40th ed.
2. T. W. Sadler, Ph.D; Langman’s medical embryology, 11th ed. Pg 252 – 253.
3. Infecundity, infertility and childlessness in developing countries. DHS comparative reports No. 9. Calverton Maryland, USA: ORC Macro and the World Health Organization; 2004. World Health Organization.
4. F. Gary Cunningham, MD, John C. Hauth, MD, Kenneth J. Leveno, MD, Larry Gilstrap III, MD, Steven L. Bloom, MD, Katharine D. Wenstrom, MD; Williams Obstetrics, 22nd Ed (2005), p 950-952.
5. House M, Kaplan DL, Socrate S. Relationships between mechanical properties and etracellular matrix constituents of cervical stroma during pregnancy. 2009, 33(5): 300-307.
6. Saravelos S.H., Cocksedge K.A., Li T.C.: Prevalence and Diagnosis of Congenital Uterine Anomalies in Women with Reproductive Failure: A Critical Appraisal. Hum Reprod Update. 2008 Sep-Oct; 14(5): 415-29 PMID: 18539641.
7. Grigoris F. Grimbizis, Michel Camus, Basil C. Tarlatzis, John N. Bontis and Paul Devroey: Clinical Implications of Uterine Malformations and Hysteroscopic Treatment Results. Human Reproduction Update 2001; Vol.7 No.2 pp.161-174.
8. Tulandi T., Arronet G.H., McInnes R.A.: Arcuate and Bicornuate Uterine Anomalies and Infertility. Fertil Steril October 1980; 34(4): 362-4 PMID: 7418888.
9. Pentti K. Heinonen, Seppo Saarikoski and Paavo Pystynen: Reproductive Performance of Women with Uterine Anomalies: An evaluation of 182 Cases. Acta Obstetricia et Gynecologica Scandinavica 1982; Vol. 61 No. 2, Pages 157-162.
10. Heinonen P.K., Pystynen P.P.: Primary Infertility and Uterine Anomalies. Fertil Steril. 1983 Sep; 40(3): 311-6 PMID: 6884534
11. Pedro Acién: Reproductive Performance of Women with Uterine Malformations. Human Reproduction 1993; Vol. 8 No. 1 pp. 122-126.
12. Pedro Acién, and Maribel Acién: Evidence-based Management of Recurrent Miscarriage. International Congress Series April 2004; Volume 1266 Pages 335-342.
13. A. M. Khalil, G. B. Azar, A. B. Hannoun, J. T. Sawaya, A. A. Abu-Musa and K. S. Karam: Reproductive Outcome Following Abdominal Metroplasty. International Journal of Gynecology and Obstetrics May 1995; Volume 49 Issue 2 Pages 157-160.
14. Francisco Raga, Celia Bauset, Jose Remohi, Fernando BonillaMusoles, Carlos Simon, Antonio Pellicer: Reproductive Impact of Congenital Mullerian Anomalies. Human Reproduction. 1997; 2277–2281.
15. Bruseo G.F, Arena S., Angelini A.: Role of Diagnostic Hysteroscopy in Infertile Women. Minerva Gynecol. 2001 Oct; 53(5): 313-9 PMID: 11549995.
16. Lin Paul C.; Bhatnagar Kunwar P.; Nettleton G. Stephen; Nakajima Steven T.: Female Genital Anomalies Affecting Reproduction. Fertility and Sterility 2002; 78(5): 899-915.
17. Pui M.H.: Imaging Diagnosis of Congenital Uterine Malformation. Comput Med Imaging Graph 2004 Oct; 28(7): 425-33 PMID: 15464882.
18. Braun P., Grau F.V., Pons R.M., Enguix D.P.: Role of Hysterosalpingography in diagnosis of uterine malformations. Eur J. Radiol. 2005 Feb; 53(2): 274-9 PMID: 15664292.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareAPPLICATION OF GRAFTED POLYNOMIAL MODEL AS APPROXIMATING FUNCTIONS IN FORECASTING COTTON PRODUCTION TRENDS IN ZAMFARA STATE, NIGERIA[1995-2013].
English6873Odedokun V.O.English Ahmed B.English Omolehin R.A.English and Atala T.K.EnglishThe aim of this paper was to predict cotton production trends based on time series data from 1995 to 2013 in Zamfara state, Nigeria. The forecasting model that was applied to estimate cotton production trends was a grafted polynomial model “quadraticquadratic- linear” function. Grafted models are used in econometrics to embark on economic analysis involving time series. Economic time series data were used in order to estimate the possible production and supply trends of cotton in the study area. In the application of the grafted polynomial model used to forecast cotton production trends, the estimates of the linear and grafted
functions were utilized to obtain ex-post forecast of cotton. The values of the grafted (mean) function of 123,000 tons were closer to the observed values of 129,000 tons resulting in smaller difference during the sub- period (2006-2013) under consideration when compared with linear values of 137,000 tons. The forecast of production and supply trends among cotton farmers revealed that the grafted model provided better estimates since they were closer to the observed values during the sub-period under consideration.
EnglishGrafted model, Forecasting, Cotton, Production, Zamfara state, NigeriaINTRODUCTION
At independence, the contribution of agriculture to the GDP was about 25% between 1975 and 1977. This was partly due to the phenomenal growth of the mining and partly as a result of the disincentives created by macroeconomic environment. Similarly, the growth rate of agricultural productivity exhibited a downward trend during the period. Thus, between 1970 and 1982 agricultural productivity stagnated at less than one percent annual growth rate at a time when the population growth rate was 2.5 to 3.0% per annum (Adubi, 2001). According to the National Bureau of Statistics (NBS) (2011), the percent share in the GDP of the crop sub-sector between 1981 to 1990 had been fluctuating between 28.37% and 22.99% and did not register any significant increase. This trend continued as the contribution of the crop sub-sector was almost stagnant at about 36% from 1994 to 1997 and from 2003 to 2006. Furthermore, the Central Bank of Nigeria(CBN, 2011) in its annual report indicated the per cent share in total of the contribution of the agricultural sector to the GDP at 1990 constant basic prices. From 2007 through 2012, the share has been declining from 42% of the total GDP to 40.2%. The place of the crop production sub-sector in the total GDP have shown similar trend with a decline from 37.5% to 35.8% between the same periods. Despite these marginal decline in recent years, the demand for many agricultural products outweighs the supply. It is with respect to this that cotton was chosen to form the basis of this study. With regards to fibre crop, cotton is an important crop in the world, it ranks first followed by jute,kenaf and sisal in the world production of fibres. It is noticeable from the performance of the cotton production industry that since 2003/2004 cropping season, there has been a fall and fluctuating pattern in the production trends in cotton. According to United State Department of Agriculture, (USDA, 2011), the production trend in cotton had not witnessed remarkable improvement between 2007/2008 cropping year while the 2010 – 2012 cropping seasons experienced a decline. This phenomenon revealed a glaring disparity between demand and supply thereby creating a gap in the cotton production industry. Batterham (2000) asserted that supply is yet to satisfy the level of demand for cotton. This has caused great concern in the textile cotton fibre supply situation in the local market and export profile in the country thereby having a declining effect in its contribution to the agricultural economy of the country.
Research Question and Objectives
It is based on the above credence that these research question and objective were raised. What are the patterns of production and supply trends for cotton in the state? The objective of the study is to; Predict cotton production trends based on time series data from 1995 to 2013 in the state.
METHODOLOGY
Study Area Zamfara state was used for this study. The state lies between latitude 100 50`N and 130 38`N and longitudes 4o 16`E and 7o 18`E. The state is located in the Sudan Savanna ecological zone of Nigeria. It has a land area of 39,762km2 . Zamfara state shares common borders with Sokoto and the Republic of Niger to the north, Katsina and Kaduna states to the east, Niger and Kebbi states in the South (Yakubu, 2005, www.zamfarastate.net, 2010). The state has a population of about 3,259,846 people in 2006 according to the National Population Commission (NPC; 2006). This is projected in 2011 to be 3,667,326 representing3.2% annual growth rate in population (UNFPA 2013).The climate is essentially that of tropical climate. The climate is generally characterized by alternating dry and wet seasons.
Data Source
Secondary data were collected and used in this study. Data on cotton output from the state for various years were collected from Central Bank of Nigeria (CBN annual reports), Food and Agriculture Organizations (FAO) production yearbook or quarterly bulletin of statistics, Federal Office of Statistics (FOS), National Agricultural Extension and Research Liaison Services (NAERLS) Wet Season Production Report, Bulletin of Prices, internet and the Zamfara State Agricultural Development Project (ZADP).
Grafted Polynomial Model
Grafted polynomial model was used to achieve the objective of the study. Grafted models are used in econometrics to embark on economic analysis involving time series. It was assumed that different functional forms may fit different segments of a time series or response studies. Segments of polynomials can be used to approximate production surfaces or frontiers and to forecast time series. The segment to be used to forecast time series as in trend studies must end in a linear form.These segmented curves are restricted to be continuous and differentiable at the joined points. This is shown in appendix I
Grafted Polynomial Model
Grafted polynomial model was used to achieve the objective of the study. Grafted models are used in econometrics to embark on economic analysis involving time series. It was assumed that different functional forms may fit different segments of a time series or response studies. Segments of polynomials can be used to approximate production surfaces or frontiers and to forecast time series. The segment to be used to forecast time series as in trend studies must end in a linear form.These segmented curves are restricted to be continuous and differentiable at the joined points. This is shown in appendix I
= a + bt (1)
This is an observed time series that do not relate linearly to trend as shown in the graph above. The three segments of the functional relationship can be expressed as functions of the form;
= a0 + a1 t + a2 t 2 , for t ≤ k1 (2)
= b0 + b1 t + b2 t 2 , for k1 < t ≤ k2 (3)
= c0 + c1 t, for t>k2 (4)
There should be a priori expectation. In this model, we are assuming that the mean function is to be continuous, linear in parameters and differentiable at the joined points (k1 and k2 ) as contended by Fuller, (1969); and Philip, (1990). In other words, we need to derive a mean function which encompasses all the key local trends observed in the time series . Thus, it is imperative that the following restrictions must hold. There are four restrictions namely; two continuities and two differentiabilities.
At continuity, the following expression holds.
a0 + a1 k1 + a2 k2 2 = b0 + b1 k1 + b2 k1 2 (5)
b0 + b1 k2 + b2 k2 2 = c0 + c1 k2 (6)
At differentiability, we derive these expressions as shown in equations (7) and (8).
a1 + 2a2 k2 = b1 + 2b2 k1 (7)
b1 + 2b2 k2 = c1 n (8)
It is noticeable that, there are eight parameters namely a0 , a1 , a2 , b0 , b1 , b2 , c0 , and c1 . There are also four restrictions on the mean function. In other words, this implies that only four parameters can be estimated. The parameters to be estimated depend upon the motive of generating or formulating the mean function which is to forecast.
For forecasting, it is highly important to retain the coefficient in the terminal trend function and this is usually linear. Thus c0 , c1 , a2 and b2 are to be retained for subsequent estimation while a0 , a1 , b0 and b1 are to be dropped and eliminated.
For ease and simplicity, it is better to start the derivations with equation (8) and making b1 the subject of the formular. From equation (8)
Equation (15) represents a grafted continuous (mean) function which encompasses all the key local trends indicated by the set of restrictions in equations (2), (3) and (4). Equation (15) is the empirical (grafted) model suitable for computing an ordinary least Squares (OLS) regression.
RESULTS AND DISCUSSION
Forecasting Cotton Production Trends in Zamfara State, Nigeria
The linear function and the mean functions represented in equations (1) and (15) were utilized in the analysis using the ordinary least squares (OLS) method. The results of the regression analysis and the estimates of the structural parameters are presented in table 1. The data for the 2006-2013 Subperiod were retained for the ex-post evaluation or forecast of the estimated equation. Also, equation (1) was estimated in order to purposely evaluate the predictive performance of equation (15).
The calculated T-values for the grafted function in the trend model for both X1 and X3 were statistically significant at 1% and 5% levels of probability. This suggests that the mean trend model must have captured and infused all the observed key and major local trends in the model. Unlike the mean trend model, the linear trend model failed to explain the desired variation observed in cotton production trend. This is because time series do not always correlate linearly to trend during the entire sample period. The estimates of the linear and grafted functions in table 1 were utilized to obtain ex-post forecasts of cotton production in the study area. The numerical ex-post values of cotton production were used to forecast the trends over the 2006 – 2013 sub-period as retained in the analysis (Table 2). This was based on the linear and grafted models. The result of ex-post forecastof production and supply trends among cotton farmers revealed that the grafted function provided better estimates of cotton production during the sub-period. The values of the grafted (mean) function of 123,000 tons were closer to the observed values of 129,000 tons resulting in smaller difference during the sub-period (2006-2013) under consideration when compared with linear values of 137,000 tons.This is due to the fact that, the grafted (mean) function entrenched the key and major observed local trends in the forecasting framework which has enhanced a more relevant time series prediction over the entire sample period. This type of forecasting may be useful for policy makers and agricultural administrators in planning for future cotton production based on the available information of the past periods.
The result of this work agrees with that of Rahman and Damisa (1999) in forecasting performance of a grafted model on cowpea price in Zaria area of Kaduna State, Nigeria. The result revealed that, the mean trend model predicted better than the linear model because the mean trend model was built on the principle that past local trends in the observed time series (linear, quadratic, exponential etc.) have been incorporated into the body for forecasting immediate future values. This had helped to achieve a more relevant time series prediction that provided appropriate flexible and useful policy guide especially in cases where forecasts are obtained based on estimation. In the same vein, the result of this analysis is in agreement with the work of Oyakhilomenet al. (2013) who estimated the numerical ex-post forecast of rice consumption in Nigeria using the structural parameters of the linear and grafted models to determine their predictive performance with the linear model utilized as a benchmark. The result of their work showed that, the estimates of the grafted model were closer to the observed rice consumption trend in comparison with the estimates of the linear model.
CONCLUSION AND RECOMMENDATIONS
Economic time series data were used in order to estimate the possible production and supply trends. In the application of the grafted polynomial model used to forecast cotton production trends, the estimates of the linear and grafted functions were utilised to obtain ex-post forecast of cotton. The values of the grafted (mean) function of 123,000 tons were closer to the observed valueof 129,000 tons resulting in smaller difference during the sub- period (2006-2013) under considerationwhen compared with linear value of 137,000 tons during the same period. Based on these results the following recommendations were made.
• Provision of sufficient incentives by government in terms of inputs and timely inputs delivery system through private inputs voucher distribution network will enhance production.
• Intensive research and extension programme are required to disseminate and increase the level of awareness of farmers on the need to adopt and use improved cotton production technological packages.
• Formation of organized statutory market such as commodity Marketing Corporation and fixing of guaranteed minimum prices by government will encourage farmers to improve on cotton production.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles arecited 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.
APPENDIX I: QUADRATIC-QUADRATIC-LINEAR POLYNOMIAL FUNCTION
The suggested quadratic-quadratic-linear (Q-Q-L) function is of a graphical form shown below:
APPENDIX 2: COTTON PRODUCTION TREND IN ZAMFARA STATE, NIGERIA (1995 – 2013)
APPENDIX 3: GRAFTED POLYNOMIAL MODEL
This summary presents the derivation of the reduced form of expressions in coefficients ao , a1 , bo and b1 in the grafted polynomial model. These were presented earlier in the study as equations (28) – (31). For ease and simplicity, it is convenient to start our derivations with equation (29) and making b1 the subject of the formula.
Englishhttp://ijcrr.com/abstract.php?article_id=473http://ijcrr.com/article_html.php?did=4731. Adubi, A. A. (2001). Agriculture in the Nigerian Economy. Being a Paper Presented At the Workshop on Planning and Management of Agriculture Sector, August 14 – 25, Organized by Nigeria Centre for Economic Management. (NCEMA), Ibadan.
2. Batterham, R. (2000). The Chance to Change. Discussion Paper by the Chief Scientist Camberra, African Summit, Abuja, Nigeria.
3. Central Bank of Nigeria (CBN), (2011). Estimated Output of MajorAgricultural Commodities. Annual Report.
4. Central Bank of Nigeria (CBN), (2011). Gross Domestic Product at 1990 Constant Basic Prices. Central Bank of Nigeria. Annual Report.
5. Fuller, W. A. (1969). Grafted Polynomials as Approximating Functions: In Australian Journal of Agricultural Economics. 35- 46.
6. National Bureau of Statistics (NBS), (2011). Nigeria Gross Domestic Product at 1990 Constant Basic Prices.
7. National Population Commision (NPC), (2006). Population Census of the Federal Republic of Nigeria. Analytical Report at the National Population commission, Abuja, Nigeria.
8. Philip, D. O. A. (1990), Grafted Polynomials as Forecasting Functions: Application to Cotton Production in Nigeria 1(1): 103-108.
9. United Nations Population Fund (UNFPA), (2013). Available on-line @http: Nigeria. unfpa.org/zamfara.html. Retrieved: 05/12/2013.
10. United State Department of Agriculture. (USDA), (2011). Nigeria Cotton Production by year.http://www.indexmundi.comAccessed, 02/09/2011.
11. Yakubu, A.A. (2005). Risk and Risk Management in Cotton Production among Farmers in Zamfara State, Nigeria. Unpublished M.Sc. Thesis Submitted to the Department of Agricultural Economics, Usman Dan Fodio University, Sokoto, Sokoto State, Nigeria.
12. Zamfara State (2010). www.zamfarastate. etAccessed Jan. 2013.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareKNOWLEDGE, ATTITUDE AND PRACTICES OF MEDICAL STUDENTS REGARDING ORGAN DONATION
English7477Sahana B.N.English Sangeeta M.EnglishIntroduction: Medical advances have resulted in transplant surgeries today that are very successful. The demand for organs for transplantation continues to vastly surpass the inadequate supply capacity all over the world.Healthcare professionals are the key link in the organ procurement process.Healthcare professional’s knowledge, attitude and practices are essential factors in fostering an environment that positively influences organ donation rates.
Materials and Method: A total of 141first year Medical students were included in the study. Data of this cross sectional study was collected by self-administered questionnaire.
Results and Conclusion: Percentage of correct responses was calculated to assess the knowledge, attitude and practices and we documented the limitations in knowledge and practices regarding organ donation in first year medical students. The need of the hour is to introduce the subject at an early stage in medical curriculum to bridge the gap that exists in their knowledge on the same.
EnglishOrgan, Campaign, Donor, RecipientINTRODUCTION
Organ transplantation is a story of remarkable achievement and an ongoing challenge1 . Medical advances have resulted in transplant surgeries today that are very successful. Organ transplantation has become the preferred treatment for many terminal end stage organ diseases. Very often the best solution is to replace the damaged organ with the healthy one 2 . Organs are donated by individuals at the time of their death and some by living donors. Organs that are damaged and non-functioning due to accidents, burns, and illness as a result of type II diabetes, cardiovascular disease, infections, etc. can now be replaced by using donated organs in a transplantation procedure that extends life and improves the quality of lives3 . The demand for organs for transplantation continues to vastly surpass the inadequate supply capacity all over the world. The number of patients awaiting organ donations is increasing every day. However, the number of organ donations is significantly lower than the number of patients waiting for organ donations4 . A better understanding of the barriers, facilitators and opportunities for organ donation and transplantation is needed in India. State governments are being aided by the NGO’s to establish safety systems to facilitate organ donation so as to meet the demands of the huge requirement in the country5 .Despite the positive attitude towards organ donation, the actual number of organ donors is significantly smaller than the number of patients needing transplanted organs6 . The shortage in organ supply is due to lack of awareness and correct knowledge among public, myths and misconception surrounding organ donation due to religious and cultural barriers leading to hesitancy in donation of organs5 . Healthcare professionals are the key link in the organ procurement process. Healthcare professional’s knowledge, attitudesand practices are essential factors in fostering an environment that positively influences organ donation rates 7 . Therefore enhancing a physician’s knowledge of and their association in the donation and transplantation process is achieved by educational programmes in medical schools and to achieve this goal the knowledge, attitude and practices of medical students should be assessed at an earlier stage as they are the future physicians of the country
MATERIALS AND METHOD
A total of 141first year Medical students from MVJ Medical College and Research Hospital, Bangalore were included in the study. Sample size was selected by convenient sampling and those who were present and gave oral consent were included in the study. Data of this cross sectional study was collected by self administered questionnaire. The questionnaire consists of section A with demographic information such as age, gender, religion, education. Section B included 25 questions to assess the level of knowledge, attitude and practicestowards organ donation among first year Medical students. The data was analysed using Microsoft Excel 2010. Out of 141 students 73 were females and 68 were males.The age of the study participants was between 17 to 21 years. Among 141 participants, 130 were Hindus, 4 were Muslims, 6 were Christians and 1 was a Buddhist student. All the students belonged to first year MBBS.
RESULTS
Assessment of knowledge: Percentage for the correct responses was calculated. Only 21.9% responded the organ transplantation is no more underexperimental stage. A majority of 87.9% responded that organs can be donated even after death. 68.7% responded that organs can be donated when alive. 65.2% responded that organs can be donated after brain death. 63% were aware that there is a shortage of organs for transplant. 64.5% were aware of the organ donation act. 50% responded that organs cannot be sold. 65% were aware that they need not pay to become an organ donor. Only 29% responded that there is noage limit to donate organs. 75.8% responded that organs can be donated to anyone and not just family members. Only 36.8% responded that the identity of the recipient will not be revealed to the donor family. 41% responded that organ donation will not cause any disfigurement to the donor after death. Only 7% responded that HIV patient can donate organs and 12% responded that cancer patient can donate organs. 43.9% responded that money or any other benefits should not be accepted for donating organs.
Practice of organ donation: 62.4% were aware that their religion allows organ donation. 50.3% were not aware where to register for organ donation. 9.2% had a family history of organ donation.
Attitude of the students: 57.4% were of the opinion that donated organs could be misused/ abused. 73.7% were of the opinion that an effective law to govern the process of organ
donation was needed. 86.5% were of the opinion that education about organ donation should be made a part of primary education. 76.5% were willing to motivate others to donate organs. 65.2% were willing to work in organ donation campaign. 65.2% were willing to donate organs.
The reasons given by the students who were willing to donate organs are as follows;
65(68.4%) students: Organ donation gives life to a person.
6 (6.5%)students: Influenced by reading article.
2 (2.2%)students: Friend’s family received or donated organ to others.
4 (4.3%)students: Due to other reasons.
15 (16.3%)students: Gave no specific reason for their willingness to donate.
The reasons given by the students who were not willing to donate organs are as follows;
9 (30%)students: Dislike of separation of organ from body
4 (13.3%)students: Religious restriction.
7 (23.3%)students: Objection by family.
1 (03.3%)student: Unsuitable cause of old age or disease.
7 (23.3%)students: Due to other reasons.
2 (6.6%)students: Gave no specific reason for not willing to donate organ.
DISCUSSION
The transplant of organs has become a routine surgical procedure and is no longer experimental, ironically majority of them in our study thought that it was still under experimental stage. Organs can be donated at the time of death, when alive and by brain dead patients. There is a scarcity of organs for transplantation in India and organ donation act enables people to register themselves to donate organs. The buying and selling of organs is illegal and at the same time one need not pay anything to donate his/her organ. No set age limit exists fororgan donation, knowledge pertaining to this was found to be poor among the study group. The identity of the recipient and donorare not disclosed to each other. Donation does not disfigure the body or interfere with funeral arrangements. All major religions in the country approve of organ donation and consider it a gift. HIV and cancer patients can also donate organs under certain circumstances and the knowledge regarding to this was found to be poor in the study group. Organ donation should be an act of charity and one shouldn’t accept money for the same. It was encouraging to know that 9.2% had a family history of organ donation. In our study 65% were aware that they need not pay to become an organ donor which was lower compared to study done by Juan M et al. where 95.7% correctly understood that the cost of organ donation are not charged to the donors family6 . In a study done by Donal McGlade et al. 82% responded that their religion allows organ donation and 67% responded that organs can be donated after death8 . Whereas in our study 62.4% were aware that their religion allows organ donation and 87.9% responded that organs can be donated after death. In a study done by Prasanna Mithra et al. 95.4% were aware that organs can be donated when alive9 , in our study 68.7% were aware about this. It was noted that in our study 76.5% of the first year medical students were willing to donate organ. This figure was higher compared to the study done by Nisreen Feroz Ali et al in 2013 in which 158 Medical students participated and only 45% were willing to donate organ10. In a study done by Sree T Sucharitha et al 53.5% out of 213 medical students were willing to donate organ which was lower compared to our study5 .
CONCLUSION
Our study documents, the limitations in knowledge and practicesregarding organ donation in first year medical students. The need of the hour is to introduce the subject at an early stage in medical curriculum to bridge the gap that exists in their knowledge on the same. Medical curriculum should incorporate modules specifically directed at increasing factual knowledge and addressing problems that impede organ donation. It was however good to find out that majority of the students had a positive attitude towards organ donation and such students should be further encouraged and educated about organ donation. A well informed healthcare provider will certainly play a vital role in motivating the community to donate organs.
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=474http://ijcrr.com/article_html.php?did=4741. Watson C J E, Dark J H. Organ transplantation: historical perspective and current practice. British Journal of Anaesthesia 2012;108(S1):129-142.
2. Manojan K K, Raja R, Nelson V, Beevi N, Jose R. Knowledge and attitude towards organ donation in rural Kerala. Academic Medical Journal of India 2014;2(1):25-27.
3. Hodge F S, Bellanger P, Norman C. Organ donation and transplantation: A dialogue with American Indian healers and western health-care providers. American Indian Culture and Research Journal 2011;35(3):79-90.
4. Gungormu? Z, Dayapoglu N. The Knowledge, Attitude and Behaviour of Individuals Regarding Organ Donations. TAF Prev Med Bull. 2014;13(2): 133-140.
5. Sucharitha S T, Sirki R, Dugyala R R, Mullai, Priyadarshini, Kavya et al. Organ donation: awareness, attitudes and beliefs among undergraduate medical students in South India. NJRCM 2013;2(2):83-88.
6. Juan M, Nicole M, Maria C, Omar E, Esther A. knowledge of and attitudes towards organ donation: A survey of medical students in Puerto Rico. PRHSJ 2013;32(4):187-193.
7. Mekahli D, Liutkus A, Fargue S, Ranchin B, Cochat P. Survey of first-year medical students to assess their knowledge and attitudes toward organ transplantation and donation. Transplant Proc. 2009;41(2):634–638.
8. McGlade D, Pierscionek B. Can education alter attitudes, behaviour and knowledge about organ donation? A pretest and posttest study. BMJ Open 2013;3:e00396.doi:10.1136/bmjopen-2013-003961.
9. Mithra P, Ravindra P, Unnikrishnan B, Rekah T, Kanchan T, Kumar N, et al. Perception and attitudes towards organ donation among people seeking healthcare in tertiary care centers of costal South India. Indain J Palliat Care 2013;19:83-87
10. Ali N F, Qureshi A, Jilani B N, Zehra N. knowledge and ethical perception regarding organ donation among medical students. BMC Medical Ethics 2013, 14:38 doi:10.1186/1472-6939-14- 38.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241716EnglishN2015August21HealthcareCLINICO HISTOPATHOLOGICAL STUDY OF UPPER GASTROINTESTINAL TRACT ENDOSCOPIC BIOPSIES
English7885Syed Imtiyaz HussainEnglish Ruby ReshiEnglish Gulshan AkhterEnglish Ambreen BeighEnglishBackground: Upper gastrointestinal tract is an important site for wide variety of lesions especially malignant tumors. Endoscopy in combination with endoscopic biopsy plays an important role in the diagnosis of upper gastrointestinal tract neoplasms and therefore aids in their early management.
Aim: To study the histopathology of upper Gastrointestinal endoscopic biopsies and correlate them with clinical presentation, age, sex and to find the density of Helicobacter pylori in gastritis, gastric ulcers and duodenal ulcers.
Methodology: A two and a half year observational study was carried out on 132 upper Gastrointestinal endoscopic biopsies. Endoscopic upper Gastrointestinal biopsies were fixed in 10% formalin overnight before processing. Routine Hematoxylin and Eosin stain and a special stain Giemsa was done to detect H. pylori.
Results: Out of total 132 upper Gastrointestinal endoscopic biopsies, 37 were from esophagus, 13 from Gastrointestinal junction, 75 from stomach and 7 from Duodenum. Squamous cell carcinoma was more common in esophagus (89%), adenocarcinoma in Gastrointestinal junction (61.5%) and Gastritis in 56% of patients. Dysphagia was common symptom in patients
of Squamous cell carcinoma (100%), epigastric pain in patients of adenocarcinoma (42.9%), dyspepsia in gastritis patients (71.4%). Squamous cell carcinoma, adenocarcinoma and gastritis was more common in the age group of 41-60 years with male predominance (66.7%, 84.6% and 69% respectively). Helicobacter pylori gastritis was present in 32 cases (76.1%) while Helicibacter pylori negative gastritis was present in 10 cases (23.8%). Two duodenal ulcer cases were Helicobacter pylori positive
(100%) and one gastric ulcer case was Helicobacter pylori positive (33.3%).
Conclusion: The endoscopic biopsy not only permits exact diagnosis of specific entity but also provide an opportunity to see H. pylori status and plans for specific medical or surgical therapy. However histopathological study detects mucosal lesions at an early stage especially atrophy, intestinal metaplasia and dysplasia as to prevent progress of these lesions to invasive cancer.
EnglishEndoscopic biopsies, Upper gastrointestinal tract, Squamous cell carcinoma, AdenocarcinomaINTRODUCTION
Upper gastrointestinal tract is a common site for neoplasms, especially malignant tumours. Worldwide, gastric adenocarcinoma is the second most common cancer, and carcinoma esophagus is the sixth leading cause of death.1,2 In India, according to the National Cancer Registry, esophageal and gastric cancers are the most common cancers found in men, while esophageal cancer ranks third among women after carcinoma of breast and cervix.3 Squamous cell carcinoma of esophagus is usually seen in the middle third. Squamous cell carcinomas of the oesophagus emerges mainly through a sequence of chronic-esophagitis, progressive dysplasia, carcinoma in situ, finally invasive carcinoma (Munoz et al. 1982). In the stomach, the great concern is to pick the early gastric lesions on histopathology of the gastric mucosal biopsies (early gastric cancer) that does not extend beyond the mucosa or submucosa even though there may be lymph node metastasis in contrast to the invasive gastric carcinoma which extend beyond muscularis propia where the prognosis is poor.4 Endoscopy provides numerous small mucosal biopsies to diagnose and monitor the course of a variety of gastrointestinal tumours. It allows for biopsy under direct vision and opportunity arises from improved correlation of histologic features with gross features of the disease in both early and advanced phases. Thus, the role of upper gastrointestinal mucosal biopsies for the histopathological identification of the earlier stages of various gastrointestinal tumours by endoscopy allows an early therapeutic decisions without unnecessary delay. Helicobacter pylori (H. pylori) are found more frequently within the mucus layer and in the gastric pits, on electron microscopy the organisms are adherent to the surface epithelial cells. The organisms are often visible on Hematoxylin and Eosin staining, though are more easily seen with a Giemsa stain, which is useful in detecting small numbers. Warthin Starry Stain demonstrates H. pylori well but is expensive and seldom used in routine work.5,6 It has been confirmed that the development of gastric cancer spans several decades sequentially starting from the H. pylori infection, development of chronic active gastritis to development of glandular atrophy and intestinal metaplasia in a subset of patients.7 The Sydney system for the classification of gastritis emphasizes the importance of topographical, morphological and etiological information.8 This system was revised at the Houston Gastritis Workshop held in 1994. The histological severity of Helicobacter pylori density, inflammation, activity, atrophy and intestinal metaplasia were graded according to the updated Sydney system.9
AIMS AND OBJECTIVES
• Study the histopathology of endoscopic biopsies of upper gastrointestinal tract.
• Study the correlation between various histopathological lesions of upper gastrointestinal tract with age, sex and clinical presentation.
• Study the Helicobacter pylori density in Gastritis, Gastric ulcers and Duodenal ulcers.
MATERIALS AND METHODS
The study was conducted in the Postgraduate Department of Pathology, Government Medical College, Srinagar on 132 upper gastrointestinal endoscopic biopsies performed at Shri Maharaja Hari Singh (SMHS) and its associated hospitals during two and half year period from January 2011 to June 2013. Brief clinical data was noted from the case records, which included the age, sex and presenting symptoms of the patients. Biopsies obtained were oriented, fixed in 10% neutral formaldehyde and routinely processed. Approximately 5μm thick serial sections were cut and stained with hematoxylin and eosin (H and E). In addition, a special stain Giemsa was performed to confirm the presence of H. pylori. For detection of H. pylori induced lesions, the surface epithelium and foveolarlumen were searched for curved bacilli in H and E. Giemsa stain was used to facilitate their recognition. Organisms were searched under oil immersion (100X). The sections were examined for various histopathological features related togastritis like chronic and mixed inflammatory infiltrates, neutrophilic activity, intestinal metaplasia, atrophy, and presence of H. pylori. The sections were also examined for the presence of malignant changes. The findings were then correlated with the age, sex, and clinical presentation.
Inclusion Criteria
• All upper gastrointestinal endoscopic biopsies performed at SMHS and its associated hospitals and referred to Postgraduate Department of Pathology, Government Medical College, Srinagar.
• Lesions present in oesophagus, stomach and up to second part of duodenum (D2).
Exclusion Criteria
• Patients presenting with lesions in the oral cavity and pharynx.
• Patients presenting with lesions beyond the second part of duodenum (D2).
OBSERVATIONS AND RESULTS
The present study included 132 upper GIT endoscopic biopsies between the period January 2011 to June 2013. The following results were observed
Dysphagia was common complaint (100%) in patients of squamous cell carcinoma, epigastric pain in adenocarcinoma patients(35.9%), dyspepsia was common in celiac disease(100%),duodenal ulcer(100%) gastritis(71.4%) patients. Out of total 42 cases of gastritis H. pylori was present in 32(76.2%) with grade 1 in 20(47.6%) and grade 2 in 12(28.6%). H. pylori was absent in 10(23.8%) gastritis patients. Out of 3 gastric ulcer cases, one (33.3%) was H. pylori present and out of 2 duodenal ulcer patients 2(100%) were H. pylori positive. Out of 32 H. pylori positive gastritis cases, 3 cases (9.4%) have chronic inflammatory infiltrate and 29 cases (90.6%) have mixed inflammatory infiltrate. While as 10(100%) H. pylori negative gastritis cases have chronic inflammatory infiltrate. Of total 32 H. pylori positive chronic gastritis, 28 cases (87.5%) show activity while out of 10 cases of H. pylori gastritis cases only 2 cases (20%) shows activity. Out of total 32 H. pylori positive gastritis, atrophy was present in 22 cases (68.75%) with mild atrophy in 20 cases (62.5%) and moderate in 2 cases (6.3%) and out of total 10 H. Pylori negative cases, 4 cases (40%) shows mild atrophy. Out of total 32 H. pylori positive gastritis cases 10 cases(31.2%) shows intestinal metaplasia with 9 cases (28.1%) of mild and 1 case (3.1%) of moderate intestinal metaplasia and out of total 10 H. pylori negative cases 4 cases (40%) shows mild intestinal metaplasia.
PHOTO MICROGRAPHS
DISCUSSION
In the present study, a total number of 132 endoscopic biopsies from the upper gastrointestinal tract were received in the Post graduate Department of Pathology, at Government Medical College Srinagar. The present study was carried out for a period of 30 months, from 1st January 2011 to 30thJune 2013. The study included 37 esophageal biopsies, 13 gastroesophageal junction biopsies, 75 stomach biopsies and 7 duodenal biopsies.
Sex distribution of all cases:
Of the 132 patients with upper gastrointestinal tract endoscopic biopsies, 26.5% were females and 73.5% were males. This was also proved by another study done by Shennak MM et al10.The male: female ratio was 2.8: 1. This gender ratio favoring males could be reflective of the fact that males are exposed to more risk factors than females and gastrointestinal malignancies are more common in males according to JC Paymaster et al11 or due to large number of male patients attending outpatient department of the hospital as compared to female patients.
Our incidence of gender ratio of adenocarcinomas matches with that of Sujata Metan et al17.
Chief complaints of all cases:
In the present study the most common complaints were dyspepsia (37.9%), dysphagia (30.3%) followed by epigastric pain (18.2%), hematemesis (6.1%), recurrent vomiting (4.5%) post prandial distension (3%). Dysphagia was common symptom in patients of SCC (100%), same was reported by Kumar MK (1973)20, Gadour et al (2004)21 Epigastric pain in patients of adenocarcinoma (35.9%), followed by dysphagia (17.9%), dyspepsia (15.4%), recurrent vomiting (15.4%). Similar symptoms were reported by Gadour et al (2004)21, Sivagamani et al (1974).22
CONCLUSION
• Squamous cell carcinoma was a common malignancy histologically diagnosed from esophagus.
• Dysphagia was a common clinical presentation of squamous cell carcinoma cases.
• Adenocarcinoma was a common malignancy histologically diagnosed from gastroesophageal junction.
Epigastric pain was a common clinical presentation of adenocarcinoma cases.
• Histologically diagnosed gastritis was common from stomach and dyspepsia was a common clinical presentation of gastritis cases.
• Histologically diagnosed chronic non-specific duodenitis was common from duodenum and dyspepsia was a common clinical presentation.
• Helicobacter pylori was seen in maximum number of gastritis and duodenal ulcer cases.
• Majority of H. pylori gastritis cases show mixed inflammation, neutrophilic activity and glandular atrophy.
Thus the endoscopic biopsy not only permits exact diagnosis of specific entity but also provide an opportunity to see H. pylori status and plans for specific medical or surgical therapy. However histo pathological study detects gastric mucosal lesions at an early stage especially atrophy, intestinal metaplasia and dysplasia so as to prevent progress of these lesions to invasive cancer.
Conflict of interests
The author(s) have not declared any conflict of interests. Source of funding There is no source of funding.
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
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