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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareULTRASOUND GUIDED FINE NEEDLE ASPIRATION CYTOLOGY IN DIAGNOSIS OF THYROID NODULE
English0108Karthikesh S.English N.S. KannanEnglish C.P. Ganesh BabuEnglish M. PalaniappanEnglishIntroduction: The prevalence of clinically palpable thyroid nodules is approximately 4–7%, but the prevalence of ultrasound-detectable nodules is 19 to 67%. FNAC is widely accepted and has become cornerstone in evaluation of thyroid nodules, because it is a simple and accurate screening test with high sensitivity and specificity in the preoperative evaluation of thyroid lesions. Ultrasound guided FNAC is the most cost-effective and accurate way to evaluate thyroid nodules.
Aim: This study was done in an attempt to identify the Sensitivity, Specificity, Positive predictive value, Negative predictive value and diagnostic accuracy of ultrasound guided FNAC of thyroid nodules and to correlate with the findings of previous authors.
Methodology: Thirty two patients with age group greater than 15 years of age presenting with thyroid nodules were included in the study. Ultrasound Guided FNAC was done for all the patients before surgery. Results of Ultrasound Guided FNAC and Histopathology were tabulated and statically analysed to identify the Sensitivity, Specificity, Positive predictive value, Negative predictive value and Diagnostic Accuracy of ultrasound guided FNAC of thyroid nodules.
Results: Female patients were dominant when compared to male patients. The mean age was 49 and 44 for female and male patients respectively. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of ultrasound guided FNAC of the thyroid swelling were 87.5%, 91.67%, 77.78%, 95.65% and 90.62% respectively.
Conclusion: In our study, ultrasound guided FNAC proved to be a better modality for diagnosing the etiology in thyroid nodules that gave a high accuracy rate of 90.62%. Further more studies are needed with the larger sample size to confirm it.
EnglishThyroid nodule, Ultrasound guided FNAC, Sensitivity, Specificity, Positive predictive value, Negative predictive value, Diagnostic accuracyINTRODUCTION
The prevalence of clinically palpable thyroid nodules is approximately 4–7%, but the prevalence of ultrasounddetectable nodules is 19 to 67%.1 Prevalence of thyroid nodules increases in frequency with age and decreasing iodine intake, history of head and neck irradiation and are more common in females.2,3,4 A family history of thyroid cancer also increases a patient’s risk to develop a thyroid nodule.5 FNAC was first reported by Manheim with the use of fine, 22-gauge needle. The elaboration of FNA by the Swedish school in the forthcoming years was crucial for the establishment of the technique and its world-wide acceptance.6 FNAC is widely accepted and has become cornerstone in the preoperative evaluation of thyroid lesions because it is a simple and accurate screening test with high sensitivity and specificity. It is considered as the gold standard investigation in diagnosis of thyroid nodules. Ultrasound guidance is being increasingly used to direct the fine needle into minute non palpable thyroid nodules or into the solid or peripheral areas of complex nodules to avoid cystic or necrotic areas, which might lead to inadequate samples.7 FNAC done under ultrasound guidance is the most cost-effective and accurate way to evaluate a thyroid nodule.8–11 This study was done in an attempt to identify the Sensitivity, Specificity, Positive predictive value, Negative predictive value and diagnostic accuracy of Ultrasound guided FNAC in diagnosing thyroid nodules and to correlate with the findings of previous authors.
MATERIALS AND METHODS
Thirty two consecutive patients presenting with thyroid nodule to the surgery outpatient department of Mahatma Gandhi Medical College and Research Institute Pondicherry during the period from 01.02.2013 to 31.07.2014 were included in the study. Cases previously diagnosed by FNAC, pregnant women and toxic nodules were excluded. Ultrasound Guided FNAC was done with the patient in supine position with slight hyperextension of the neck. Local anaesthetic was not routinely used unless requested by the patient. A 7.5-mega-hertz probe was placed on the neck perpendicular to the thyroid, allowing clear visualization of the nodule. A 23 gauge needle was used and the tip of the needle was visualized while it was being guided to the biopsy site. Once the needle was into the solid part of the nodule, 3–5 ml of negative syringe pressure was applied. The aspirate was smeared on slide and fixed in 95% ethyl alcohol for haematoxylin and eosin staining. FNAC reports were documented and correlated with post operative Histopathology report. The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were calculated statistically analyzed and documented. The results were compared with those of previous authors.
RESULTS
Out of 32 patients, 27 patients (84.38%) were females and 5 patients (15.62%) were male in this study. Female patients were dominant when compared to male patients. The mean age was 49 and 44 for female and male patients respectively (Figure 1and Table 1). Out of 32 patients, Multinodular goitre was more common than solitary thyroid nodule. Multinodular goitre was seen in 17 (53%) patients. Solitary thyroid nodule was found in 15 (47%) patients (Figure 2 and Table 2). Out of 32 patients, the benign swelling was found in 24 patients (75%) and the remaining 8 patients (25%) were found to be malignant. In case of male patients, 2 patients were malignant and remaining 3 patients had benign colloid goitre. In case of female patients, 21 patients had benign swelling and 6 patients had malignant swelling (Table 3). Ultrasound guided FNAC was done for all 30 patients. Benign colloid goitre was found in 21 patients (65.63%), papillary carcinoma in 7 patients (21.87%), inadequate sample in 3 patients (9.37%), and follicular neoplasm in 1 patient (3.12%) (Figure 4 and Table 4). Histopathological examination was done for all 32 thyroid swellings in which benign colloid goitre was found in 21 patients (65.63%), papillary carcinoma in 8 patients (25.00%), follicular adenoma in 2 patients (6.25%) and Hashimoto’s thyroiditis in 1 patient (3.12%) (Figure 5 and Table 5). Out of 17 patients who presented with multinodular goitre, 11 patients (64.70%) were benign, 5 patients (29.41%) were malignant and 1 patient (5.89%) was not reported due to inadequate sample (Figure 6 and Table 6). Out of 15 patients who presented with solitary thyroid nodule, 10 patients (66.67%) were benign, 3 patients (20.00%) were malignant and 2 patients (13.33%) were not reported due to inadequate sample (Figure 7 and Table 6). The results of FNAC showed malignancy in 7 patients in which, 4 patients were presented with MNG and remaining 3 patients presented with STN and also showed follicular neoplasm in 1 patient which was presented as MNG. The frequency of malignancy is more in MNG when compared to STN (Table 7). The result obtained by ultrasound guided FNAC was compared with the postoperative histopathology result. 3 patients showed inadequate sample on FNAC has turned to be benign in 2 patients and malignancy in 1 patient, which was papillary carcinoma. Over all, out of 32 patients, 24 patients (75%) had benign pathology and 8 patients (25%) had malignant pathology (Table 8). The Sensitivity, Specificity, Positive predictive value, Negative predictive value and Diagnostic Accuracy of Ultrasound guided FNAC of the thyroid swelling were 87.5%, 91.67, 77.78%, 95.65% and 90.62% respectively (Table 9).
DISCUSSION
There were 32 patients totally, in which 5 were males and 27 were females with the male to female ratio of 1:5.4 in this study, which correlates with KC S et al12 and in contrast with Gupta et al11 with the ratio of 1:11.1, this may be due to double the number of patients (table 10). In the present study of 32 patients who undergone ultrasound guided FNAC showed 21 were benign colloid goitre, 1 was follicular neoplasm, 7 were papillary carcinoma, 3 were inadequate samples. 3 inadequate samples were found in this study when compared to 1 inadequate sample in the study of Chandanwale et al13. The study by Gupta et al11, KC S et al12 and Rajbhandari et al14 had no inadequate sample, which is a demerit in this study. In the present study, follicular neoplasm has been diagnosed as Hashimoto’s thyroiditis in histopathology and 3 inadequate samples were diagnosed as 1 with papillary carcinoma and other 2 with colloid goitre in histopathology. (Table 11) A study done by Braga et al15, non-diagnostic and falsenegative results on conventional fine needle aspiration cytology were probably due to cystic thyroid nodules. Ultrasound-guided fine-needle aspiration cytology has been a highly effective diagnostic method for the assessment of non palpable nodules which yielded a satisfactory cytology in 94% of the nodules.15 In the study by Gupta et al, there were total of 75 patients who had undergone surgery and their histopathology results showed 42 were benign colloid goitre, 12 were follicular adenoma, 3 were hashimoto’s thyroiditis, 12 were papillary carcinoma, 3 were hurtle cell adenoma, 3 were hurtle cell carcinoma. In the study by Chandawale et al, there were total of 46 patients who had undergone surgery and their histopathology results showed 29 were benign colloid goitre, 3 were follicular adenoma, 3 were hashimoto’s thyroiditis, 5 were papillary carcinoma, 1 hurtle cell adenoma, 1 medullary carcinoma 4 follicular carcinoma and 1 was follicular neoplasm with unmalignant potential. In the study by KC S et al, there were total of patients who had undergone surgery and their histopathology results showed 20 were benign colloid goitre, 3 were follicular adenoma, 3 were hashimoto’s thyroiditis, 27 were papillary carcinoma, 1 medullary carcinoma, 1 thyroglossal cyst and 1 Graves disease. In the study by Rajbhandari et al, there were total of 24 patients who had undergone surgery and their histopathology results showed 6 were benign colloid goitre, 8 were follicular adenoma, 3 were hashimoto’s thyroiditis, 4 were papillary carcinoma and 3 were follicular carcinoma. In the present study, there were total of 32 patients who had undergone surgery and their histopathology results showed 21 were benign colloid goitre, 2 were follicular adenoma, 1 was hashimoto’s thyroiditis and 8 were papillary carcinoma. (Table 12) In the study of Gupta et al, 9 of the 12 cases of papillary carcinoma were correctly diagnosed on FNAC with the diagnostic accuracy of 75%. In the study of KC S et al, 17 of the 27 cases of papillary carcinoma were correctly diagnosed on FNAC with the diagnostic accuracy of 63%. In the study of Chandanwale et al, 4 of the 5 cases of papillary carcinoma were correctly diagnosed on FNAC with the diagnostic accuracy of 80%. In the study of Rajbhandari et al, 3 of the 4 cases of papillary carcinoma were correctly diagnosed on FNAC with the diagnostic accuracy of 75%. In the present study, 7 of the 8 cases of papillary carcinoma were correctly diagnosed on FNAC with the diagnostic accuracy of 87.5%. 1 case of inadequate. In the study by Gupta et al, there were 60 non neoplastic and 15 neoplastic lesions with a ratio of 1:4 In the study by KC S et al, there were 27 non neoplastic and 29 neoplastic lesions with a ratio of 1:1 In the study by Rajbhandari et al, there were 17 non neoplastic and 7 neoplastic lesions with a ratio of 1:2.4 In the present study, there were 24 non neoplastic and 8 neoplastic lesions with a ratio of 1:3 which is consistent with Rajbhandari et al. The study by KC S et al and Gupta et al is contrast from the present study which showed a ratio of 1:1 and 1:4. (Table 14) Gupta et al in their study had a sensitivity of 80%, specificity of 86.6% and diagnostic accuracy of 84%. KC S et al in their study had a sensitivity of 62.6%, specificity of 100% and diagnostic accuracy of 82.1%. Chandanwale et al in their study had a sensitivity of 90%, specificity of 100% and diagnostic accuracy of 87.5%. The present study had a sensitivity of 87.5%, specificity of 91.67, positive predictive value of 77.78%, negative predictive value of 95.65% and diagnostic accuracy of 90.62% which is consistent with chandanwale et al which a sensitivity of 90%, specificity of 100% and diagnostic accuracy of 87.5%. (Table 15) Izquierdo et al16 has compared cytologic diagnostic accuracy, sensitivity, and positive predictive value of Ultrasound guided FNAC and palpation guided FNAC. This study showed better results with Ultrasound guided FNAC in comparison with Palpation guided FNAC. The malignancy rate for nonpalpable thyroid nodules and palpable nodules were similar in this study. Krishnappa et al17 has compared the free-hand FNA with US-guided FNA in the evaluation of thyroid nodules. Sensitivity, specificity and diagnostic accuracy of US-guided FNA to detect neoplastic lesions were 81.81%, 92.85%, and 88%respectively, compared with free hand FNA, for which the sensitivity, specificity and diagnostic accuracy were 54.54%, 92.85%, and 76% respectively. Ultrasound guided FNAC provides a better diagnostic rate in the evaluation of thyroid lesions. Cesur M et al18 had compared palpation-versus ultrasound-guided fine-needle aspiration biopsies in the evaluation of thyroid nodules. And he concluded that ultrasound guided FNAC to be superior to palpation guided FNAC for providing more accurate cytological results. 20 dollars was the difference as cost wise. Can et al19 compared the cost-effectiveness between palpation and ultrasound-guided thyroid fineneedle aspiration. Authors concluded that universal application of ultrasound guided FNAC for all thyroid nodules is cost-effective and saves 138 Euros per additional accurate diagnosis of benign versus malignant thyroid nodular disease. The study is limited due to its small sample size, so a study with a larger sample will be needed to confirm that ultrasound guided FNAC can be used for all patients to know the etiology of the thyroid swelling.
CONCLUSION
Based on the results of our study, we have concluded that: 1. Ultrasound guided FNAC of thyroid nodules helps in taking sample from the representative part of the nodule, avoiding the cystic areas. 2. In our study, the ultrasound guided FNAC of thyroid nodule has given a sensitivity of 87.5%, positive predictive value of 77.78% and negative predictive value of 95.65%, it has yielded a high specificity rate of 91.67% and diagnostic accuracy rate of 90.62%. 3. Hence ultrasound guided FNAC seems to be a promising investigation for thyroid swellings. 4. Since our study sample is very small, further studies involving larger sample is needed.
ACKNOWLEDGEMENT
Authors duly thank the department of general surgery, Mahatma Gandhi Medical College and Research institute and Sri Balaji Vidyapeeth University, for permitting us to publish the contents of PG Dissertation of Dr. Karthikesh S. as an article in IJCRR. Authors also acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Conflict of interest: All authors declare that there is no conflict of interest.\
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4. Schneider AB, Bekerman C, Leland J, Rosengarten J, Hyun H, Collins B, et al. Thyroid nodules in the follow-up of irradiated individuals: comparison of thyroid ultrasound with scanning and palpation. J Clin Endocrinol Metab.1997 Dec;82(12):4020–7.
5. Hemminki K, Eng C, Chen B. Familial risks for nonmedullary thyroid cancer. J Clin Endocrinol Metab. 2005 Oct;90(10):5747–53.
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7. Leenhardt L, Hejblum G, Franc B, Fediaevsky LD, Delbot T, Le Guillouzic D, et al. Indications and limits of ultrasoundguided cytology in the management of nonpalpable thyroid nodules. J Clin Endocrinol Metab. 1999 Jan;84(1):24–8.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareDIAGNOSTIC DILEMMA IN RING ENHANCING LESION- A CASE REPORT
English0911Sahid Imam MallickEnglish Auriom KarEnglish Arijit SamantaEnglish Soumava MukherjeeEnglish Sneha Jatan BothraEnglish Roshni DasguptaEnglish Ritwik GhosalEnglish N.B. DebnathEnglishHere we report a 22 years old boy with fever, headache and signs of meningitis with CT scan of brain showing multiple small enhancing lesion with minimal perilesional edema seen on both sides of cerebral cortex which was initially thought to be neurocysticercosis (NCC), but diagnosed subsequently to be tuberculomas by Magnetic Resonance (MR) spectroscopy and was subsequently treated with antitubercular drugs. This case report highlights the role of strong clinical suspicion and MR spectroscopy in the conformation of diagnosis of ring enhanced lesions.
EnglishNeurocysticercosis, Tuberculoma, Ring enhancing lesion, MR spectroscopy.INTRODUCTION
Neurocysticercosis (NCC) is the most frequent parasitic infestation of CNS in the world. Also cysticercal meningitis is very difficult to distinguish from tuberculomas associated with meningitis, the two most common causes of inflammatory granulomas encountered in clinical practise and differentiation between the two is very difficult and defied conventional investigations1,2. We highlight the importance of strong clinical suspicion and MR spectroscopy in differentiating the lesions. This distinction is important because parenchymal cysticercosis is benign and self limiting condition, but tuberculomas are active infection requiring prolonged therapy that involves potentially toxic drugs.
CASE REPORT
A 21 years old boy presented with 1 month history of low grade continuous fever with frontal headache and vomiting. His symptoms increased over time and gradually became irritable with subsequent drowsiness 4 days prior to hospitalization. He did not have any episode of convulsion during this 1 month period of illness. History of contact with tuberculosis was absent. On examination he was drowsy, febrile, apart from tachycardia vital was stable. Neurological examination was positive for meningeal signs without focal neurological deficits. Other systemic examinations were normal. Chest X-Ray was normal, mantoux test was negative, serology for cysticercal antigen was negative. CT scan revealed presence of multiple small enhancing nodular lesions with minimal perilesional edema seen in both the sides of cerebral cortex, suggestive of neurocysticercosis, there was no evidence of midline shift. On ophthalmological examination there was no papillaedema, or intraocular cysticercal parasite.MRI with contrast was done which showed extensive tiny ring and nodular enhancing focal lesions with mild to moderate perilesional odema scattered in cerebral hemispheres, cerebellum and right thalamic region and mild patchy irregular enhancement in basal cisterns and few cortical sulci of both cerebral hemispheres. Till now diagnostic dilemma persisted between NCC and tuberculoma so CSF was done which showed wbc-120/mm3 with 60% neutrophil and 40% lymphocyte, protein-151mg/dl, glucose-11mg/dl, cl—94m/dl ADA was normal. TBPCR, gram stain, AFB and Indian ink stain was negative. Patient clinical condition deterioted and he became comatose. ATD (HRZE) with steroid was empirically started and MRI spectroscopy was planned, which subsequently identified lipid lactate peaks within the lesions and diagnosis of tuberculoma was considered. In the meanwhile patient responded to treatment, his conscious level improved and was ultimately discharged with ATD and steroid, and advised to follow-up in OPD. After 6 weeks CT scan was done which showed disappearance of many lesions.
DISCUSSION
The diagnostic dilemma of inflammatory granuloma and the use of MR spectroscopy to diagnose tuberculoma and importance of starting ATD early on strong clinical suspicion are highlighted from the above case. Common causes of inflammatory granuloma includes neurocysticercosis, followed by tuberculosis, toxoplasmosis, cerebral abscess, fungal lesion.3 This boy presented with fever, headache, along with meningeal signs with neuroimaging suggestive of neurocysticercosis, all lesions ≤20 mm in size with regular outline and no midline shift. Yet the patient was actually having tubercular granulomatous lesion where we expect ≥20mm lesions with irregular outline and midline shift4 . The deterioting clinical condition of our patient prompted us to review our diagnosis on following facts. NCC commonly present with seizures5, 6, but there was no seizures in our patient. Fever is also present rarely in NCC. Also in several studies it was shown that cysticercal meningitis lacks nuchal rigidity5 . Several diagnostic criteria for NCC has been proposed but none of the criteria has addressed the differentiation between cysticercal granuloma and tuberculoma and this is the most difficult clinical situation a clinician face in developing country like India. Also positive serological test may help to confirm the diagnosis of cysticercosis but negative result does not exclude it7. Here MR spectroscopy may be helpful to differentiate tuberculoma from NCC. In a study by Pretell et all8 MR spectroscopy was used to differentiate single enhancing brain lesions as due to tuberculomas or NCC, tuberculomas has ↑peak of lipids, more choline and less NAA.
CONCLUSION
CNS tuberculomas with tubercular meningitis has a very similar presentation like cysticercal meningitis and differentiating between two is difficult in our country, where both are endemic. With increase in incidence of HIV, coinfection rates have also increased. Clinical examination directed to find evidence of tuberculosis and cysticercosis elsewhere is invaluable, but when absent creates a great diagnostic dilemma. CT scan and MRI can differentiate but again are not confirmatory as in our case. So to conclude, in such case where there is a high index of suspicion, MR spectroscopy may be a non-invasive alternative to determine their etiology.
ACKNOWLEDGEMENTS
The authors like to acknowledge the help rendered by department of General Medicine and also Dr. S.P. Saha, Professor and Head of the Department of Neurology. 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=492http://ijcrr.com/article_html.php?did=4921. Clinicoradiological and pathological correlation in patient with cysticercal granuloma and epilepsy with focus on presence of parasite and edema formation. Vedantan Rajshekar, Geeta Chako et al.
2. Single enhancing ct detected lesion in immunocompetent patients. Ravindra Kumar Garg, M.D, DM neurosurg focus 2002,12 (6)
3. Sethi PP, Wadia Rd, Kiyawat DP, et al ring or disc enhancing lesions in epilepsy in India J. Trop Med Hyg 97:347-353 1994
4. Rajshekhar V, Haran RP, Prakash GS et al. Differentiating solitary small cysticercal granulomas and tuberculomas in patients with epilepsy. Clinical and CT criteria J. Neurosurg 78; 402-407 1993
5. O.H Del Brutto, J. Sotelo and G. Roman. Neurocysticercosis;a clinical handbook, Swets and Zeitlinger Lisse, The netherland 1998
6. O.H Del Brutto, R. Santibonez C, A.Noboa, R. Aguirre, E. Diaz, and TA Alarcan “Epilepsy due to NCC; Analysis of 203 patient; Neurology, vol 42, no 2, pg 389-392,1992
7. Del Brutto OH, Rajshekar V, White AC et al, proposed Diagnostic Criteria Of Neurocysticercosis, Neurology 157:177- 183;2004.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareCARBON NANOTUBES: A REVIEW OF THE CURRENT STATE-OF-THE-ART MATERIAL SCIENCE AND TECHNOLOGY TOWARDS ACHIEVING LARGE-SCALE INDUSTRIAL PRODUCTIONS AND COMMERCIALIZATION
English1218Boye T.E.English Oyekale J.O.English Arivie G.O.EnglishWe reviewed state of the art and science towards achieving large-scale industrial productions and commercialization of Carbon nanotubes’ (CNTs). It transcends their physical and chemical structure to the identification of the need for large-scale production of carbon nanotubes in enhancing manufacturing industrial processes, and potential frame work for commercialization. Solution potential with reference to the research and manufacturing industry, particularly in electronic device was x-rayed and evaluated estimating production capacity of the CNT process plant and the processes involved. The cost of manufacturing Nano-emission display (NED) device with CNTs was highlighted showing great commercial potential in this specified area. Furthermore, the viability of CNTs for possible large-scale industrial productions and commercialization was critically examined using PEST analysis.
Finally, it was concluded that, there are huge potentials for large scale industrial productions of CNTs investment both by the governments or private sectors.
EnglishCarbon nanotubes’ (CNT’s), Large scale industrial production, Flat panel display devicesINTRODUCTION
Carbon nanotubes are novel material that holds huge potential in the electronics, biomedical sensor, pharmaceuticals, aerospace and photolithography manufacturing (with direct or indirect applications in domestic, commercial and industrial products) if mass production and commercialization is done[1-5]. They form a major building blocks of nanotechnology possessing100 times the tensile strength of steel, higher thermal conductivity than pure diamond with higher electrical conductivity with copper. These properties make them outstanding engineering materials and hence they spring research interest amongst industrialist, academics, government and investors as captured in [1].
Origin of Carbon Nanotube
Carbon nanotube (CNT), discovered by Sumio Iijima in 1991 [2] in the soot of an arc discharge apparatus. The discovery of CNT ignited research on growth, characterization and application development has exploded due to the amazing electronics and extraordinary mechanical properties[3]. Thus CNT can be metallic or semi-conducting, and hence provides the potential to create semiconductor to semiconductor and semiconductor to metal junctions, useful in electronics devices. The high-tensile strength and Young’s Modulus, and other mechanical properties assured for the production of high-strength composites for structures application[3]. Siochi, et al (2003) also identified that the revolutionary design concept in future aerospace vehicles would basically rely on novel materials with extraordinary structural properties which enables significant reduction of mass and size of components to be achieved while imparting intelligence. Hence, Carbon Nanotubes (CNTs) are expected to allow this paradigm shift in design concepts. However, Siochi et al [4], pointed out that significant challenges still exist in translating these CNT properties into macrostructures needed for future aerospace vehicles.
Meyyappan and Srivastave[5], identified that researchers have been exploring CNT in the area of nanoelectronics, sensors, field-emission base displays, batteries, polymer matrix composites, re-enforce materials, electrodes, etc.
Carbon Nanotubes Structures and Properties
Basically they are two chemical structures of CNTs with the same properties; the single-wall carbon nanotubes, SWCNT and the multiple-wall Carbon nanotubes, MWCNT as shown in Figure 2. Both interesting nano-materials can either be metallic or semiconductor, depending on its chiral vector (n, m) where n and m are two integers [3].
Doudero and Gorge [6], that carbon nanotube can be synthesized in two structural forms single-wall and multiple-wall. Iijima[2] first discovered the first tubules exhibiting a multiwall structure of concentric nanotubes forming into a tube (MWCNT) and the single-wall structure by observing a single-shell structure believed to be precursor to the MWCNT. The single-wall CNT (SWCNT) can be best described as a rolled-up tubular shell of graphitic sheet shown in figure 2 which is capped at both ends by half dome-shaped half-fullerene molecules with a diameter of 1 nm which are made of benzene-type hexagonal rings of carbon atoms [5]. The multi-wall CNT (MWCNT) is a rolled-up stack sheet in graphitic and concentric cylinders, ends either capped by half fullerenes or kept open. An arrangement (n,m) used to identify each SWCNT, refers to integer indices of two grapheme unite pattern vector corresponding to chiral vector for nanotubes[4-5]. Furthermore, nanotubes are described by using one of the three morphologies: armchair, zigzag and chiral. Figure 3 shows the assembly of the carbon hexagon of the graphitic sheet with distinct chiral vectors and angles [6]. The indices of the vector determine the morphology of the nanotubes[6]
Srivavastava et al [7], in their explanation of the morphologies of nanotubes structures suggested that nanotubes of type (n,m), (in figure 3(b)), are commonly called armchair because of their shape, which is perpendicular to the tube axis and a symmetry along the axis of short unit cell (0.25nm) that can be repeated to make the entire section of long nanotubes. The nanotubes type (n,0) are known as the zigzag nanotubes, figure 3(c), because of the zigzag shape perpendicular to the axis, and they also have a short unit cell (0.43 nm) along their axes. Dresselhaus [8]argued that the variance of morphology of the nanotubes can lead to change of the properties of the nanotubes; for example, the electronic properties of an armchair are metallic. On the other hand, the electric properties of the zigzag nanotubes are semiconducting. Lau and Hui[9]believed that the behavior of nanotube structure morphologies is determined based on a mathematical model developed using the chiral vector indices.
Advantages of Carbon Nanotubes
Iijima, Mayyappan, and Siegel investigated the physical properties of carbon nanotubes and the potential to drive research and adapted the use of vibration of nanotubes as a function of temperature in calculating Young’s modulus at 1Tpa [10]. Figure 4 shows a chart comparing the tensile strength of CNT to other materials. Methods commonly used to measure elastic properties of individual carbon nanotubes include the micro Raman spectroscope [11], thermal oscillation by transmission microscope [10, 12] and application of force on a nanotube rope suspended across a pit using an atomic force microscope cantilever [13 - 15]. However, Pan et al [16] also shows that the results of tensile test experiments of the CNT rope properties and obtained an average value for each tube based on the numbers of nanotubes on the rope. The values measured have tensile modulus and strength for single-wall (SWCNTs) and multi-wall CNTs (MWCNTs), ranging from 270GPa to 1TPa and 11GPa to 200GPa respectively [9].
Yu and Lieber[17] research potentials of nanoscience and nanotechnology in chemistry, physics, materials science, engineering, and life sciences.
The Needs Analysis for Carbon Nanotubes
Carbon nanotubes have been promising for applications in large areas on consumer and non-consumer products. Consumers products such as electronics, temperature sensors, biomedical devices amongst others, non-consumers products such as in aerospace industry, lightweight manufacturing industry, research, business etc. The substantial increase of the demand of CNTs has presented major challenges of the need for industrial scale productions. Mass productions of CNT are still insignificant because of the lack of raw materials. Currently bulk production rate of SWCNTs is hovering around few kilograms per day, large-scale composite effort are nonexistent at present [5]. Table 1 show the present approximate amount produced worldwide per day.
The Need for Carbon Nanotubes in Flat Panel Display
Nanotubes have been promising in the manufacturing of flat panel display products such as flat TV screen, computer monitors, smart phones display etc. The use of carbon nanotubes in display technology has posed a new challenge to other display product such as LCD, plasma and OLED display[17]. Nano- emission display (NED) based on carbon nanotubes is basically a thin, flat cathode ray tube with thousands of electron guns at each pixel and it shows that NEDs have a promising future for use in flat panel displays [17]. However the manufacturing of NED for commercialization still faces the major challenge of availability of raw materials of CNTs to meet the lager areas of application of display panels and other products for commercial demands in the long term. Figure 11 shows the continuous rise of demand for flat panel display.
Table1 below shows approximated figures in grams per day of carbon nanotubes produced worldwide while Table 2 shows the common areas of applications and desire form of functionalization of carbon nanotubes, especially SWCNTs. The information obtained from both tables indicates that the quantity of CNTs produce per day cannot be compared to the quantity needed for large areas of applications in terms of large-scale production. Clearly there is huge demand for the manufacturing of CNTs.
However the concerns of large-scale productions of CNTs have been observed by researchers in this field. Agboola et al, Do et al[18, 20] has presented conceptual designs of CNTs process plants if implemented may be a possible solution for large-scale production of CNTs for commercialization.
Framework Solutions for CNT Large-scale Production
Possible framework solutions of the needs for large-scale production have been initiated and conceptual design delivered by Agboola et al, Do. [18, 20], and in different occasion, they both presented a conceptual design of carbon nanotubes process plant that will have the capability of producing hundreds kilograms per year. The growth technique used by both researchers is the Chemical Vapor Discharge (CVD) method which is a novel development of the CVD growth technique which establish the one (CNT-PFR process) used the high pressure carbon monoxide disproportional reaction iron over catalytic particle clusters (HiPOC reactor), and the other (CNT-FBR process) used catalytic disproportional carbon monoxide over a silica supported cobalt- molybdenum catalyst (CoMoCAT reactor). The tables below show the capability of both HiPOC and CoMoCAT process plants of CNTs [18].
Research on Commercial and Demand forecast of Carbon Nanotubes
The outcome of the research on commercial and demand of carbon nanotubes shows realistic market potentials of the state-of-art material and economic viability its products.
Forecast Demand Curves
The information obtained from the demand graph in Figure 14is as follows: Demand for research and commercial sectors in short and long term; the demand curves to the right with time; indicated that demand becomes less inelastic with time and at lower price, this, indicates market potential in future.
However, figure 15 below shows an approximate forecast of the numbers of companies into the market and it was estimated base on the past trends and the average production rate is determined from the market research.
Supply Forecast and Market Equilibrium
Figure 16 and 17, graphically illustrates the forecast of supply curves, quantity of large-scale production of carbon nanotube to market price.
This forecast supply curves is assume to be linear and it is estimated base on the projected numbers of companies’ entry into the market by 2015, with average production increase by 10% per year. This indicates potential of steady increase in supply in future market.
Nano Emission Display Flat Panel
According to Motorola’s “Motorola’s Nano Emission Display (NED) technology is demonstrating full colour video with good response time,” Barry Young, the CFO of Display Search, states that “According to a detailed cost model analysis conducted by our firm, we estimate the manufactured cost for a 40-inch NED panel could be under $400” [21].If compared to other flat panel display products such as plasma and light-emitting diode (LED) on the market today’s. Nano-emission displays (NED) based carbon nanotube would be significantly cheap to manufacture. The low costs of manufacturing NED will have potential low market price as well and perhaps dominate the market segment of flat display panels.
Therefore, Presumably Nano-emission display (NED) will have very large market segment in display components such as smart phones, computer monitors, large display screens, and related display applications due to its outstanding features and opportunities of the product and as well the superior electron properties of the material carbon nanotube.
DISCUSSION
It is obvious that research carried out on this novel material since itsfirst discovery [2] has opened new era of exploration of carbon and its isotopes and materials sciences in general due to its composites. Thus, critical appraisal of nanotechnology and carbon nanotubes arises, it will be appropriate to employ the school of thought ‘PEST’ an acronym for the following words: Politics, Ecology, Sociology/Economic and Technology respectively for appraisal.
Politics of CNTs Large-Scale Production Carbon nanotubes have not only caught the interest of scientists, researchers, investors, engineers but also governments [24]. The government of some western countries, especially the United States of America (USA) have invested billions of dollars in research and development (R and D) program of Nano-science, Nano-technology and the buildings blocks (carbon nanotubes and carbon nanowires) through governmental R and D agencies like National Aeronautic Space Administration (NASA), National Nanotechnology Initiatives (NNI) and a host of other governmental and private research agencies. According to the NNI Nano-science, Technology and Engineering Handbook 2007, it states that. The American Government believes that significant breakthrough of nanotechnology will enhances economic creativities and democratization in the present time and more in the future. This positive attitude of the USA in this regards will no doubt inspire more developed countries to key into, and developing countries to be abreast with the carbon nanotubes development challenges in order for them to contribute their quota as well.
Ecology (Environment) of CNTs Large-Scale production
This emerging technology and the production and manufacturing of carbon nanotubes could be relatively ecofriendly. The environment must be carefully considered due to climate change (global warming) experienced on the Earth, probably caused by human activities such as indiscriminate burning of large amounts of hydro-carbons into the atmosphere. Agboola et al[18] stated that, in the conceptual design of the carbon nanotube process using two CVD methods to product CNTs for industrial scale, these processes are energy intensive and emits significant amounts of carbon dioxides of about 2700kg/h. This will definitely increases the greenhouse gases in the atmosphere. Thus, Xu et al[22], claims that “sustainable development in the concept should be developed to meet the needs in the present without compromising the future to meet the needs” therefore, a sustainable solution was devised, ensuring that the carbon dioxides produced from the industrial processes could be utilized as a raw material in other carbon dioxide processes, for example production of urea and methanol, amongst others reported [22]. In effect, the utilization of carbon dioxides emission from the CNTs processing will not only make carbon nanotube processes significantly eco-friendly but reduce the costs of production, because the resources needed to control the carbon dioxides released into the atmosphere by the industrial processes of CNT production can be utilized by re-investment into the industrial processes for continuous improvement of the processes and technology.
Sociology/Economic of CNTs Large-Scale production
Nanotechnology and carbon nanotubes have demonstrated flexibility and integration into multiple disciplines from science, technology and economics. This can be justified by the high numbers of application areas such as Nano-science, Nano-biomedical, Nano-electronic, Nanosuper computer etc. [23]. The formulation of NNI is basically to create a platform of an interdisciplinary nanotechnology community to facilitate R and D infrastructures that will constitute significant growth. This initiative will attract thousands of professional and NGOs contributors that will constitute wide participation thereof. So it has become an alternative to the centralized approach in the United States. But apart from Japan and United Kingdom which have contributed little to in this respect. Other nations of the world probably have not done significant campaign on the state-of-the-art material [24].The major economic issue with CNTs is the costs of manufacturing for various applications for commercialization; therefore, the potential for batch productions of CNTs may significantly reduce the manufacturing costs for carbon nanotubes commercialization initiatives.
Technology of CNTs Large-Scale production Nano-technology is a novel technology which revives the study of matters of atoms and molecules in their nanoscale state, and thus the manipulating of carbon atoms and molecules in nano-scales, defining its functionality for useful macro applications. According to the American National Science Foundation (NSF) and the National Nanotechnology Initiative (NNI), the definition of nanotechnology “is the ability to understand, control and manipulate matters at the level of individual atoms and molecules, as well as ‘supermolecular’ the level involving clusters of molecules (in the range of 0.1 to 100nm), in order to create materials, devices, and systems with fundamental properties and functions because of their small structure”. or the case of flat panel display, nano-emission display (NED) technology based on carbon nanotubes has presumably fulfilling the anticipated future of nano-based electronics applications with the feature of lager size components but lighter weight, smaller components but smarter, low energy consumptions and probably cheaper. Motorola has successful design and built a prototype of NED that “outperform today’s flat-panel televisions are ready to move out of the lab and into factories” [19].
CONCLUSION
This study carried out a critical review on the current state-of –art material science and technology towards achieving large-scale industrial productions and commercialization of Carbon nanotubes (CNTs). The following conclusions were being drawn:
• A promising engineering material for modern technological devices, which have shown significant level of progress in the past decade. Following the continuous development of their extraordinary mechanical and unique electronic properties, provides the opportunities for stateof-the-art applications that will break the jinx for large-scale production for commercialization that will amount to wealth creation.
• Initial breakthrough for large-scale production for commercialization has been achieved. For example, the developed consumer’s product like Motorola’s Nano emission displays technology of full colour flat display panel prototype and with the developed detail design of CNTs production process plant.
• For private investors, there is high potential for returns on investment (ROI) in short term and long term. And also, governments have nothing to lose by investing significantly into the developmental strategies that would results into large-scale production. Hence, huge investment by governments shall be beneficiary overall. This will definitely contribute to the reduction of unemployment, improvement of nation’s defense strategies, and facilitating robust research and development (R and D) communities of Nano science and Nanotechnology locally and internationally.
Finally, it would be safe to end this conclusion section, in recognition of the huge potentials for large-scale industrial productions and commercialization of CNTs. Tangible investment both by governments or private sectors will change the status quo of production challenges and take advantage of Nano-science and Nano-technology trend.
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=493http://ijcrr.com/article_html.php?did=4931. P. Holister, T. E. Harper and C. Román Vas, 2003, NANOTUBES White Paper CMP Científica.
2. S. Iijama, 1991, Helical microtubes of graphitic carbon. Nature, 354(6348):56-58. 3. M. Mayyappan, 2004, Carbon nanotubes: science and applications, CRC press, Boap Raton FL
. 4. E. J. Siochi, P. T. Lillehei, K. E. Wise*, C. Park* and J. H. Rouse* 2003, Design and characterization of carbon nanotube nanocomposites, Advanced Materials and Processing Branch NASA Langley Research Center Hampton, VA 23681 *National Institute of Aerospace Hampton, VA 23666.
5. M. Meyyappan, and D. Srivastave, 2007, Carbon Nanotubes-Functional structures: Hand book of Nanoscience, Engineering and technology Ames NASA research center Vol.2 pp.722- 751.
6. W. Doudero and K.E. Gorga, 2007, Carbon nanotubes-Textile Nanotechnologies: Hand book of Nanoscience, Engineering and technology Vol.2 pp 680-689.
7. D. Srivastava M. Menon, C. Kyeongyae 2001, Computational Nantechnology with carbon nanotubes and fullerenes. Computing in Sciences and Engineering (CISE), 3(4) pp.42-45.
8. M.S. Dresselhaus, 2004, Electrical, thermal and mechanical properties of carbon nanotubes. Philtransroy sol soc London A 362(1098):2065-209.
9. K.T. Lau and D. Hui, 2002, The revolutionary creation of advance materials- Carbon nanotubes composites. Port B.Eng 33(4):263-277.
10. M.M.J. Treacy, T.W. Ebbeson, 1996, Exceptional high Young’s modulus observed for individual carbon nanotubes. Nature, Vol.381(6584): pp.78-680.
11. O. Lourie, D. M. Cox, and H. D. Wagner, 1998, Buckling and collapse of embedded carbon nanotubes Physics Review literature Vol. 81 (8):1638-1641.
12. A. Krishram, 1998, Young’s modulus of single-walled carbon nanotube, Physics Review literature Vol. 58(20):10413- 14019.
13. J. P. Salvetat, G. Briggs, J.M. Bonard, R. Basca, A. Kulik, T. Stöckli, N. Burnham and L. Forró.1999, Elastic and shear moduli of single-walled carbon nanotubes rope. Physics Review literature Vol. 82(5): 944-947.
14. D. A. Walters, L. M. Ericson, M. J. Casavant, J Liu, D.T. Colbert, K.A. Smith and R.E. Smalley 1999, Elastic Strain of freely suspended single wall carbon nanotube ropes Physics Applied Physics Letters Vol.74(25):3803-3805.
15. F. Li, H. M. Cheng, S. Bai, G. Su, and M. S. Dresselhaus, 2000, Tensile strength of single walled carbon nanotubes directly measured from their macroscopic rope. Applied Physics Review literature Vol.77(20):3161-3163.
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17.G. Yu, and C.M. Lieber, 2010, Assembly and integration of semiconductor nanowires for functional nanosystems, Pure Appl. Chem. 82, 2295-2314. 4.
18. E.A. Agboola, R. W. Pike, T. A. Hertwig, and H. H. Lou, 2007, Conceptual design of carbon nanotubes processesclean technology Vol. 9 pp. 89-311.
19.http://nanotechweb.org/cws/article/tech/22244
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareELONGATED STYLOID PROCESSES OF HUMAN DRIED SKULLS OSTEOLOGICAL STUDY - RESEARCH ARTICLE
English1921Raju SugavasiEnglish Moula Akbar BashaEnglishExistence of abnormal elongated styloid process is rare, traumatic fractures of this may entrap the neurovascular structures anatomically surrounding it. Aim: We conducted an osteological study in 100 human dried skulls to find out elongated styloid process, Results: found only one unusual case of elongated styloid processes situated bilaterally. Conclusion: Awareness on this kind of bilateral variation is useful to the surgeons for better diagnosis and treatment.
EnglishStyloid processes, Elongation, SkullINTRODUCTION
Styloid process is a slender bony projection extending from anterio inferior aspect of the temporal bone, with an average length of 2.5 cm. Anteriolateral surface of the base of styloid process is ensheathed by tympanic plate and distal part is attached by muscles and ligaments. The process is covered laterally by parotid gland, stylohyoid ligament connects tip to the lesser horn of hyoid bone. Styloglossus, stylopharyngeus and stylohyoid muscles take origin from anterior, medial surface and the tip in respect to Styloid process. The facial nerve crosses the base and external carotid artery crosses the tip of styloid process within the parotid gland (Gray’s) [1]. The symptoms, diagnosis and treatment associated to abnormal elongated styloid process were first described by eagle (Eagle, 1962) [2]. The normal length of Styloid process is 5 to 50 mm, but according to some authors more than 30 mm length was considered as elongated styloid processes (Skrzat et al, 2007) [3].
MATERIALS AND METHODS
The present study was conducted in Osteology section of department of anatomy at Rajiv Gandhi institute of medical sciences (RIMS), Kadapa, Fathima Institute of Medical sciences (FIMS), Kadapa and Viswabharathi Medical College Kurnool, Andhra Pradesh, India. In this present osteological study we were searched for elongated styloid process in 100 human dried skulls but we found bilaterally elongated styloid processes in only one skull. The measurements were taken from base to tip by measuring tape and the length of styloid process was 6.5 cm on right side and 5.9 cm on left side (Figure 1 and Figure 2). These processes were extending downwards forwards but with more of medial deviation, which may aggravate the symptoms. Existence of bilateral variation of elongated styloid process is very rare, but has much clinical significance.
RESULTS
The present osteological study was found only one unusual case of elongated styloid processes on either side bilaterally among 100 dried human skulls. The incidence of existing variation is 1%.
DISCUSSION
The styloid process is derived from the second branchial arch. Apex of the styloid process and lesser cornu of hyoid bone are connected by stylohyoid ligament. This ligament represents as continuation of the styloid processes apex embryologically, styloid processes, lesser cornu of hyoid bone, stylohyoid ligaments are called as styloid chain (Reichert’s cartilage), and the whole chain derives from four cartilages embryologicaly, tympanohyale, stylohyale, ceratohyale, and hypohyale (Standing S., 2004) [4].
The styloid process is generally composed of dense connective tissue but may retain its embryonic cartilage and the possible for ossification (Rodriguez Vazquez JF et al, 2006) [5]. There are many cases of unilateral elongated styloid processes already previously reported, so the presence of the above said is very frequent (Scaf et al, 2003) [6]. Bilateral variation reported in the present case is rare as there were only few authors who reported it, that too recently. (Rathee et al, 2010) [7] reported it in 50 yrs old female by MRI scan (Length was 3.8 cm on right and 4 cm on left side), According to (Sanjeev iranna kolagi et al, 2010) [8] the total length of process is 8 cm and (Padeyappanavar KV et al, 2010) [9] the incidence was 3 out of 40 skulls. (Cawich et al, 2009) [10] reported bilateral elongation was seen in 75% of cases and occurrence was four times more in males than females. Various studies and theories were proposed for the occurrence of elongated styloid processes. According to (Camarda et al, 1989 and Ferrario et al, 1990) [11] ossification of stylohyoid ligament may lead to this asymptomatic variation although frequency varies (2-4% to 84.4 %). According to (Murtagh et al, 2001) [12] elongated styloid process was due to persistence of stylohyal cartilage, calcification of stylohyoid ligament and abnormal growth of bony tissue at the insertion of stylohyoid ligament. According to (Langlais et al, 1986 and Gossman et al, 1977) [13] elongated styloid process may produce symptoms like throat pain, foreign body sensation in the pharynx, otalgia, headache, dysphasia, pain while rotation of neck, , vertigo, syncope and facial pain. It also reduces the range of mandibular opening, changes the voice and taste with hyper salivation. Fracture of ossified stylohyoid ligament due to trauma or spontaneous is one of the causes for symptoms, only nine such cases were reported so far according to (Blomgren et al, 1999) [14].
CONCLUSION
Bilateral elongated styloid processes of human dried skulls were rarely present, so traumatic fractures of this may entrap the neurovascular structures anatomically surrounding it. Awareness on this kind of bilateral variation is useful to the surgeons to improve the diagnosis and treatment.
ACKNOWLEDGEMENTS
The authors are grateful to previous publishers of all those articles, journals and books from where the present literature has gathered and also for technical support.
Englishhttp://ijcrr.com/abstract.php?article_id=494http://ijcrr.com/article_html.php?did=4941. Standing S. Gray’s Anatomy. 2005. The Anatomical basis of clinical practice. 39th Ed Skull and Mandible. Edinburg. Elsevier Churchill Livingstone: 470.
2. Eagle WW. 1962. The symptoms, diagnosis, and treatment of elongated styloid process. Am Surgery, 28:1-5.
3. Skrzat J, Mroz I, Walocha J, Zawilinski J, Jaworek JK. 2007. Bilateral ossification of the stylohyoid ligament. Folia Morphol. 66(3):203-206.
4. Standing S. Gray’s Anatomy. 2005. The Anatomical basis of clinical practice. 39th Ed Skull and Mandible. Edinburg. Elsevier Churchill Livingstone: 470.
5. Rodriguez-Vazquez JF, Merida-Velasco JR, Verdugo-Lopez S, Sanchez-Montesinos I, Merida-Velasco JA. 2006. Morphogenesis of the second pharyngeal arch cartilage (Reichert’s cartilage) in human embryos. J Anat. 208: 179–189.
6. Scaf G, de Freitas DQ, de Castro Monteiro Loffredo L. 2003. Diagnostic reproducibility of the elongated styloid process. J Appl Oral Sci. 11: 120–124.
7. M. Rathee, A. Hooda, S.P.S. Yadav, J.S. Gulia. 2010. Bilateral Elongated Styloid Process: A Case Report and Review of Literature. The Internet Journal of Otorhinolaryngology. 12 (1). DOI: 10.5580/902.
8. Sanjeev iranna kolagi, Anita Herur, Ashwini Mutalik. 2010. Elongated styloid process – report of two rare cases. International Journal of Anatomical Variations. 3: 100–102.
9. Kiran V.Padeyappanavar, P.S. Bhusareddy and A.S. ?agaleekar.2010. Case Report on Elongated Styloid Process. Al Ameen J Med Sci. 3(1):99-101.
10. Cawich SO, Gardner M, Shetty R, Harding HE. 2009. A post mortem study of elongated styloid processes in a Jamaican population. The Internet Journal of Biological Anthropology; (3):1.
11. Camarda AJ, Deschamps C, Forest D. 1989. Stylohyoid chain ossification: A discussion of etiology. Oral Surg Oral Med Oral Pathol . 67: 512-520.
12. Murtagh RD, Caracciolo JT, Fernandez G. 2001. CT findings associated with eagle syndrome. AJNR Am J Neuroradiol. 22: 1401–1402.
13. Langlais RP, Miles DA, Van Dis ML. 1986. Elongated and mineralized stylohyoid complex: A proposed classification and report of a case of Eagle’s syndrome. Oral Surg Oral Med Oral Pathol. 61: 527-532.
14. Blomgren K, Qvarnberg Y, Valtonen H. 1999. Spontaneous fracture of an ossified Stylohyoid ligament. Journal of Laryngology and Otology. 113:854-855.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareCHRONIC TELOGEN EFFLUVIUM - A SHORT REVIEW
English2224ShashikantEnglish Veeresh DyavannanavarEnglish Sidramappa R. WaradEnglishDiffuse hair loss is a common complaint which dermatologists can come across in daily clinical practice. Women present more frequently with this complaint. Chronic telogen effluvium is a diffuse, generalized form of hair loss of unknown cause which is common in middle aged women. It often starts abruptly and is alarming to the patient as large number of hair are shed.
EnglishHair loss, Chronic telogen effluviumINTRODUCTION
Chronic telogen effluvium (CTE) was first described by Whiting DA in 1996.1 It is characterized by an abrupt onset of diffuse hair loss of scalp persisting for more than six months. This condition predominantly affects healthy women in their fourth to fifth decade of life.2 It may be primary chronic telogen effluvium or may be secondary to various causes.3
Epidemiology
The exact incidence of CTE is not known. Garcia-Hernandez MJ reported an incidence of 67% in post-menopausal women out of 109 females of CTE.4
Etiopathogenesis
Most cases of CTE are primary or idiopathic. However, it may also occur secondary to various systemic causes. Various causes of secondary CTE areas follows:
- Iron deficiency. - Hypothyroidism and hyperthyroidism.
- Protein energy malnutrition.
- Zinc deficiency.
- Chronic renal failure.
- Liver failure.
- Systemic lupus erythematosus and other connec
- Systemic lupus erythematosus and other connective tissue disorders.
- Drugs (Heparin, colchicine, methotrexate)5,6
- Diabetes mellitus.5
Iron deficiency is the most common cause one can come across as compared to others.6 The exact pathogenesis of chronic telogen effluvium is uncertain, but it may be due to shortening of the anagen phase of the hair cycle without miniaturization of hair follicles, synchronization phenomena of the hair cycle or premature teloptosis.1,3,6 It has been suggested that shedding is not noticeable until the length of anagen phase is reduced by 50%, with a subsequent doubling of telogen hair. The patient should be assured that this type of shedding will not lead to baldness.6,7
Clinical features
Chronic telogen effluvium may be triggered by an acute telogen effluvium. In primary CTE no specific triggering agent is evident. It predominantly affects women.6 The presentation of this type of hair loss tends to be distinctive.6 The typical patient is an otherwise healthy woman between 30 to 50 years with dense scalp hair (figure 1).1,6,8 It is characterized by abrupt, excessive, alarming, diffuse shedding of hair that runs a fluctuating course over several years.1,6,8 Patient often gives history of long hair during childhood, suggestive of a long anagen phase, and they report a high density of hair prior to the onset of hair loss.8 Patients insist that previously they had more hair and are distressed by the prospect of going bald. Many patients frequently bring large ball of hair for showing to clinician. However, no clinically obvious finding can be established. This condition tends to run a fluctuating course, at times reflecting seasonal periodicity in the growth and shedding of the hair with a maximal proportion of telogen hair at the end of summer and beginning of autumn. In the long run, the disorder appears to be self-limiting. It is of importance to reassure the patients that this condition represents exaggerated shedding rather than actual hair loss.6 Chunks of hair are usually seen in the bathroom, pillow, hair brush and comb. Usually patients will display a hand-full of hair to corroborate the complaint of excessive shedding (figure 2). Thinning of hair is not a feature of CTE, though many women do notice 50% reduction in ponytail thickness. Family history of androgenetic alopecia is usually absent.8
On examination moderate to severe bitemporal recession may be seen.1 There is no widening of the central part, as common in androgenetic alopecia. Hair pull test is usually positive over the vertex and occipital scalp.8 Diagnosis of CTE cannot be excluded by one single negative hair pull test.8 If the insult is prolonged and/or regularly repeated, it results in diagnostic difficulty.3 Investigation Histopathological picture is normal except for a slight increase in the telogen hair follicles.1 To exclude androgenetic alopecia scalp biopsy is usually required.3 The biopsy should be at the level of sebaceous gland.9 Normal terminal to vellus hair ratio is 7:1. A ratio of more than 8:1 is considered as diagnostic of CTE.9 In a study conducted by Sinclair R in 2002, out of 305 women with chronic diffuse hair loss, 54(18%) were diagnosed as CTE, 181(59%) were as FPHL and 70(23%) showed intermediate features on single horizontal biopsy.10 Iron deficiency has been reported in majority of women complaining of diffuse hair loss, but this probably has been overestimated.
Differential diagnosis:
Acute telogen effluvium and female pattern hair loss (FPHL) are important differential diagnosis of CTE. It can be differentiated with acute telogen effluvium by its long and fluctuating course. Differences between CTE and FPHL are mentioned in table 1.
Treatment
If a particular cause for chronic telogen effluvium is identified, such as hypothyroidism or iron deficiency, then suitable treatment should be given. If any drug is under suspicion as the cause of hair loss, then the patient should be advised to stop taking that drug, or that has to be substituted with an alternate drug which has lesser risk of causing hair loss. If the diet is inadequate, then it should be rectified.11 It is said that CTE is a self-limiting process, which may resolve spontaneously in 3-10 years, but there is no evidence to substantiate this assertion.1 Patient is usually anxious to have some form of treatment.11 The natural history of CTE is poorly characterized and the prognosis is less certain.1 No specific drug is available for the treatment of CTE. Topical minoxidil 2% has been suggested in anticipation that it will prolong anagen growth.1
CONCLUSION
It is a diffuse hair loss of scalp persisting for more than six months. This condition predominantly affects healthy women in their fourth to fifth decade of life. Most cases are primary. Patients with CTE can however be reassured that the condition is non-progressive and self-limiting.
ACKNOWLEDGEMENT
We acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. We 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=495http://ijcrr.com/article_html.php?did=4951. Shrivastava SB. Diffuse hair loss in adult female: approach to diagnosis and management. Indian J Dermatol VenereolLeprol 2009;75:20-31.
2. Wadhwa SL, Khopkar U, Nischal KC. Hair and scalp disor- Wadhwa SL, Khopkar U, Nischal KC. Hair and scalp disorders. In: Valia RG, Valia AR, editors. IADVL Text book of dermatology, 3rd edn. Mumbai: Bhalani Publishing House; 2010.p.- 864-948.
3. Sinclair R. Diffuse hair loss. Int J Dermatol 1999;38:1-18.
4. Garcia-Hernandez MJ, Camacho FM. Chronic telogen ef- Garcia-Hernandez MJ, Camacho FM. Chronic telogen effluvium: incidence, clinical and biochemical features, and treatment. Arch Dermatol 1999;135:1123-1124.
5. Steinberg S, Ezers IA. Alopecia in women. Can Fam Physi- Steinberg S, Ezers IA. Alopecia in women. Can Fam Physician 1970;64-66.
6. Trueb RM. Diffuse hair loss. In: Blume-Peytavi U, Tosti A, Whiting DA, Trueb R, editors. Hair growth and disorders, 1st edn. Berlin: Springer; 2008.p.-259-272.
7. Chartier MB, Hoss DM, Grant-Kels JM. Approach to the adult female patient with diffuse nonscarring alopecia. J Am AcadDermatol 2002;47:818-820.
8. Messenger AG, Berker DA, Sinclair RD. Disorders of hair. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook’s text book of dermatology, 8th edn. Oxford: Blackwell Publishing; 2010.p.- 66.1-66.100.
9. Dhurat R, Saraogi P. Hair evaluation methods: Merits and demerits. Int J Trichology 2009;1:108-119.
10. Sinclair R, Jolley D, Mallari R, Magee J. The reliability of horizontally sectioned scalp biopsies in the diagnosis of chronic diffuse telogen hair loss in women. J Am AcadDermatol 2004;51:189-199.
11. Whiting DA. Chronic telogen effluvium. Dermatol Clin 1996;14:723-731.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareUTERORECTAL FISTULA MANIFESTING DURING SECOND TRIMESTER OF PREGNANCY AS MASSIVE LOWER GASTROINTESTINAL BLEEDING: IS IT A MENACE OF MTP?
English2528Papa DasariEnglishA 27-year-old G2 A1 post IVF conception, DADC twins was hospitalized at 11 weeks with a diagnosis of threatened abortion.. History documented included that she conceived soon after marriage 5 years ago and underwent MTP by surgical method (D&E) at 8 weeks of pregnancy following which she suffered from secondary infertility. Laparoscopy for evaluation of secondary infertility a year ago revealed bilateral tubal block and she was treated with ATT for 6 months elsewhere. She conceived following second attempt of IVF. At admission, she had mild bleeding and USG confirmed DADC twins with good cardiac activity and the
placenta of the first twin was posterior encroaching Os and that of second twin was also posterior wall but near fundus of the uterus .She was managed conservatively with bed rest, progesterone support and psychological support. She expelled the first fetus at 16 weeks following 18 days of leaking. Conservative management was continued. At 20 weeks she developed leaking from the second sac and developed severe pain abdomen and acute gush of bleeding per rectum. USG revealed empty uterus and the fetus outside the uterus. Emergency laparotomy with a provisional diagnosis of spontaneous rupture uterus revealed a large rent on the posterior surface of uterus and anterior rectal wall and the fetus which was in the rectosigmoid was extracted by squeezing. There was a mucus fistula between the uterus and rectum. Uterine rent was closed and colostomy was done. She was discharged home with advice to opt for surrogacy or adoption.
EnglishMedical termination of pregnancy, Secondary infertility, Bilateral tubal block, IVF, Acute gastrointestinal haemorrhage, Uterorectal fistulaINTRODUCTION
Enterouterine fistulae are very rare and around 58 cases were reported over 200 years prior to 19551 . In the later years 24 cases of colouterine fistulae were reported in English and French literature and these were due to diverticulitis in the non-pregnant state2 . Colouterine fistula presenting during pregnancy is so rare only 2 case reports are available. The following case is unique because of its clinical presentation as massive gastrointestinal bleeding during second trimester of twin pregnancy following IVF.
CASE REPORT
A 27 year old G2 A1 attended our emergency Obstetric services at 11+1 weeks of gestation with history of bleeding per vaginum of two weeks duration. Bleeding was moderate in amount and bright red in color and was not associated with pain abdomen. This pregnancy was achieved after the second attempt of IVF performed for bilateral tubal block at a private ART centre. She was on micronized progesterone support since then and it was a dichonionic and diamniotic pregnancy. Her past history revealed 5 years of secondary infertility following first trimester medical termination of pregnancy (MTP) by dilatation and evacuation (D&E) at a private hospital soon after marriage. She was investigated for secondary infertility after 4 years of MTP at another private hospital and was diagnosed to have bilateral tubal block after laparoscopy and was given ATT (Anti-Tubercular Treatment) empirically for six months.
On examination, she had no palor and was normotensive. Systemic examination was normal. Abdominal examination revealed 16 week size pregnant uterus. Per speculum examination showed minimal bleeding through os and on per vaginal examination cervix was 2 cms and os was closed. USG confirmed dichorionic diamniotic twins with good cardiac activity. CRL of twin A was 57.5 mm and twin B was 53.5 mms and the NTs were within normal limits. The placenta of twin A was posterior and was low in the cavity encroaching the OS. There was a small subchorionic hematoma. Twin B placenta was also in the posterior wall and up towards the fundus. She was hospitalised with a provisional diagnosis of threatened abortion and was managed conservatively with continued progesterone support and bed rest. Her initial investigations soon after admission were normal. Hb 11gm%; WBC 6,400 /cmm; urine culture and cervical swab culture were sterile. GTT and TFT were normal. She continued to have mild bleeding per vaginum with occasional pain abdomen and bouts of excessive bleeding and constipation on and off. She was given psychological support and required sedatives on and off. She developed leaking per vaginum 2 weeks after admission i.e., at 13+6 weeks of gestation. The first sac had no liquor and the fetus was alive but compressed. The patient was reassured and explained the possibility of spontaneous abortion/absorption of the first twin and conservative management was continued. Cervical swab culture and urine culture at this time revaled growth of E.Coli and she was treated with the sensitive antibiotic, injection Amikacin for 10 days. After 18 days of leaking pervaginum, the cord of the first fetus prolapsed and after 3 days she spontaneously expelled the placenta and the fetus. Conservative management was continued and she was receiving injection Proluton 500mg im weekly. Repeat Cervical swab culture did not grow any organisms. The follow up USG at 19 weeks revealed less liquor in the sac of the existing live fetus and after 2 days she complained of leaking per vaginum. At 19+6 weeks of gestation she had persistent pain abdomen not releived by sedatives and complained of fresh bleeding per vaginum in the midnight. She had tachycardia which progressively increased and her BP was maintained and after 4 hours she complained of sensation of passing stools and there was a gush of fresh blood on the bed. On perspeculum examination, there was minimal bleeding through cervix and Os was closed. At the end of examination, large fresh blood clot was expelled through the anus. After securing the iv access and starting intravenous fluids a gentle per rectal examination was performed which revealed a tear in the anterior rectal mucosa. Emergency surgical opinion was sought. Clinically they deferred regarding the rent in anterior rectal wall and performed anal packing with adrenaline soaked gauze. Immediate USG performed revealed empty uterine cavity and fetus lying transversely to the left of uterus. A provisional diagnosis of spontaneous rupture uterus was made and she was taken up for emergency laparotomy with General Surgeon back up after taking consent for hysterectomy and necessary procedure. At laparotomy there was 300 ml of haemoperitoneum, dense adhesions between bowel, omentum and fundus of uterus. There was a large 12x12 cm irregular rent in the posterior wall of uterus. Placenta was partially extruding through the rent and morbidly adherent to the edges. Fetus was contained wholly inside the rectum. (Fig. 1)
There was a large rent 6x6cm with irregular margins involving more than 3/4th of the luminal circumference of the lower sigmoid and rectum. There was a mucus fistula approximately 10 cm. There was a solid mass of 4x4 cm in the right ovary which was adherent to the right cornu of uterus. Right tube agglutinated and was adherent to the right lateral pelvic wall. Left fallopian tube and ovary agglutinated and fixed to left broad ligament. The fetus was extracted enmass by gentle traction and squeezing of the rectosigmoid. (Fig. 2). The uterine rent was closed in two layers with inturupted sutures using chromic catgut. Defunctioning Colostomy was performed by the Surgeons and the rent in the rectum was closed transversely with interrupted 2-0 vicryl sutures. Omentum was interposed between the rectal suture line and uterus. The mass in the right ovary was excised and the cut section revealed sebacious material with hair. Saline wash was given. Intraperitoneal drain was kept. Abdomen was closed enmass with continuous No.1 PDS. She received 4 units of packed cells and 4 FFPs. Postoperatively she was on intravenous fluids and nil per oral for 72 hours and was on intravenous antibiotics and the drain was removed after 5 days. She had febrile spikes for 10 days and workup for sepsis revealed again colonization of E. coli in cervical swab. Wound swab culture and blood culture were sterile. She was treated with injection Meropenum. Sutures were removed on day 15 and she was discharged after explaining the risks of contemplating pregnancy again and with advice to follow up in Surgery OPD for colostomy care and closure. She was counseled for adoption / surrogacy and advised against conception under any circumstances.
DISCUSSION
The common causes of bleeding per rectum during pregnancy include hemorrhoids, fissure in ano and rectal polyps.. Rare causes are arteriovenous malformations, intussusceptions, enteric fever, tuberculosis etc. A rare case of acute lower gastrointestinal hemorrhage due to ectopic pregnancy eroding the colon was misdiagnosed preoperatively as choriocarcinoma and enema prior to colonoscopy to rule out colonic causes induced massive hemorrhage and the women died of sepsis after laparotomy3 . Uterorectal fistula can also present with bleeding during menstruation (menochezia)4 in the non-pregnant state and with chorioamnionitis and post-abortal bleeding during pregnancy5 . The present case did not have history suggestive of menochezia. Massive gastrointestinal bleeding leading to shock due to uterorectal fistula during pregnancy is not found in literature search. The common causes of uterorectal fistula are diverticulitis and malignancies and rarely endometriosis. The other rare causes are radiation injury, perforation involving uterus and bowel during dilataion and curettage, pelvic surgery and polypectomy2 etc., Obstetric injury leading to enterouterine fistula was reported as the most common etiology prior to 19551 Of the causes injury due to curette was responsible for the fistulae in good number of cases and the clinical manifestations occur after few days to few months. In the present case there was history of curettage in her first pregnancy when she underwent surgical abortion and however there was no history suggestive of menochezia following this. Colouterine fistula due to endometriosis involving caecum presented during pregnancy with sepsis and biochemical DIC at 16 weeks of gestation. She needed subtotal hysterectomy and resection and anastamosis of bowel to save life because of severe uterine sepsis.5 A case of enterouterine fistula presented with recurrent early pregnancy and chorioamnionitis. She had spontaneous abortion and suffered from malena on the second post abortal day of her third pregnancy. Later she underwent laparotomy and an ileouterine fistula was found along with a piece of cartilage. The authors concluded that this fistula was due to the cartilage which she swallowed as there was no history of instrumentation of uterus in her previous pregnancy losses. In both the above cases and the present case of ours intermittent pain abdomen was present and sepsis was evident. In the present case sepsis was due to colouterine fistula and not ascending infection as her cervico- vaginal swab was sterile on admission and later after rupture of the first sac Escherichia coli was grown.
CONCLUSION
Uterorectal fistula due to uterine perforation that occurred long ago can manifest during subsequent pregnancy and the symptoms mimick those of threatened abortion. One of the acute manifestations can be sudden episode of bleeding per rectum. Closure of uterine perforation at the time of its occurrence should be undertaken to prevent fistula.
ACKNOWLEDGEMENT
I would like to acknowledge the help rendered by Dr. Manikandan, Associate Professor, Dept of Obstetrics and Gynaecology, Dr. Nandakishore, Associate professor, Department of general Surgey for the emergency laparotomy I also acknowledge all the authors of the references which I mentioned as the learning resources. They are of immense help to me to understand and write this case report.
Englishhttp://ijcrr.com/abstract.php?article_id=496http://ijcrr.com/article_html.php?did=4961. Martin DH, Hixson CH and Wilson EC. Enterouterine fistula. Obstet Gynecol. 1956; 7:466-469.
2. Uzan J,Koskas M, Fournier P, Marguiles AL, Luton D,Yazbeck C. Colouterine fistula after polymyomectomy: a Case report. Journal of Medical Case Reports. 2014, 8:199-202.
3. Ekwaro L,Kizza PM, Nassali G,Lubega J. Ectopic pregnancy: Unusual cause of lower GIT bleeding. A Case report East and Central African Journal of Surgery, 2004; 9: 5-7
4. P Pinto, L Sharma, P.Kini Chronic uterorectal fistula with menochezia and amenorrhea. IJGO.1990;
5. Siganeshan V, Willis IH, Zarate LA,Howard L,Robinson MJ. Colouterine fistula secondary to endometriosis with associated chorioamnionitis. Obstet Gynecol 2006; 107:451–3
6. Shaw FM, Renius JF, Leiken EL, Tejani N. Recurrent chorioamnionitis and second trimester abortion because of an enterouterine fistula. Obstet Gynecol.1995;86:639-641.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareEVALUATION OF PSYCHIATRIC MORBIDITY IN THE COMMUNITY THROUGH APPLICATION OF
SCHEDULE FOR CLINICAL ASSESSMENT IN NEUROPSYCHIATRY (SCAN)
English2934P. K. ChaudhuryEnglish Dhrubajyoti BhuyanEnglishBackground: Hospital based reports do not reflect prevalence of psychiatric morbidity in the community. Even the lack of knowledge and stigma associated with mental disorders cause hindrance to avail hospital services. Community based survey in a well defined sample is the right and appropriate approach for proper estimation of prevalence of such illnesses.
Aims: To estimate the prevalence of psychiatric illnesses in the community and to study the socio demographic co-relates of the positive cases.
Methods: 10% of participants from the pool of three thousand (3,000) respondents recruited for World Mental Health (WMH) Survey were selected, by using systemic random sampling method and psychopathology was tested by using the translated Assamese version of Schedule for Clinical Assessment in Neuropsychiatry (SCAN).
Results: The prevalence of psychiatric morbidity in the community was found to be 13.18%, with Alcohol Use Disorder being the most common psychiatric morbidity.
Conclusion: Alcohol Use Disorders are the commonest psychiatric morbidity (4.39%) in the study population followed by Depression (3.38%), Anxiety (1.69%) and Psychosis (1.69%). The figures reflect only the point prevalence of the diseases.
EnglishPsychiatric morbidity, Clinical assessment, Composite international diagnostic interviewINTRODUCTION
Psychiatric conditions are a growing public health concern, – they are responsible for little more than 1% of deaths and accounts for about 11% of disease burden1 . Though psychiatric conditions are well known to impose a great burden to the sufferer, family and also to the society, mental health is still the most neglected portion of the spectrum of health2 . May be due to lack of awareness and associated social stigma, patients even if they are suffering for a longer period hesitate to present to psychiatrists3 . Therefore, what we see in the clinical setup is probably the tip of the iceberg; the actual problem may be much more greater than one can anticipate. So, proper evaluation of psychiatric morbidity is a necessity for any intervention to be taken. Although there are various instruments designed to study the epidemiology of mental illness in the community, like Diagnostic Interview Schedule (DIS) (1981) and Composite International Diagnostic Interview (CIDI) (1993), which can be used by trained non-mental health professionals, the results obtained by application of such instruments may not also be able to identify the actual magnitude of the illness. However, the diagnosis made by application of another sophisticated instrument called Schedule for Clinical Assessment in Neuropsychiatry (SCAN) adopted by WHO requires trained mental health professionals and is recognized as a valid and reliable instrument. Therefore the current study attempts to estimate the prevalence of psychiatric illnesses in the community through application of this instrument. This instrument was applied in its translated Assamese version to see its applicability and any technical problem in the administration in a small-defined population.
AIMS AND OBJECTIVES
The aims and objectives of the study are
1. To estimate the prevalence of mental disorders in the community.
2. To study the socio-demographic correlates of the positive cases.
METHODOLOGY
Sample Selection: The samples for the study were drawn from a predetermined sample for another study – The World Mental Health (WMH) Survey, conducted by the WHO. The WMH study was completed in the Department of Psychiatry, Assam Medical College and Hospital, Dibrugarh in the month of October 2004. This study has the advantage of having a meticulously worked out sample of 3000 households, which was made on the basis of sample proportion to size. From this pool of 3000 households the sample for our study was drawn by using systematic random sampling method (every 10th sample). The investigators were blind about the diagnostic status of the sample, which has already been evaluated by the WMH – CIDI in the study mentioned above.
Size of the Sample: We have selected a sample of Three hundred respondents by using the method mentioned above.
Inclusion Criteria: 1. Age: 18 years and above 2. Sex: Both sexes.
Exclusion Criteria: 1. Age: Below 18 years. 2. Respondents with chronic debilitating illness.
Instruments Used: Schedule for Clinical Assessment in Neuropsychiatry (SCAN): It is an instrument for assessing, measuring and classifying major psychiatric illnesses, It was developed in the framework of the World Health Organization and the National Institute of Health joint project on Diagnosis and Classification of Mental Disorders, Alcohol and Drug related problems. It consists of four parts:
1. The Tenth Edition of Present State Examination (PSE10)
2. The Glossary of Differential Definitions.
3. The Item Group Checklist (IGC)
4. Clinical History Schedule (CHS)
PSE 10 itself has two parts, Part I covers Somatoform, Dissociative, Anxiety, Depressive and bipolar disorders and problems associated with basic bodily functions and use of Alcohol and other Substance use, while Part II contains Psychotic and Cognitive disorders and observed abnormalities of speech, affect and behaviour. The instrument was translated into Assamese and adopted after testing the inter-rater reliability which was found to be of higher order.
Place of Study: The study was conducted in the rural and urban areas of Dibrugarh District having a total population of 2,08,548 households according to the 2001 census.
Procedure: The Study was undertaken after receiving ethical clearance of Institutional ethical committee of Assam Medical College and Hospital, Dibrugarh For the purpose of the study, a SCAN trainer who had been trained in New Delhi trained five PG students from the Department of Psychiatry, Assam Medical College and Hospital Dibrugarh. Informed consent was obtained from each respondent before evaluation. Those respondents suffering from debilitating systemic illness were excluded from the study. The diagnosis was obtained by using the diagnostic algorithm of SCAN.
RESULTS
Though our original sample size was 300, 4 respondents were excluded from the study due to their debilitating physical illnesses as per the criteria. Therefore effective sample size reduced to (300 – 4) = 296. 181 male & 115 female respondents participated in the study and their age wise distribution is shown in table 1:
The study was conducted in both urban & rural areas of Dibrugarh District. As many as 255 ( 86.15%) respondents hailed from rural areas and only 41 (13.85%) were from urban area. This is depicted in table 2:
Table 3 shows marital status of the respondents participating in the study:
The educational status was measured in terms of years of formal education and the distribution of the samples according to this variable is shown in table 4:
Our study shows 13.18% prevalence on psychiatric illnesses including mental and behavioural disorders due to use of alcohol. Alcohol related mental problems alone have the prevalence on 4.38% and this accounts for about 33.33% of the total psychiatric morbidity.
Alcohol related mental and behavioural problems accounts for about 33.33% of all the psychiatric morbidity followed by Depression, which accounts for about 25.64%, Anxiety and Psychosis each contributes to 12.82% of all psychiatric morbidity.
Data analysis:
I. Analysis based on age wise distribution According to the statistical analysis based on age wise distribution of the positive cases the following results were obtained –
According to the statistical analysis co- relation between age and depression was found to be 0.230, which indicates that as the age increases the occurrence of Depression also increases and it its percentage of increment is 23%. Such type of positive co-relations were also found with Mixed Anxiety Depression, Alcohol Use Disorder, Psychosis and Dementia:
This indicates these disorders are related to age and they increase as the age progresses. However, a negative co-relation (-0.442) was found between Age and Anxiety indicating that as the Age increases prevalence of Anxiety decreases and its percentage of decrease is 44.2%, in other words Anxiety is more common in early adult ages. However, statistical analysis shows no linear co-relation between Age and Obsession. Positive co-relation was found between Years of Formal Education and Anxiety, the co-relation coefficient being 0.700. A negative co-relation of –0.705 was found between Years of Formal Education and Dementia. Obsession, Psychosis, Mixed Anxiety Depression and Alcohol Use Disorder also show a positive co-relation with literacy.
However, no co-relation was shown to occur between Years of Formal Education and Depression.
DISCUSSION
Our study shows point prevalence of 13.18% psychiatric illnesses including Alcohol Use Disorders, which is in keeping with the study- NIMH – Epidemiological Catchment Area (ECA) Programme (1984) conducted in USA, which showed 1-month prevalence of psychiatric illnesses being 15.14%4 . Alcohol Abuse and Dependence were found to be the most common psychiatric condition in this part of the country accounting for about 33.33% of all psychiatric illnesses. This is most common in males and incidentally we have not found any female alcoholic during our study, this was probably because we were handicapped with a small sample size. Depression was the second common psychiatric morbidity in the community and majority of the sufferers were the females. Though the sample size was small the detection of the cases with the help of SCAN was very meticulous and the results were in accordance with the other standard literature5,6,7. Though our study samples were drawn from the pool of respondents recruited for the WMH (World Mental Health) Survey which was done by using another instrument (CIDI) which was completed in the Department of Psychiatry, Assam Medical College, Dibrugarh during 2002 – 2004 with support from WHO and Ministry of Health, Government of India. The two results could not be compared as the data of the WMH Survey are under process of analysis at WHO headquarters, and results are yet to be published. Hopefully the two results may be compared once the WMH results are published.
Limitation:
1. Sample size was too small for a community-based study.
2. Burden of disease was not assessed.
3. Utilization of health services for various mental illnesses was not studied.
4. The study does not reflect the course of illness, as it was a cross-sectional study.
Conclusion
Epidemiological studies involving this type of sophisticated instrument are quite a few in the world and ours is one of its kinds in this part of the country. Although the sample size was small the case detection with the help of SCAN was very meticulous and the results were in accordance with the standard literature. The translated Assamese version of SCAN was found to be very useful and no technical problems during its application was met with. This study is expected to be a guide in the field of Community Based Study and inspire the future generation for a more comprehensive study in the field of Mental Health Disorders.
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=497http://ijcrr.com/article_html.php?did=4971. Murrey C J L and Lopez AD, Summary Global Burden of Disease and Injury Series Global Burden of Disease a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020 The Harvard School of Public Health on Behalf of The World Health Organization And The World Bank.
2. WORLD HEALTH ORGANIZATION (2005) Mental health: facing the challenges, building solutions Report from the WHO European Ministerial Conference WHO Regional office for Europe Scherfigsvej 8 DK-2100 Copenhagen, Denmark.
3. Stier A and Hinshaw SP, (2007) Explicit and Implicit Stig- Stier A and Hinshaw SP, (2007) Explicit and Implicit Stigma Against Individuals With Mental Illness, Australian Psychologist 42(2), 106-117.
4. Eaton WW, Holzer CE, Von Korff M et al (1984): The Design Of The Epidemiologic Catchment Area Survey; Archives of General Psychiatry: 41: 942-948.
5. Regier DA, Myers JK, Kramer M et al (1984) The NIMH Epidemiologic Catchment Area Program; Archives of General Psychiatry: 41: 934-941.
6. Robbins LN, Helzer JE, Weissman MM et al (1984): Life- Robbins LN, Helzer JE, Weissman MM et al (1984): Lifetime Prevalence of Specific Psychiatric Disorders in Three Sites; Archives of General Psychiatry: 41:949-958.
7. Dr. Kulkarni AP and Dr. Baride J P (2002): Textbook of Community Medicine, 2nd Edition; Vora Medical Publication, Mumbai.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareCHALLENGES AND FUTURE DEVELOPMENT OF PHYSIOTHERAPY EDUCATION IN NEPAL
English3542Acharya R.S. Adhikari S.P. Oraibi S.A. Baidya S.EnglishBackground: Globally, the culture of health care has been changing.The health professionals must have the best available education and training to improve the health outcomes. Good education is a backbone for an effective physiotherapy intervention and good patient care. Physiotherapy education has evolved widely in developed countries whereas in Nepal, the education has started very recently and the recognition is still under a question.
Objectives: To investigate the challenges of Physiotherapy education and to address the strategies
Methods: A modified Delphi method was used to obtain information from key informants involved in the area of physiotherapy education in Nepal. In 1st round, an open ended questionnaire on challenges and strategies of Physiotherapy education in Nepal
was sent to 20 key informants via email. In 2nd round, themes were listed , ranked in a likert scale and was mailed to the respondents. In 3rd round, the compiled final likert scale responses was mailed to the respondents for further comments.
Results: Fifteen out of twenty informants completed all three rounds of Delphi survey. The important challenges highlighted were lack of awareness, lack of job opportunities, lack of leadership of governing bodies, lack of retention of staff, lack of continuous professional development and lack of mentoring.
Conclusions: It is concluded that physiotherapy education in Nepal at its initial phase, needs a strong governing policy and leadership to facilitate a rightful place in the health team.
EnglishDelphi, Physiotherapy education, PhysiotherapyINTRODUCTION
Physiotherapy education has evolved worldwide in different ways. The development of physical therapy as an autonomous profession based on current scientific knowledge was in large part due to Per Henrik Ling of Sweden known as the “Father of Gymnastics”.1 In 1813, he founded the Royal Central Institute of Gymnastics (RCIG) in Stockholm for the training of gymnastic instructors. In the United Kingdom, Norway and Finland it was introduced through the Society of Trained Masseur, by the work of Ling and with an emphasis on massage training respectively.1 A confluence of events and developments around the world led to the formal recognition of physical therapy as a health care profession in the second decade of the 20th century. In the United States, physiotherapy was introduced as a result of the polio epidemics and the need to treat those wounded during World War I.1 Accordingly, the formal education of Physiotherapy started at different years in different countries like in US (1917)2 , UK (1894)3 ,Canada (1917)4 , Australia(1906)5 & New Zealand (1913)6 . It took decades to introduce physiotherapy education in developing countries like, Pakistan (1956)7 and Nigeria (1966)8 . In Nepal, physiotherapy services started around 30 years ago where few nurses from Bir hospital (Government hospital in Nepal) were provided physiotherapy training and they continued working as a physiotherapist. Gradually, Nepal received support from International volunteers, who started providing physiotherapy training in various hospitals. The first formal Certificate level in physiotherapy course was initiated by Ms. Mary Beatrice Martin (Canada) at the Institute of Medicine (IOM) from 1983-1990. Certificate in Physiotherapy (CPT) course was later commenced in Dhulikhel Medical Institute (DMI) at Kathmandu University (KU) from 2003 - 2009. Kathmandu University upgraded the CPT course to Bachelor of Physiotherapy (BPT) in June 2010, to bring the education of physiotherapists in line with the recommendations of the World Confederation of Physical therapy (WCPT). 9 It is seen that compared to many other countries, the physiotherapy education commenced very late in Nepal. While Nepal is struggling to produce qualified physiotherapist at Bachelor level, other countries have already evolved in producing highly qualified physiotherapist at Masters or Phd level. Physiotherapy education should reflect the health and society priorities of the nation. With the developments and rapid changes of education worldwide, Nepal needs to keep in line the development and recent advances in the education to augment a quality physiotherapy services to the nation. To improve the health outcomes, it is important that physiotherapists have the best available education and training to work in health care teams. In order to provide a quality education, it is important to look into the challenges of physiotherapy education in Nepal. So, the main objective of the study is to investigate the challenges and identify the strategies to the challenges of physiotherapy education in Nepal.
METHODOLOGY
A modified Delphi survey was conducted for the study. Ethical approval was obtained from Institutional review committee (IRC), Kathmandu University School of Medical Sciences. The Delphi method is a structured process that uses a series of questionnaires or ‘rounds’ to gather information which are continued until ‘group’ consensus is reached .10,11,12,13 It is a recognized method of deriving expert opinion to determine the degree of consensus where there is a lack of empirical evidence.13 The study maximizes the benefits of using an expert panel while minimizing the disadvantages acknowledged in the literature from collective decision-making.14 If the Delphi Survey demonstrates consensus, it provides evidence of both face and concurrent validity. Because of all these reasons, the Delphi design is adopted in this study. Modified Delphi is useful in reducing the number of rounds to increases the response rate by reducing the respondent’s fatigue.15 How much consensus to be considered is an important aspect of Delphi study. Experts agreement can differ and it would be difficult to gain 100% agreement on all issues. Literatures are evident for varied range of consensus between 50% to 100%. 16, 11 Considering our research area and literature evident on the related topic, we would like to consider the consensus from 70% (likert scale of extremely important and very important). A purposive sampling method was used for the study, where the key informants view was collected through e-mails. A total of 20 participants were included in the study. Out of 20 participants, one refused to participate and four participants did not participate in all the threerounds. Prior consent was taken via email. The modified Delphi study was conducted in three rounds. Round 1) An open ended questionnaire was formulated by the researcher as “What do you think are the challenges and strategies for development of physiotherapy education in Nepal’ and was sent via e-mail to physiotherapy educators who had been involved in teaching physiotherapy students in Nepal. Round 2) From the responses received in 1st round, list of themes were categorized by the research committee and each theme was ranked in a likert scale of 5. And, the respondents were asked to rate each theme in a likert scale and were invited for any additional comments. Round 3) Final compiled themes with the highest response was mailed and were asked for further comments. The participants were National & International Physiotherapists who have experience of working in Nepal as Physiotherapy educator or academic mentor in physiotherapy at Kathmandu University School of Medical Sciences (the only physiotherapy school in Nepal). The demographic data of the informants is given in table no.1.
Statistical Analysis
Data were analyzed qualitatively as well as quantitatively. A level of agreement has been pre-defined as 70%. Therefore, ≥ 70% of agreement has been established as a consensus for the key elements. The cut off points for items to be included in subsequent rounds had been set as ≥ 50%.17 Demographic data were analyzed using descriptive statistics. Quantitative analysis of this Delphi study was done to describe the percentages of level of agreement for each statement median, range and standard deviations. Spearman’s correlations have been calculated to analyze grading of each Physiotherapists on different attributes with median values. The analysis was done using SPSS 19.0 version with the significant level 0.05.
RESULTS
A total of 15 participants out of 19 completed all the three rounds of delphi. In the 1st round, 15 out of 19 informants responded to the open ended questionnaire with at least 6 challenges and strategies. In the 2nd round, a total of 17 themes were categorized by the researcher from the responses received in 1st round, which were then put in likert scale of 5 for each theme. In the 3rd round the themes were listed according to the rank response from 2nd round and was mailed to respondents for any further comments. The percentages of each level of agreement for different statements as shown in table 2 ranged from 0 to 100%. Agreement of 100% at extremely important level was seen for lack of awareness of physiotherapy. Extremely important was graded by more than 50 % participants for lack of job opportunities (63.6%), lack of retention of staff (54.5%) followed by lack of leadership(45.5%) and lack of curriculum according to Nepal context (45.5%). Very important response was graded by more than 50% participants for lack of licensing and practice standards (72.7%), lack of qualified faculties (54.5%), lack of mentoring (54.5%) and lack of continuous professional development (54.5%). Majority of participants gave moderate level of importance for future bachelor of physiotherapy programs (63.65%), lack of highly qualified students (63.6%), potential creation of future Bachelor of Physiotherapy program (63.6%) and lack of funding (54.6%).
DISCUSSION
Lack of awareness Informants reported low awareness about the physiotherapy profession among health care professionals, high school level and general populations. Lee K and Whitfiled TWA similarly reported a lack of clear identity and understanding of the scope of the professions role among the public and health professionals .18,19 A study done by Acharya SR et al reported that there is lack of referral of cases from medical practitioner in Nepal.20 One of the informants indicated that “the gaps in service providers in Nepal is an immense problem and likely not to be resolve in the immediate future, but continuing to promote the role of physiotherapy and liaising with other organizations slowly and steadily over time will hopefully make a difference”. The informants reported various ways of increasing awareness through, “advertising the potential benefits of the physiotherapy profession, increasing the number of job opportunities for Bachelor and Masters trained physiotherapists in government sectors, giving seminars to other medical professionals about the importance of physiotherapy and increasing public relations and networking
Lack of job opportunities
There is a clear lack of workforce data of Nepal as there has not been any prior research done. The Ministry of health and population (MoHP) Nepal ,have listed the job opportunity of physiotherapists according to different specialty and the number of job opening, but it is lesser than the actual requirement of the number of physiotherapists accepted worldwide.21 A study from Africa reported that the number of requirement of physiotherapists is limited compared to the requirement, documented in 2000, for developed countries i.e the average physiotherapists to population ratio (1:1,400).22 According to the informal data collection from Nepal Health Professional Council, approximately 500 physiotherapists are registered and they have to serve a population of 23 million. Hence, the data of Nepal showed a dearth of understanding of the profession . Dean 23 stated that it is the responsibility of every health-care practitioner to find ways to prevent common health risks. Traditional and unauthorized practices stills prevails in Nepal especially in rural areas which is one of the major drawback of lack of job opportunity. In Nepal there are still short term courses conducted (3 months course) and practicing as a physiotherapists. Moreover, many institutions are looking forward to start a certificate course (3 years course), which is not in line with the WCPT recommendation.9 Also, in Nepal most of the certificate level graduates are employed as a Physiotherapist (not as a physiotherapy assistant) as the employer/ organization can get the job done in a lesser pay compared to hiring a Bachelor/Masters of Physiotherapists. The future for physiotherapists is daunting as there will be a competition between certificate graduates and bachelor graduates due to lack of job description and further hindrance in the job opportunity. The informants reported that “to achieve a parallel development in demand and supply, health services needs to be provided “to the less attractive rural and remote parts of Nepal ’. Informants indicated various views of how job opportunities can be initiated: “ To ensure enough employment, an effective communication with all the players in the health sector (eg politicians, NGOs -both Nepali and foreign, private clinics, etc) needs to be established and maintained, to identify ways to motivate physiotherapists to work in rural areas of Nepal, where there is a great need for physiotherapy, but a lack of well trained physiotherapists (and probably a lack of paid posts) . The informants further stated that “Employment prospects can be secured by monitoring the job availability in Nepal, by seeking out new opportunities and forging links with likely employers – maybe offering placements free of charge to demonstrate the need for therapists in the work place and by linking with government agencies . Furthermore, to consult a local group of experts, who are familiar with Nepal’s structures, to create an environment analysis on the actual demands , to adjust mission, vision, and values to the actual demands in an ongoing process , to find and tap local sources of finance for the creation of physiotherapy jobs and to lobby all stakeholders in the health care sector . The informants also identified the initiation required from Nepal Physiotherapy Association (NEPTA) for the creation of jobs in government hospitals. A study from Africa 24 reported that physiotherapists play a major role in acute care and rehabilitation but the information should be effectively translated to the stake key holders, policy makers and medical practitioners which can be achieved if physiotherapists are able to show the effectiveness of interventions and the contributions it make to the heath and well being of the society.
Lack of retention of academic staff
Retaining of fresh graduate is always challenging to underdeveloped and developing country. Every country emphasizes on retaining its youths for the country however for Nepal , migration is very common, and the total Nepalese nationals working overseas in different capacities is estimated to be about half a million. 25 Physiotherapists are not left alone from this situation. Better job, better pay, better quality of life always seeks attention worldwide. Nepal being vulnerable politically, young physiotherapists from Nepal aims to achieve the summit in the diverse field of physiotherapy. One of the informants strongly commented that the “ exodus” of experienced staff to countries outside of Nepal results in loss of skills and experience and identified that career progression for academic staff based on both quality teaching and research output with good salary and benefit packages will help retain physiotherapists in the country.
Lack of leadership governing bodies
Informants indicated that the major drawback in physiotherapy education and profession is due “to lack of policies and standards of practice in the physiotherapy profession, lack of its own governing body to regulate the profession and keep it safe for public. Lack of appropriate licensing criteria and credential evaluation of the candidate graduating from a physiotherapy school/university from within and outside Nepal was identified by the informants. Accreditation, Registration and Licensing exam ensures the quality of the health practitioner. Countries like Australia26, USA27, Canada28, Singapore29, and Dubai 30 have a strict regulations of physiotherapy practice. Lack of adequate regulatory standards was reported from Kuwait as the main reason for the inconsistencies of practice .31 The informants indicated that “lack of professional leadership and attitude of NEPTA (which is understandable considering its financial situation and that of physiotherapists in the country) and lack of vision of NHPC, more specifically the inadequate understanding of international trends and developments with respect to physiotherapy education and employment has mentioned to be the shortcoming of the physiotherapy education. One of the informants strongly mentioned that “lack of priority to the course or feeling of inclusiveness by the top level administrators/other medical fraternity personnel” led to the lack of job opportunity in the country. The recommendation for the challenges identified by the respondents were: “communication with all the players in the health sector (eg politicians, NGOs -both Nepali and foreign, private clinics, etc) needs to be established and maintained, to distinguish physiotherapy job responsibilities from similar and related professions (eg physio assistants, etc) . The informants further reported that Nepal Health Professionals Council(NHPC) need to be responsive to changing health needs and changing requirements for undergraduate training.
Standards of curriculum and lack of curriculum according to Nepal context
Every country is different in terms of geographical presentation, language, culture and technology. Likewise Nepal being a very different country in its own ways, our informants viewed that “ the physiotherapy curriculum must addresses the specific health care context of Nepal and the content needs to address the quality clinical practice in rural and underprivileged populations through specific student study.” Also further stated that “education needs to be provided as same quality as the international universities, but ensuring the students are taught in a way that their clinical practice matches the needs of the Nepalese patient population” The informants also mentioned that it is important “to maintain a balance between research and “hands on” treatment and to train the students according to the needs in Nepal. Similarly in a study done in Afghanistan, the study reported that the physiotherapy curriculum needs updating and links with ongoing research need to be established to keep abreast of new developments.32
Lack of licensing/ practice standards
Every profession needs accreditation to enroll for certain academic program or to upgrade a career in a profession through means of a licensing exam. The governing body for Physiotherapy profession in Nepal is NHPC (Nepal health professional Council). In order to practice legally as a physiotherapists, every physiotherapists needs to register to Nepal Health Professional Council (without licensing exam). Maximum of our respondent felt the need of licensing exam to ascertain quality physiotherapy practice in Nepal like how it is practiced in various countries.26, 27,28,29,30 Other medical practitioner in Nepal (MBBS/BDS) graduate needs to give a licensing exam to qualify for practicing as a Doctor/Dentists.
Lack of mentoring and qualified faculty
Most of the physiotherapists in Nepal are trained from India (which meant the same kind of education background) and there seems to be a lack of role model. One of the informants reported that “Potential for professional isolation of academic staff in Nepal due to current low numbers in teaching roles and relatively small physiotherapy workforce in Nepal lead to dependence from international input and support (both intellectually and logistically). Informants viewed that there is lack of efficient and experienced teachers. The respondents further stated that in recruitment of staff the tutor needs to be clinically fit and not only academically. Informants also indicated that tutors should be exposed to new teaching methods, to continue bringing in expert faculty, to consider exchange programs or sending faculty abroad for short time periods to other university programs so that they can see other aspects of running courses/programs (administration, group work, clinical placements, etc.) and liaising with an overseas professional physiotherapy organization the tutors The reason that the respondents felt for lack of mentoring was lack of resources and expertise/ expert tutors for teaching, mentoring, and clinical reasoning. Lack of mentoring can put a question on quality and evidenced based practice leading to “lack of modern teaching methods and facilities”. A continuous mentoring to assist faculty is considered to be an important issue from the respondents.
Lack of CPD
Higgs J, reported in his study that continuous education for physiotherapists is essential to increase professional standards as well as to facilitate educational developments.33 Continuous Professional development and its creditability are well accepted worldwide. However in country like Nepal it is still in a phase of trials. Well established council like Nepal Medical Council is in the phase of adapting it. Physiotherapy profession still lacks a platform to continue the professional development other than NEPTA annual conference. Our informants provided various recommendation of improving the quality through “collaboration with International universities, by conducting workshops/continuing education by overseas and local physiotherapists in each region and not just in Kathmandu, to provide more educational videos for physiotherapists, to offer online teaching courses for the students using international faculty, to set up dialogue with physiotherapy education programs/experts in other “like countries” and an active participation of KUSMS( Kathmandu University School of Medical Sciences, only physiotherapy school in Nepal) staff and students.
Limitation of the study
The limitation of the study is that there was no focus group for the study. Furthermore, as there is only one physiotherapy school in Nepal, the participants were very limited.
Conclusions
The important challenges highlighted were lack of awareness, lack of job opportunities, lack of leadership of governing bodies, lack of retention of staff, lack of CPD and lack of licensing exam. The results of the analysis highlighted the importance of prioritizing development and growth of the Physiotherapy education. In order to overcome the challenges, the regulatory bodies (Nepal Physiotherapy Association and Nepal Health Professional Council) should facilitate to influence the policy makers for a better future of the profession. Furthermore, the regulatory bodies need to establish a strong policy, and standards of physiotherapy education and profession for a better education, service and good health outcome in Nepal.
ACKNOWLEDGEMENT
The authors would like to thank all of the national and international participants who participated in this study. The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. We are also grateful to the authors’ /editors /publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareAN EFFICIENT REAL TIME OHR SYSTEM BY INTEGRATING GOOGLE CLOUD SERVICES
English4346Karthikayini T.English Padmapriya M.K.English Arya S.EnglishThe proposed approach is fully developed based on Google cloud applications and Google cloud services. In this paper, we have developed a web application for hall reservations by integrating Google UI service and Google apps services. It avoids usage of back end servers which in turn reducing the complexity of usage and maintenance. The cloud service also provides flexibility for reserving and cancelling the booked halls. Integrating Google cloud services enables quick and easy generation of reservation reports at anytime from anywhere through any device. Google authorization has in addition provided a centralized access
to the resources with unique authentication identifier for every user. The system is made centralized at both the user-level and developer-level where the developer can revise the system from anywhere.
EnglishGoogle apps, Google calendar, Google spreadsheet, Google UI service, Google sites, OHR(online hall reservation)INTRODUCTION
In the recent times, there are various platforms for online hall reservation systems are available. All the traditional hall reservation systems are processed by using back end servers for maintaining the event data. There is [1] a need of installing and maintaining the rack server for those traditional systems. The online booking system for the meeting and seminar halls will provide flexible and sustainable services for saving time and emulate mistakes. From the other hands, users are looking for an interactive and easy way to communicate and do their jobs via internet. The usefulness of providing such a reservation services is to help administration staffs in their daily work by making their reservation up to schedule, connected, and generating reports easily [1]. Rozinah [1] began to study what factors affect the speed of the online reservation system in the centralized environment by classifying the respondents to the booking system by their age, gender, time, date of access, and time to request and to get response. Classification was done on the time constraint basis and it is compared with manual applications on booking system survey. Karthikayini [6] proposed an efficient online lesson plan management system which automate the tasks, requires less level of monitoring and optimization, Server is capable enough for the centralized system which provides efficient query performance by using Google cloud services. Ahsan Habib [2] began to study what factors affect this propensity in a negative manner i.e. what discourages individuals from adopting the technology. In this approach, middleware is used instead of database, by further reducing the complexity of data maintenance. Bobbitt and Dabholkar [3] has attempted to integrate the various attitude-based theories with external factors (such as the product/service category and perceived risks) to explain why individuals may choose technology-based self-service options [3]. Abu Zakir Rizvi [2] showed that in a single server system, all pressure goes through the server. As a result, it increases the possibility of causing server failure. It also reduces the ability to increase the scale the size of server as the clients increase by the time. Using multi-server system, server load is reduced by distributing the load among other server and that’s the way to improve the server related major issues like failure possibility, scalability etc. A middleware based three-tier architectural system provides a more easy way to manage clients’ request to different RMs/servers and to giving output back to clients from server. Ultimately, this approach provides benefits such as reusability, flexibility, manageability, maintainability, and scalability. This paper mainly focuses on the existing booking system for the meeting and seminar halls of Universities, which face several issues regarding the booking procedures that mainly performed manually. Overcoming the drawbacks in [2], this proposed approach is used in developing web applications integrated with distributed Google servers. It avoids the back-end connectivity of the web application with database, single server or even with a multiple servers. Further, this system provides no complexity of maintenance, additional flexibility, any manageability and scalability. Instead of having local server for reservation system, the proposed system uses Google Calendar as a data storage (service provided by Google) to develop an online web application for hall reservations. Google app script is an online scripting tool which is quite similar to java script, is used to create the proposed system. The whole architecture is designed for the user-friendliness and automatism. Because exiting models always needs a system to be updated all the time. But in proposed system, once the system is developed, each amendment can be made automatically and can achieve consistency easily. The proposed system is developed in a centralized way and can be used in a decentralized manner such as through any device, at anytime and from anywhere. The developers can do troubleshooting, code optimization and usage can be done globally from anywhere.
AN OVERVIEW OF GOOGLE CLOUD SERVICES
Google’s providing both SaaS and PaaS solutions in cloud computing. Some of the example for SaaS solutions including Google Apps which including Gmail, Doc, etc., and PaaS includes Google App Engine [8]. In the Platform as a Service (PaaS) space Google is a key player. App Engine is a platform to create, store and run applications on Google’s servers using development languages as java and python. App Engine contains various tools to deal with the data store, site management and its resource utilization, checking errors and classification. A user can serve the app from his own domain name (such as http://www.example.com/) using Google Apps. Or, he can serve his app using a free name on the appspot. com domain. A user can share his application with the world, or limit access to members of organization. App Engine costs nothing to get started. All applications can use up to 1 GB of storage and enough CPU and bandwidth to support an efficient app serving around 5 million page views a month, absolutely free[5]. Applications requiring more storage or bandwidth can purchase which is divided into five buckets: CPU time, bandwidth in, bandwidth out, storage, and outbound email. Google App Engine enables users to build a basic web application very quickly. Configuring and setting up an application is quick and easy. The Google App Engine Architecture provides a new approach without dealing with web servers and load balancers but instead deploying the applications on the Google App Engine cloud by providing instant access and scalability. The Google App Engine Software Development Kit (SDK) provides Java and Python programming languages. The languages have their own web server application that contains all Google App Engine services on a local computer. The web server also simulates a secure sandbox environment. The Google App Engine SDK has APIs and libraries including the tools to upload applications. The Architecture defines the structure of applications that run on the Google App Engine [1]. JavaScript: The Google App Engine allows implementation of applications using Java Script and Google scripting language and running them on its interpreter. The Google App Engine provides rich APIs and tools for designing web applications, data modeling, managing, accessing apps data, support for mature libraries and frameworks like Django [1]. Google offers services like cloud endpoints, translate APIs, prediction APIs, also a variety of storage capabilities like Google cloud SQL, Cloud data store, Cloud storage for different volume of data. Even the Petabytes of data can be processed in seconds using Google Compute Engine. In addition Google provides Big Data service like Big Query which doesn’t require an infrastructure to manage, a database administrator by using familiar SQL and can take advantage of a pay-as-you-go model [7].
ARCHITECTURE OF ONLINE HALL BOOKING SYSTEM
The entire architecture (Fig.1) speaks about the integration of various Google products which are used to design the proposed system. It shows that there is a way to integrate any Google products and can develop the application. Various Google products such as Google calendar, Google app script, Google spreadsheet & Google site is integrated here. According to the requirement of application, the developer can choose the Google products to make the application more useful & user-friendly for the end-level users. In the proposed system, the user authentication is needed in order to develop the application. Google drive which is an online storage cloud resource with the collection of various Google products such as Google Document, Google Spreadsheet, Google Calendar, Google App script and more. Google app script, an online script editor tool, is used to develop the scripts. Google calendar is acting as a database for storing the hall reservation information in the respective date, month and year. Plenty of classes and methods available from the Google app script tutorial, out of which, Calendar class and its methods were chosen to manipulate the data. In Google calendar, either default calendar or any calendars can be created and used in the script. Day agenda, week, month agenda is available in it. Once the end-level user registers the halls, the inputs are prompted and exported to the specified Google calendar events. The Google spreadsheet is used for report generation and be either implemented in one of two ways.
a. The user-inputs can be directly imported to Google Spreadsheet and can be kept visible for users in order to ensure whether the same hall is booked for the same date and same time. User can view the sheet and decide for booking without any overlaps with the previous registration. The system will deny the user if he tries to book on the same day and same timings for a same hall.
b. Data can also be imported from Google calendar to Google spreadsheet. Different sheets can be used for displaying each and every month hall reservations. A separate website is created for the hall reservation online application using Google site. It is possible to make the site visible for the entire world. Sharing and managing access permissions are also available for the site. Hall reservation app script URL link and Hall cancellation URL link is inserted in a site and it is made visible lively.
System Design and implementation:
The Fig 2 describes that; the user will be first authenticated through the email-id in order to access the application. Google site is created especially for this application and provide the access permission and sharing settings. In order to access the site, it redirects the user directly to Gmail sign-in page. Appscript link is inserted for both hall reservation and hall cancellation. To book the hall, Google calendar is inserted as a view inside the site itself for the users, to look at the already booked events. After viewing the calendar, the user can decide accordingly to reserve the halls or cancel the halls. So that, it’s an initial level of revising that no overlaps have occurred among the events by the user-level itself. User can click on listed links such as Hall-reservation and Hall-cancellation.
Designing user interface:
Hall -reservation: Hall reservation link will be available in the site. Once the user clicks the link, this system will authorize the user for accessing the application. If not, it denies the user to access the application and just displays a message that “You are not authorized to access this app”. After user authentication, it lets that particular app script to execute and shows the panel to the user. Now user can start registering the form and can click submit. The server handler will directly calls the Class Calendarapp, as well as Spreadsheet app and imports the user-inputs directly according to the date picked by the user. Incase if the user gives the same date, same time and trying to book the same hall, then the system denies the user to do it.
Hall-cancellation: If the user desires to cancel the reserved halls, system will ensure for the authenticated user and then it abandons the reserved halls. Both hall reservation and hall booking system are synchronized to Google calendar through app script. All the events which is registered and cancelled by a particular user will be reflected in Google calendar along with date and time stamps. Here the user can be able to cancel the booked halls if and only if he is the one who created that particular event and nobody else can cancel that event. The system will deny the user for cancelling the events created by other users. The user fills out the form and the system is automatically removing those events from the Google calendar and Google Spreadsheet respectively.
Advantages: The proposed system provides an automated reservation system and once the system is developed, it requires 0% man power. The query performance will be better when compared to other conventional systems. There is no probability of server crash due to the mirroring storage technology; the documents are distributed to the servers located in various places in the world. Even though the mirroring technology enables increases memory usage, various algorithms and compression techniques are implemented to overcome the disadvantages of the mirroring technology. Ultimately the system remains fault tolerant and provides 24x7 supports for incoming requests. The traditional system uses a separate standalone server and database for running the application which requires a man power. Instead using database to store the events, the proposed system is using Google calendar to store the events. So it’s an effective and intelligent way to use this product. Google Calendar is attached to the users Gmail-id itself. Hence forth, there is no need to install any kind of software and the system is made using readymade Google products. The privileged users can access the product from anywhere, at any time through any device.
CONCLUSION AND FUTURE WORK
With the vast and rapidly growing technology “Cloud Computing” which is a new evolving research field since the entire world is moving towards cloud, that attracts the attention of an astonishingly diverse set of software developers or researchers from various related fields. We have used Google APIs, global cloud service provider that gives high energy efficiency and supports Go-Green environment by reducing paper work. It gives a substantial impact to the entire world economy if it is implemented in all major business areas. The proposed approach will emerge and has the potential to become a very popular in near times. We believe that our work has created an efficient automatic framework. In future, one more module can be included for modifying the reserved slots and Google analytics can be integrated to the site to check the number of users visited, including the browser and the country as well.
Englishhttp://ijcrr.com/abstract.php?article_id=499http://ijcrr.com/article_html.php?did=4991. Omar Abdullah M. Al-Maktari, Rozinah Jamaludin, Al-Samarraie Hosam, “The Acceptance of Online Booking System (OBS) Based on the Theory of Reasoned Action (TRA): A Case of Sana’a University”, International Journal of Scientific & Engineering Research, Volume 3, Issue 2, February-2012.
2. Mohammad Badrul Alam Miah, Md. Abu Zakir Rizvi, Md. Ahsan Habib, Khandaker Hamidul Haque,“A Multipurpose Online Reservation System In Distributed Environment Using Middleware Architecture” International Journal Of Scientific & Technology Research Volume 2, Issue 2, February 2013.
3. L. M. Bobbitt and P. A. Dabholkar, “Integrating attitudinal theories to understand and predict use of technology-based self-service: the internet as an illustration,” International Journal of Service Industry Management, vol. 12, pp. 423- 450, 2001.
4. Rabi Prasad Padhy, Manas Ranjan Patra and Suresh Chandra Satapathy, “X-as-a-Service: Cloud Computing with Google App Engine,Amazon Web Services, Microsoft Azure and Force.com”, International Journal of Computer Science and Telecommunications Volume 2, Issue 9, December 2011.
5. Site:baselinklabs.blogspot.com/2014_09_01_archive.html
6. Site:pnrsolution.org/DataCenter/Vo
7. Site: https://cloud.google.com/
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcarePHOTOBIOMODULATION, THE PHYSIOLOGICAL RESPONSE OF MUSCULOSKELETAL SYSTEM TO LOW
POWER LASERS: A REVIEW
English4750Arun Kumar M.English Venkatesh D.EnglishLasers, as a source light energy has gained its importance in various applications in the field of medicine. The low power lasers also called as low level lasers are known to bring about a series of changes in the organs at the cellular and subcellular level. These changes collectively bring about various changes like wound healing, tissue regeneration, controlled secretion of cytokines, expression of gene proteins and various other physiological and biochemical actions. This review is intended to understand the physiological actions of lasers and their beneficial effects on musculoskeletal system.
EnglishPhotobiomodulation, Musculoskeletal system, Bloodless, Unpigmented tissueINTRODUCTION
The term “laser” originated as an acronym for “light amplification by stimulated emission of radiation.” A laser form of light is very useful when compared to other sources of light because it emits light coherently. Coherence is of two types’ spatial coherence and temporal coherence. Laser can be focused to a spot; this property is called spatial coherence. This property is used laser cutting and lithography. Temporal coherence is property which enables Laser to emit light with a narrow spectrum. They can emit a single color of light and also to pulses of light. Laser has a number of applications. They are used various biomedical and non-biomedical applications. Non biomedical applications include there use in printers, barcode scanners, optical communication, cutting, welding materials, and laser lighting in entertainment . When it comes to biomedical applications lasers are used in the tattoo removal, laser surgeries, diagnostic procedures, therapeutic uses, and as an adjuvant therapies in several disorders. Low Level Laser Therapy (LLLT) is treatment modality in which the energy delivered to the tissue is low so that the temperature of it does not rise above the normal body temperature. LLLT is known to bring about photobiomodulation in the treated tissues. Physiological actions of cold laser will be discussed under following headings: Tissue penetration of light, Target organelles, Activation of photoreceptor, Reduction of oxygen to free radicals and nitrite to nitric oxide, Increase in ATP and AMP. Tissue penetration of light: Does the laser penetrate tissue? Yes but the ability of a low level laser to penetrate the tissue depends mainly on absorption coefficient of the tissue and also several other factors. Tissues preferentially absorb light at varying wavelengths. Light has dual nature as described in Physics. When it is travelling, it is considered to be continuous wave but when it strikes a tissue or a surface it is considered as particle named as Photon: a pocket of energy . Laser photons that travel through a given tissue with a high absorption coefficient for its specific wavelength will lose energy through absorption easily. Because these photons are readily absorbed, this light travels for much shorter distance than those light wavelengths that are not absorbed. The absorption of photons from initial ray of laser eventually degrades the power of light with distance travelled. Absorption coefficient for the various tissues is lesser at the wavelength of light between 600 to 900 nm, which means better tissue penetration is seen in lasers with these wavelengths.
Penetrating power of laser in the living tissue depends on properties of light and tissue. Light parameters include its wavelength, intensity, polarization, coherence of the source. Tissue properties are the tissue compression, pigmentation, fibrotic structure, hydration, composition, the appendages, and covering of the skin. It is obvious that for a laser beam of constant wavelength and energy, the depth of penetration depends on the tissue in which the laser photons have to ‘submerge’ . Laser scattering at the tissue surface also becomes one of the major factors which can affect its penetrating power. There is loss of energy at the laser -tissue interface. This loss of energy due to the skin barrier is estimated for some of the types of laser. This can range from 50 % to 90 %, and it depends on the source as well as type of laser. For example the loss is estimated to be around 50 % in infrared pulsed laser when compared to 90% in continuous HeNe (632nm) laser. The maximum penetration of infrared lasers is observed in “bloodless, unpigmented tissue” which is around 1cm . The increase in the total energy output of the laser for a given wavelength does not increase the penetration power significantly. Considering the tissue penetration is one of the most important features of the laser treatment to get the optimum clinical benefits. The depth of penetration of laser using wavelengths from 630 nm up to 1100 nm is known to be up to 50mm. Bovine issue penetration of 808 nm and 980 nm lasers was conducted and it found that the energy density of 1mW/cm was achieved at the depth of 3.4 cm. It was determined that 808nm of light penetrates as much as 54% deeper than 980nm light in bovine tissue . A study was conducted by Esnou et al., on the human abdominal skin samples to estimate the depth of penetration of LLLT. The skin upto 0.784 mm thickness was harvested by dermatome following abdominoplasty. These samples were irradiated by a Gallium Aluminum Arsenide Laser (Wavelength 850 nm near infra-red invisible light, 100 mW, 24 kHz, using 0.28 mm diameter probe) and the transmitted radiation was measured. The intensity of laser radiation reduced by 66% after being transmitted through a 0.784mm sample of human abdominal tissue. In this study, most laser radiation was absorbed within the first 1mm of skin . Target Organelles in the Cell: When LLLT is applied, there is a significant intracellular change. It is seen that on repeated applications of LLLT, there was favorable response in the cell. This is because the cell response to LLLT might depend on the different phases of cell division. And if sensitivity of cells is more in any of the phases of the cell division then repeated exposure makes it possible for all cells to be exposed to that particular phase and thus an optimum reponse . Application of Laser of 20 J/cm2 for three, six, and 10 laser applications provided progressively better photobiomodulation effect on intact epidermis and dermis of mice. It did not produce any damage which is revealed by electron microscopy . The response is usually – augmented by the production of intracellular structural and functional proteins. Though ribosome is the organelle for protein synthesis, it doesn’t involve in absorbing light energy and there is no sufficient evidence supporting this fact . It is the same with vacuoles or storage substances. But there are studies which have demonstrated the changes in nucleus and mitochondria after laser exposure. Now it is found that mitochondria are first organelle to show the change which is succeeded by nucleus. “Power house of the cell”: the mitochondria have the ‘machinery’ to absorb light energy. Mitochondria respond immediately because of the ‘chromophobes’ which are known to absorb light energy. They are also called as photoreceptors. The response of the tissues to given light energy depends on the phase of cell division and the number of the mitochondria in the cells.
Activation of photoreceptor: There are several photoreceptors in the mitochondria. Cytochrome C Oxidase (CCO) is known to be most prominent one . The mitochondrial CCO seems to be the primary photoreceptor involved in photobiomodulation as most of light was absorbed by them and minimal amount of light was absorbed by remaining pigments. In study by CCO inhibitor, potassium cyanide was used and then near infrared laser was used to treat the neuronal cell. It was found that cell did not respond for the laser treatment but the uninhibited cells responded. When considered these studies it is clear that mitochondrial CCO is a primary photoreceptor for photobiomodulation .
Reduction of oxygen to free radicals and nitrite to nitric oxide: Mitochondrial CCO is known to possess two enzymatic activities. First one is reduction of oxygen to water and the second one is reduction of nitrite to nitric oxide. Reduction of oxygen to water results in production of reactive oxygen species (ROS) like superoxide (O ), hydrogen peroxide (H O ), and the hydroxyl ion (OH ) . The Reactive oxygen species and Nitric Oxide are known to activate several signaling pathways inside the cell which leads to the synthesis of several structural and functional proteins. Photobiomodulation increases bioavailability of nitric oxide by releasing it from intracellular storage structural heme proteins like hemoglobin or myoglobin. It has also been proposed that the beneficial effect of photobiomodulation may rest on its ability to photo-dissociate nitric oxide from CCO. Photodissociation of nitric oxide would restore oxygen consumption because nitric oxide inhibits mitochondrial respiration in normoxic cells, by binding to CCO. This explanation is applicable under normoxic conditions in which the effective wavelengths (670 nm & 830 nm) for photobiomodulation correspond to the oxidized heme a3 of CCO, and in which the nitric oxide is produced predominantly by nitric oxide synthase .
Increased in ATP and AMP: The release of nitric oxide from CCO prevents the displacement of oxygen and allows unaffected cellular respiration. There is increased CCO enzyme activity, increased movements of electron across electron transport chain and increased ATP production . This causes increase in the energy levels of the cells as well as increased AMP that is involved in many signaling pathways. The exposure of rat liver isolates, to HeNe laser found that cellular respiration was upregulated when mitochondria were exposed to HeNe laser or other forms of illumination. Laser irradiation caused an increase in mitochondrial products such as ATP, NADH, protein, RNA, and a reciprocal augmentation in oxygen consumption . A similar effect is produced when tissue that contains mitochondria is exposed to low-level radiation like visible and near-infrared (NIR) light. It is absorbed by the organelle, and an upregulation of cellular respiration is observed.
Physiological action of laser Overall actions of laser at cellular and tissue level can be summarized as follows: Laser increases nerve conduction, capillary dilatation, fibroblast migration, macrophage activity, and keratinocyte activity. It is also known to augment the production of several enzymes and nucleic acids. The exchange of ions across the membrane is increased. Overall clinical effects on LLLT (Low Level Laser Therapy) are reduced spasm, pain, increased blood circulation, and improved healing .
LLLT action on muscle: Muscle can perform work by contraction and relaxation. This process involves the utilization of the energy provided by ATP. On working continuously, muscle develops fatigue because of several factors like depletion of ATP, accumulation of muscle metabolites like ions, and lactic acid. It is known that when LLLT acts on the muscle it increases ATP production and also cause vasodilatation. This enhances the muscle performance and delay in the onset of fatigue. It has been demonstrated that LLLT increases muscle performance, delays fatigue, and hasten repair of the damaged muscles. LLLT acts on several steps like ATP production, phosphocreatinine re-synthesis, and also lactate oxygenation in the mitochondria. It is also shown that LLLT of 810 nm is more effective in improving the muscle performance because of its deeper penetrability and optimum energy transfer.
LLLT and its pain reducing action: Acute inflammatory pain is a complex process that begins at the peripheral nociceptors. A greater understanding of the phenomenon of pain reduction by low-level laser therapy has been provided. Several types of low level lasers with different wavelengths and therapeutic regimens have been used, leading to difficulty in comparing the results and formulating a theory about their mechanism of action. At present, most of the studies are based on the photochemical and photophysical theories proposed by Karu. This photophysical theory suggests that laser radiation could produce analgesia acting on the K+ channel . He-Ne laser does not induce a photophysical effect, acting directly on the mitochondria without any effect on the cell membrane. LLLT is known to reduce the acute inflammatory pain in the rat bones.
Role of LLLT in knee Osteoarthritis: According to Alghadir et al 2014 there was a significant reduction in the pain and improvement in the function of knee joint that was treated with LLLT for osteoarthritis of knee. The duration of the treatment was for 4 weeks with a frequency of twice a week. LLLT was given to 8 points around the joint with dosage of 6 J/point for 60 sec, with a total dosage of 48 J/cm in each session. The LLLT device used was a diode laser with a power output of 50 mW, a wavelength of 850 nm, and a diameter beam of 1 mm .In a study done by Rayegani et al 2012, LLLT was given to knee joint more frequently for lesser duration, 5 times a week for 2 weeks. The effect of LLLT on pain and function was compared with the usual modality of treatment. It was found that improvement with LLLT was better than other modalities of treatment.
CONCLUSION
Looking at the benefits in medical and other fields, it is clear that laser therapy holds a potential for managing disease conditions which were difficult to manage with existing modalities of treatment. However the undesirable side effects on the tissue have to be explored extensively before a decision could be made about use of laser therapy in management of various disease conditions.
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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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareDOES BLACK GRAPE JUICE INHIBIT BACTERIAL ADHERENCE AND BIOFILM PRODUCTION BY UROPATHOGENIC ESCHERICHIA COLI JUST AS CRANBERRY JUICE?
English5153Ethel SumanEnglish Arindam ChakrabortyEnglish M. Shashidhar KotianEnglishBackground and objectives: Cranberry juice is known to prevent urinary tract infections. One of the important mechanisms of pathogenesis by uropathogens is the production of biofilms and bacterial adherence which is usually prevented by cranberry juice. However, Cranberry is mainly found in America and an alternative source needs to be found. This study was therefore undertaken to study the effect of black grape juice on bacterial adherence and biofilm formation and conclude if it could be an alternative to cranberry juice.
Methods: The effect of cranberry juice and black grape juice on bacterial adherence was studied by using the method of Jackson and Fowler. Production of biofilms by the uropathogens was done by the method of O’Toole and Kolter and the effect of cranberry juice and blackgrape juice on biofilm production was studied.
Results: There was a significant reduction in the number of adherent bacteria after exposure to Cranberry juice as well as to black grape juice. Likewise, there was a significant decrease in biofilm production in the presence of cranberry juice and black grape juice. Interpretation and Conclusion: Cranberry juice and blackgrape juice cause significant decrease in biofilm production and prevent adherence to epithelial cells. Therefore this study suggests that black grape juice may also be used in the prevention of UTI
EnglishCranberry juice, Black grape juice, Biofilm, Urinary tract infection, Bacterial adherenceINTRODUCTION
Escherichia coli is the predominant cause of urinary tract infections. The organism produces intracellular bacterial communities or biofilms within the bladder epithelium and this could be an important cause for recurrent urinary tract infections. One of the preventive measures against urinary tract infections especially in the United States has been the consumption of Cranberry (Vaccinium macrocarpon) juice. Cranberries are Vaccinium berries which are known to contain proanthocyanidins and anthocyanidins1,2. Cranberry juice has been used for generations to prevent recurrent urinary tract infections and has been postulated to inhibit bacterial adherence due to the presence of proanthocyanidin. A number of clinical studies have shown the clinical use of cranberry juice as a preventative measure for UTI caused by Escherichia coli 3-5. Rane etal have demonstrated that cranberry derived proanthocyanidins prevent the adherence of Candida albicans to both polystyrene and silicone6 . Likewise, black grape (Vitis vinifera) skin contains anthocyanidins while the seeds contain proanthocyanidins and these substances are also thought to possess anti-adhesive properties7 . Cranberry is a native fruit of North America and is not commonly found in India. Therefore an alternative needs to be identified. Hence if grape juice can act in a manner similar to cranberry, it could be a promising solution for persons who suffer from recurrent urinary tract infection in places where cranberry is difficult to be procured. The aims and objectives of this study were to find the effect of cranberry juice and black grape juice on bacterial adherence of E.coli to epithelial cells and also on the biofilm production.
MATERIALS AND METHODS
Cranberry juice extract was obtained from USA and the source of black grape juice was commercially available fruit juice of Indian origin. Strains of E. coli isolated from cases of urinary tract infection (n=48) were used in the study. Bacterial adherence to buccal epithelial cells was studied by the method of Jackson and Fowler 8 . Effect of cranberry juice on bacterial adherence was done by performing the adherence assay in the presence of cranberry juice extract while the effect of black grape juice on bacterial adherence was studied by performing the adherence assay in the presence of black grape juice. The number of bacteria adherent per cell was counted. Estimation of biofilm production was done by the microtitre plate method of O’Toole and Kolter 9 . Overnight broth culture of the organism (200µl) was inoculated into microtitre wells. After incubation at 37°C for 24h the contents of each well was gently aspirated. The wells were washed with 200µl phosphate buffered saline ( pH 7.2), fixed with Bouin fixative and stained with crystal violet. The plates were washed, dried and OD 570 was recorded using an ELISA reader. Effect of cranberry juice and black grape juice on biofilm production was studied by adding 100 µl of cranberry juice and black grape juice respectively to 100µl broth culture in the microtitre plate method. 100µl distilled water was added as control to 100 µl broth culture in the microtitre plate method. Tests used for Statistical analysis were the Wilcoxon Signed rank sum test and Kruskal-Wallis test
RESULTS
The mean number of bacteria adherent per epithelial cell was 18.04 + 8.7. There was a significant reduction in the number of adherent bacteria after exposure to cranberry juice as well as to black grape juice (Table I and II).
DISCUSSION
Certain studies have shown that cranberry juice and certain other juices like grape juice have a high molecular weight inhibitor that cause inhibition of haemagglutination by urinary and non urinary isolates of E.coli expressing P fimbriae 9 . It has also been suggested that the antiadhesive agents in juice may act in preventing colonization of the host tissue. Previous investigations on the usefulness of cranberry juice in the treatment of urinary tract infections have focused on the potential of cranberry juice to increase the acidity of the urine and to increase urinary excretion of hippuric acid, a strong bacteriostatic agent associated with the ingestion of cranberry juice 10. A particular study has also suggested the total reducing capacity of ascorbic acid which is present as a component of cranberry which facilitates nonenzymatic generation of nitric oxide 11. It has also been suggested that proanthocyanidins of cranberry have both non-biospecific activity against adherence, perhaps due to steric hindrance 12, and biospecific activity against adherence, including decreased expression of fliC which is the adhesion gene 13. The potential use of cranberry juice in the treatment of urinary tract infections might be particularly beneficial in the management of patients who suffer from recurrent infections. Our study also suggests that black grape juice can be used as a substitute for cranberry juice. The presence of the proanthocyanidin and anthocyanidins in these juices with anti adherence effects also suggests their beneficial nature if used in other infections involving bacterial adherence 14. Hence the present study suggests the use of blackgrape juice as an alternative to cranberry juice.
CONCLUSION
The results of our study suggest that since both Cranberry as well as blackgrape juice cause reduction in biofilm production and prevent bacterial adherence, black grape juice can be used as an alternative to cranberry juice especially in places where cranberries cannot be grown.
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=501http://ijcrr.com/article_html.php?did=5011. Howell AB, Vorsa N, Der Marderosian A, Foo LY. Inhibition of the adherence of P- fimbriated Escherichia coli to uroepithelial cell surface by proanthocyanidin extracts from cranberry. N Engl J Med 1998; 339:1085-6.
2. Zafriri D, Ofele I, Adar R, Pocino M, Sharon N. Inhibitory activity of cranberry juice on adherence of type 1 and type P-fimbriated Escherichia coli to eukaryotic cells., Antimicrob Agents Chemother 1989 Jan; 33(1): 92-8.
3. Wang C-H, Fang C-C, Chen N-C et al. Cranberry-containing products for prevention of urinary tract infections in susceptible populations: a systematic review and meta-analysis of randomized controlled trials. Arch Intern Med 2012 Jul; 172 (13): 988–96.
4. Tempesta M, Barrett M. Cranberry products prevent urinary tract infections in women: clinical evidence. In: Cooper R, Kronenberg F, eds. Botanical Medicine: From Bench to Beside. New Rochelle, NY: Mary Ann Liebert, 2009; 203–11
5. Raz R, Chazan B, Dan M. Cranberry juice and urinary tract infection. Clin Infect Dis 2004 May; 38(10): 1413–9.
6. Rane HS, Bernardo SM, Howella AB, Lee SA. Cranberryderived proanthocyanidins prevent formation of Candida albicans biofilms in artificial urine through biofilm- and adherence-specific mechanisms. J Antimicrob Chemother 2014 Feb; 69 (2): 428–436.
7. Kalt W, Howell Amy B, MacKinnon SL, Goldman IL. Selected bioactivities of Vaccinium berries and other fruit crops in relation to their phenolic contents. J Sci Food Agric 2007 Sep; 87 (12):2279–2285.
8. Fowler JE Jr, Stamey AT. Studies of introital colonization in women with recurrent urinary infections. The role of bacterial adherence J Urol 1997 Apr;117 (4):472-6.
9. O’Toole GA, Kolter R. Initiation of biofilm formation in Pseudomonas fluorescens WCS 365 proceeds via multiple, convergent signalling pathways. A genetic analysis. Mol Microbiol. 1998 May; 28(3): 449-61.
10. Hisano M, Bruschini H, Nicodemo AC, Srougi M. Cranberries and lower urinary tract infection prevention. Clinics (Sao Paulo). 2012 Jun; 67(6): 661–667.
11. Goldman RD. Cranberry juice for urinary tract infection in children. Can Fam Physician 2012 Apr; 58(4): 398–401.
12. Rhee K Y, Charles M. Antimicrobial Mechanisms of Cranberry Juice. Clinical Infectious Diseases 2004 Sep; 39(6):877.
13. Eydelnant IA, Tufenkji N. Cranberry derived proanthocyanidins reduce bacterial adhesion to selected biomaterials. Langmuir 2008 Sep; 24 (18): 10273–81.
14. Hidalgo G, Chan M, Tufenkji N. Inhibition of Escherichia coli CFT073 fliC Expression and Motility by Cranberry Materials. Appl Environ Microbiol. 2011 Oct; 77(19): 6852–57.
15. Zhang L, Ma J, Pan K, Go VL, Chen J, You WC. Efficacy of cranberry juice on Helicobacter pylori infection: a doubleblind, randomized placebo-controlled trial. Helicobacter 2005 Apr; 10 (2):139-45.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareINVESTIGATION OF AN OUTBREAK OF CHOLERA IN SANKHEDA VILLAGE OF CHHOTAUDEPUR DISTRICT, GUJARAT
English5457Nikhil PatelEnglish Bhavesh ShroffEnglish V.S. MazumdarEnglishAim: Investigation of an outbreak of Cholera in Sankheda village of Chhotaudepur district, Gujarat
Introduction: Diarrheal disease outbreaks are causes of major public health emergencies in India. We investigated such outbreak in Sankheda village of Chhotaudepur district, Gujarat to identify the etiological agent, source of transmission and propose control measures.
Methodology: This study was conducted by a rapid response team as an investigation of outbreak to find out the root cause during the emergency response. The information was entered and analyzed anonymously. The study was implemented in collaboration with the district health officials
Results and Conclusion: The outbreak was caused by Vibrio cholerae 01 Biotype Ogawa. Cases were localized to clusters of village depending on distribution of contaminated water.
EnglishCholera, Contaminated waterINTRODUCTION
Cholera is a waterborne disease characterized by acute severe watery diarrhea followed by vomiting, rapid dehydration, muscular cramps and suppression of urine. The organism which causes Cholera is labelled as V. cholera O1 (more recently also V.cholerae O139), which colonizes the small intestine and produces an enterotoxin responsible for a watery diarrhea. Person with cholera may die of dehydration in a matter of hours after infection without prompt treatment. Cholera outbreaks are generally associated to contaminated food and water supplies. Cholera was confined only to the Indian sub-continent until 19th century.1 In this region, Cholera outbreaks were seasonal with one or two peaks per year2 and from here, cholera was spread throughout the world seven times since 18173. The last pandemic began in 1961 in Indonesia, spread through the Asian continent during the 60’s, reached Africa in 19704and Latin America in 1991.
MATERIAL AND METHODS
This study was conducted by a rapid response team as an investigation of outbreak to find out the root cause during the emergency response and was designed to provide information, so ethical approval was not sought prior to the study. It was undertaken as a public health practice rather than a research5,6. All inquiry was administered informed consents, ensured confidentiality and anonymity during and after the study. At the same moment health education was carried out in each household regarding cholera transmission and prevention. The information was entered and analyzed anonymously. The survey was carried out after obtaining permission from the district health officials.
The outbreak
In November 2014, an outbreak of diarrhea and vomiting was reported from Sankheda village of Chhotaudepur district of Gujarat. Sankheda village having a population of 9406 with approximately 1800 Households (HH). People use tap water supplied by panchayat for drinking purpose. There were total two water tanks in village, which were supplied by 4 tube wells. As per the reports of Block Health Officer (BHO) affected population was 4318 and first case was reported on 9/11/2014. There were 2 deaths due to same outbreak,
13 cases of diarrhea and vomiting were reported and hospitalized at CHC (Community Health Centre) Sankheda. So, surveillance to find other cases was started. The dean of Medical College, Baroda had constituted a Rapid Response Team (RRT) of Physician, Pediatrician, Microbiologist and Public health expert to investigate the reported outbreak on 12th of November. A map of location of water tank and tube well and the area supplied by them were made. Those who had complaints of diarrhea and vomiting were examined by the physician and pediatrician according to age and their stool samples were collected by microbiologist. The team then visited the families of those who had died due to diarrhea, elicited the history and then after the surrounding area was examined as well as water used for drinking purpose was checked. One significant finding in the history was that the both deceased had consumed water from same source, subsequently the water was found to be contaminated. The local people and the health personnel of the area suspected the quality of drinking water.
Microbiological aspects
Out of 73 stool samples sent for examination 14 samples were positive for V. cholera by the “hanging drop preparation” examination, colony and culture and sensitivity report. As reported by Public Health Laboratory, Baroda Medical College Vadodara, all three water sample sent from village were negative for chlorine and were not potable.
High risk geographical area
High risk geographical area was distribution area of 1 of the 2 drinking water supply tanks where leakages were found in distribution line. These areas were 10-12 clusters of total 18 clusters of Sankheda village. There were 13 leakages in water distribution pipes and out of them 3 were in direct contact of sewage.
RESULTS
DISCUSSION
An outbreak of cholera occurred in the Sankheda village of Chhotaudepur district in November 2014. After investigation, it was revealed that the outbreak occurred because of contaminated drinking water due to leakages found in the water pipes and bore-wells of Sankheda village. Contaminated water remains the prime vehicle for outbreaks of cholera in developing countries like India. Here at Sankheda, the affected areas have open sewage system. They have poor sanitation practices, lack of sewerage and toilets facility at residence and because of these, fecal contamination through leakages of water sources of households could be one of the possibilities. Hamne et al found same picture also in Varanasi, India and because of that hyper endemicity of water born diseases are present7 Almost 90% of patients had complaints of diarrhea, vomiting and other signs of dehydration on November 9,2014. A rapid response team was called on November 12,2014 from local authorities so there was three days of delay for initiation of epidemic investigation and man-agement. Similar to past studies of diarrheal disease outbreaks, there were certain limitation in the investigation. Secondly, we could only obtain laboratory confirmation from the limited numbers of indoor patients. Thus, we could not exclude other causes, which may be acting together or their own to cause this outbreak. However 14 positive patients out of 73 tested patients confirmed the outbreak of V. cholerae. So suspicion of V. cholerae was based on case definition compatible with V. cholerae definition of Integrated Disease Surveillance Project and Diagnosis of V.cholerae8 . Patients with complaints of diarrhea, vomiting and dehydration, irrespective of lab confirmation were also treated. The above limitations could have had an impact on the association of the outbreak and V. cholerae but main cause of outbreak was the contaminated drinking water.
Description of control measure taken
• Tap water supply was stopped and alternate supply by tanker was established.
• Repairing of 8 leakages in water supply line out of 13 leakages found was undertaken urgently.
• Chlorine tablets were distributed.
CONCLUSION
• It was concluded from the investigations that this outbreak of Cholera was caused by Vibrio Cholerae 01 Biotype Ogawa (Table-1) and the source of the infection was the consumption of contaminated water. Cases were not localized to any specific area but scattered in village depending on the consumption of the contaminated water.
Recommendation
• It is recommended in present situation that water supply should be safe and chlorinated. In affected area water supply by tanker should be continued till water quality is ensured
. • Repair of water distribution system, and if possible chlorination of water by chlorine gas as well as monitor chlorine level at source and end user.
• Chlorine tablet must be distribute and educate them how to use.
• Health education regarding water borne diseases, water safety and importance of personal hygiene should be taken up.
• Water supply system assessment is vital to look for leakages and blocked sewage lines should be cleared urgently.
ACKNOWLEDGEMENT
We would like to acknowledge contribution of the members of rapid response team of Medical College and S.S.G. Hospital, Baroda, which includes Dr. Jignesh Vasava (Assistant Professor, Dept. of Medicine) Dr. Tarun Parikh (Assistant Professor, Dept. of Pediatrics) Dr. Neelam Pandya (Assistant Professor, Dept. of Microbiology)for their valuable contribution during field visit. We are equally thankful to Dr. Vaishali, the Block Health Officer and Medical Officer and staff members of Gundiya PHC (Public Health Centre), for their co-operation during field survey. 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=502http://ijcrr.com/article_html.php?did=5021. Islam MS, Miah MA, Hasan MK, Albert MJ., Detection of non-culturable Vibrio cholera 01 associated with a cyanobacterium from an aquatic environment in Bangladesh. Transactions of the Royal Society of Tropical Medicine And Hygiene. 1994; 88:298-299.
2. Faruque SM, Albert MJ, Mekalanos JJ., Epidemiology, genetics and ecology of toxogenic Vibrio cholera.Microbiology and Molecular Biology Reviews.1998;62:1301-1314
3. Morillon M, De Pina JJ, Husser JA, Baundet JM, Bertherat E, Martet G., Djibouti, histoire de deuxepidemies de cholera:1993-1994. Bull Soc Path Ex.1998;91:407-411.
4. Islam MS, Drasar B, Bradley SR. Probable role of Bluegreen algae in maintaining endemicity and seasonality of cholera in Bangladesh: a hypothesis. J Diarrhoel Dis Res. 1994;12:245-256.
5. Washington State University institutional Review Board (IRB).Definitions, Washington State University, Pullman WA. (Internet) Available from : http:/www.irb.wsu.edu/ definitions.asp(updated May 2010), (Last cited on 2011 August 19).
6. Snider DE Jr, Stroup DF. Defining research when it comes to public health. Public Health Rep 1997;112;29-32 (PUBMED)(FULL TEXT).
7. Hamner S, Tripathi A, Mishra RK, Bouskill N, Broadway SC, Pyle BH, et al. The role of water use patterns and sewage pollution in incidence of water- borne/ enteric disease along the Ganges River in Varansi, India. Int J Environ Health Res 2006:16:113-32 (PUBMED)(FULL TEXT).
8. Integrated Disease Surveillance Project, India. Modified case definition for p-form(internet). Medical officers’ Manual, IDSP, 2006. Available from: http://www.idsp.nic.in/idsp/ IDSP/Case_Def_P_Form.pdf. (Updated 2008); (Last cited on 2011 June 21).
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareSERUM MAGNESIUM IN RELATION TO APACHE IV SCORE AND OUTCOME IN CRITICALLY ILL PATIENTS
English5861R. SudhaEnglish S. BharanidharanEnglishIntroduction: Hypomagnesemia is a common but less frequently monitored electrolyte abnormality in hospitalized patients, especially in the critically ill. Accumulating evidence suggests a potential association between magneasium levels and the morbidity and mortality of critically ill patients. Assessment of electrolytes upon admission to the ICU is necessary to identify patients at risk and to guide the appropriate management during ICU stay.
Aims and Objectives:
1. To assess the levels of serum magnesium in critically ill patients on admission.
2. To evaluate its relationship with APACHE IV (Acute Physiology and Chronic Health Evaluation) score, ventilator support and its duration, length of stay, and mortality.
Materials and Methods: 80 patients admitted to the Medical intensive care unit (MICU) were taken for the study. The subjects studied were monitored for serum magnesium levels on Day 1 of intensive care unit (ICU) admission and were followed to assess duration of ventilator support, length of ICU stay and mortality.
Results: At admission, 45% patients had hypomagnesemia, 6% patients had hypermagnesemia and 49% patients had normomagnesemia. Patients with lower magnesium levels had higher need and longer duration of mechanical ventilation, more frequently had hypokalemia, hypocalcemia, hyponatremia and a higher mortality rate (39% vs 25%). APACHE IV score and length of stay did not significantly vary in hypomagnesemic patients.
Conclusion: Since the presence of hypomagnesemia at admission in the ICU patients is associated with a worse prognosis, recognition and treatment of hypomagnesemia in patients entering the ICU are important.
EnglishCritically ill patients, Serum magnesium, Mortality, APACHE IV, HypomagnesemiaINTRODUCTION
Magnesium (Mg) once considered as the “fifth forgotten ion” is arousing interest in clinicians as there is a high incidence of hypomagnesemia in critically ill patients. Mg plays an essential role as a cofactor in countless enzymatic reactions and cellular functions. Magnesium deficiency is a common but underdiagnosed electrolyte abnormality in hospitalized patients, especially in the critically ill. Studies across the world have shown varying incidences of hypomagnesemia ranging from 20% to 65% 1,2,3 whereas Indian studies have shown 25% 4 and 52% 5 . Hypomagnesemia has been directly implicated with a higher mortality rate and worse clinical outcome in the ICU patients5, 6. It is also associated with hypokalemia7 , hypocalcemia and dysrhythmia 8 ultimately increasing the mortality. Multiple factors contribute to the low Mg levels in ICU patients like impaired GI absorption, nasogastric suction, usage of drugs like diuretics, aminoglycosides which cause renal wasting of magnesium9, 10. Hypermagnesemia is not as frequent as hypomagnesemia and is mostly due to renal failure or iatrogenic11. Based on this background, this study was undertaken to assess the magnesium deficiency in critically ill patients upon admission to the ICU and its influence on the outcome of those patients.
MATERIALS AND METHODS
A prospective observational study was conducted on 80 patients admitted to the Intensive Care Unit of Vinayaka Missions Kirupananda Variyar Medical College and Hospitals. The subjects included were 48 males and 32 females in the age group of 16 – 70 years. The study was started after the approval of the Institutional Ethical Committee. Informed consent was obtained from the nearest kin of the patient. There were no specific exclusion criteria for the patient except for treatment with magnesium products. The subjects enrolled into the study were monitored for serum magnesium levels within 24 hours of admission, 2ml of venous blood sample was taken and processed for magnesium analysis. Serum magnesium levels were estimated by Xylidyl blue method using a semiautomated analyser. Reference range for magnesium concentrations were set by drawing blood from healthy staff of our college (1.7 to 2.4 mg/dl). Serum magnesium level of < 1.7 mg/dl was regarded as hypomagnesemia and > 2.4 mg/dl as hypermagnesemia. Other laboratory investigations included were arterial blood gas analysis, sodium, potassium, calcium, bilirubin, urea, creatinine and glucose. Details collected from the patients were need for ventilator, duration of ventilator support, length of stay, general patient demographics and mortality in the ICU. Patients were followed until their discharge from the ICU. The APACHE IV score was determined on the first day. APACHE scoring system takes into consideration various parameters like physiological variables, vital signs, urine output, neurological score, along with age related parameters and comorbid conditions, which may have a significant impact on the outcome of these critically ill patients12. APACHE IV is the newest standardized scoring metrics to assess the severity of illness and prognosis among critically ill adults in the ICU. APACHE IV, an improved and updated model for predicting mortality among critically ill patients includes new variables like mechanical ventilation, rescaled Glascow coma scale, PaO2/FiO2 ratio, ICU admission diagnosis and source etc13, 14. APACHE IV is probably a more reliable prediction of high risk of death in patients with stroke than APACHE II, which has been widely used in ICU studies15. APACHE IV score was calculated using an online calculator.
Statistical analysis: Data was analysed using the SPSS program. All the data were expressed as Mean ± Standard deviation. Pearson’s correlation analysis was done for assessing the relationship between va riables. Differences were considered as statistically significant if p-value was less than 0.05.
RESULTS
Totally, 80 patients admitted to the MICU were considered for the study. At admission, 45% (36/80) patients had hypomagnesemia, 6% (5/80) patients had hypermagnesemia and 49% (39/80) patients had normomagnesemia. The serum magnesium values were ranging from 1mg/dl to 3mg/dl. When the variables were compared between patients with low and normal magnesium levels, a statistically significant difference was observed in need for ventilator support and duration of mechanical ventilation. Length of stay in the ICU did not vary significantly between the two groups. The mean APACHE IV score on admission was 43.43 ± 17.67 for the hypomagnesemic group and 42.29 ± 19.02 for the normomagnesemic patients. Mean APACHE IV score of patients in the two groups also did not significantly differ. Hypomagnesemic patients had more incidences of electrolyte abnormalities such as hypokalemia (20% vs 6.25%), hyponatremia (40% vs 12.5%) and hypocalcemia (33% vs 3%). Hypomagnesemic patients had a higher rate of mortality (39% vs 25%) when compared to the normomagnesemic patients. [Table 1] There was a significant positive correlation between serum magnesium and serum potassium levels. 47% of hypomagnesemic patients had diabetes mellitus, whereas 33% in normomagnesemic group had diabetes.
DISCUSSION
Magnesium is the second most abundant intracellular cation after potassium and is a required cofactor in hundreds of enzyme systems. Magnesium deficiency commonly occurs in critical illness and correlates with a higher mortality and worse clinical outcome in the intensive care unit. A wide range of incidences of magnesium deficiency has been reported in patients of ICU. Moreover, patients who develop magnesium deficiency in the ICU have mortality rates 2 to 3 times higher16, 17, 18 and prolonged hospitalization when compared with those who are not magnesium deficient. Although RBC magnesium is a better index of intracellular magnesium when compared to serum magnesium, clinicians rely on serum magnesium as it is easier to measure. In the present study of 80 critically ill patients, a significant number of patients had hypomagnesemia (45%). Similar incidences were observed by Deheinzelin et al (45.6%)3 and Guerin et al (44%)20. Studies carried out throughout the world in critically ill patients have shown varying incidences of Mg deficiency ranging from 14% to 66% 5. The causes of magnesium deficiency in critically ill patients are multiple, the major ones being GI losses and renal losses. Other common risk factors associated with magnesium deficiency are alcoholism and poorly controlled diabetes mellitus. It is important to address the cause of Mg deficiency while treating hypomagnesemia, to prevent future recurrences19. Hypomagnesemia has long been known to be associated with insulin resistance and diabetes mellitus. In this study, patients with higher blood glucose levels had more incidence of hypomagnesemia. Epidemiologic studies have shown a high prevalence of hypomagnesaemia and lower intracellular Mg concentrations in diabetic subjects. Reduced intracellular Mg concentrations result in a defective tyrosine-kinase activity, post-receptorial impairment in insulin action, and worsening of insulin resistance in diabetic patients21. Other electrolyte abnormalities are frequently encountered in patients with hypomagnesemia. Our study results have shown a greater incidence of electrolyte disturbances in hypomagnesemic patients than normomagnesemic patients. These results are consistent with Safavi et al8 and CS Limaye et al5 . However, only potassium had a significant positive correlation with magnesium levels (r-value – 0.48, p-value Englishhttp://ijcrr.com/abstract.php?article_id=503http://ijcrr.com/article_html.php?did=5031. Reinhart RA, Desbiens NA. Hypomagnesemia in patients entering the ICU. Crit Care Med. 1985:13:506-507.
2. Ryzen E, Wagers PW, Singer FR, Rude RK. Magnesium deficiency in a medical ICU population. Crit Care Med. 1985:13:19-21.
3. Deheinzelin D, Negri EM, Tucci MR, Salem MZ, da cruz VM, Oliveira RM, et al. Hypomagnesemia in critically ill cancer patients:a prospective study of predictive factors. Braz J Med Biol Res.2000;33:1443-1448.
4. Zafar MH, Wani JI, Karim R, Mir MM, Koul PA. Significance of serum magnesium levels in critically ill patients. Int J App Basic Med Res 2014;4:34-7.
5. CS Limaye, VA Londhey, MY Nadkar, NE Borges. Hypomagnesemia in critically ill medical patients. JAPI.Jan 2011;59:19-22.
6. Tong GM, Rude RK,. Magnesium deficiency in critical illness. J.Intensiv Care Med 2005;20(1):3-17.
7. Whang R, Oei TO, Aikawa JK, Watanabe A, Vannatta J, Fryer A et al. Predictors of clinical hypomagnesemia:hypokalemia, hypophosphatemia, hyponatremia and hypocalcemia. Arch Intern Med 1984;144:1794-96.
8. Safavi.M, Honarmand A. Admission hypomagnesemia- Impact on mortality and morbidity in critically ill patients. M.E.J.ANESTH. 2007;19(3):645-660.
9. Salem M, Munoz R, Chernow B. Hypomagnesemia in critical illness. Critical care clinics.1991;7:225-252.
10. Michael JD. Hypomagnesemic disorders. Critical care clinics.2001;17:155-173.
11. James W. Van Hook. Hypermagnesemia. Critical care clinics.1991;7:215-223.
12. Burtin P, Bollaert PE, Feldmann L, Lelarge P, Bauer P, Larcan A. Prognosis of patients with stroke undergoing mechanical ventilation. Intensive care Med. 1994;20:32-36.
13. Zimmerman JE, Kramer AA, McNair DS, Malila FM. Acute Physiology and Chronic Health Evaluation (APACHE) IV:ICU length of stay benchmarks for today’s critically ill patients. Crit Care med 2006;34:2517-29.
14. Zimmermann JE, Kramer AA, McNair DS, Malila FM. Acute physiology and chronic health evaluation (APACHE) IV: Hospital mortality assessment for today’s critically ill patients. Crit Care Med 2006;34(5):1297-310.
15. Tulin Akarsu Ayazoglu. A comparison of APACHE II and APACHE IV scoring systems in predicting outcome in patients admitted with stroke to an intensive care unit. Anaesth, Pain & Intensive care.2011;15(1):7-12.
16. Rubeiz GJ, Thill Baharozian M, Hardie D, Carlson RW. Association of hypomagnesemia and mortality in acutely ill medical patients. Crit care med. 1993;21:203-209.
17. Soliman HM, Mercan D, Lobo SS, Melot C, Vincent JL. Development of ionized hypomagnesemia is associated with higher mortality rates. Crit care med.2003;31:1082- 1087.
18. Cohen N, Almoznino-Sarafian D, Zaidenstein R, Alon I, Gorelik O, Shteinshnaider M et al. Serum magnesium aberrations in furosemide treated patients with congestive heart failure; pathophysiological correlates and prognostic evaluation. Heart.2003;89:411-416.
19. Kevin J.Martin, Esther A. Gonsalez, Eduardo Slatopolsky. Clinical consequences and management of hypomagnesemia. J Am soc Nephrol.2009;20:2291-2295.
20. Guerin C, Cousin C. Serum and erythrocyte magnesium in critically ill patients. Intensive Care Med.1996;22:724-727.
21. Mario barbagallo, Ligia J Dominguez. Magnesium metabolism in type 2 diabetes mellitus, metabolic syndrome and insulin resistance. Archives of Biochemistry and Biophysics.2007 Feb 1;458(1):40-7
22. Chernow B, Bamberger S, Stoiko M, Vadnais M, Mills S, Hoellerich V et al. Hypomagnesemia in patients in postoperative intensive care unit. Chest 1989;95:391-397.
23. Subhraprakashpramanik, Arpan kumar Dey, Pijushkantimandal,Shovan Kumar Das, Debashishghosh, Arpan Bhattacharya, Milan Chakroborty, Somnathdasgupta. Prevalence of hypomagnesemia and its predictive prognostic value in critically ill medical patients. IOSR Journal of Pharmacy.2014;4(1):1-5.
24. Escuela MP, Guerra M, Anon JM, Martinez-Vizcaino V, Zapatero MD, Garcia-Jalon A et al. Total and ionized serum magnesium in critically ill patients. Intensive care med.2005;31(1):151-6.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcarePREGNANCY OUTCOME IN ISOLATED OLIGOHYDRAMNIOS AT OR BEYOND 34 WEEKS OF GESTATION
English6268Kavitha G.EnglishObjectives: A significant reduction in the amount of amniotic fluid co-relates with an increased rate of both perinatal morbidity and mortality. The objectives of the study are to determine the neonatal outcome, and the appropriate route of delivery in isolated
oligohydramnios.
Methodology: This was a prospective case-control study conducted over a period of 22 months (November 2006 to August 2008) at department of obstetrics and gynecology, Basaveshwar Teaching and General Hospital and Sangameshwar Hospital, attached to Mahadeveppa Rampure Medical College, Gulbarga. The study consists of analysis of pregnancy outcome in 50 antenatal patients with the ultrasound diagnosis of oligohydramnios (AFI ? 5) at or beyond 34 weeks of gestation. Oligohydramnios was defined as ultrasound diagnosis of amniotic fluid index ?5cm. Inclusion Criteria included singleton pregnancy of any order of parity with gestational age ? 34 weeks and AFI ? 5cm. Multiple gestation, gestational age 40 weeks, AFI > 5cm and EnglishIsolated oligohydramnios, Non stress test, FHR deceleration.INTRODUCTION
Importance of amniotic fluid volume as an indicator of fetal status was appreciated relatively recently.1 Amniotic fluid has a number of important roles in fetal development. It cushions the fetus against trauma, has antibacterial property and promotes growth and development of gastrointestinal and musculoskeletal system.2 It helps to maintain the fetal body temperature and plays a part in the homeostasis of fluid, and permits fetal movements.2, 3 Amniotic fluid volume maintains amniotic fluid pressure there by reducing the loss of lung fluid - an essential component to pulmonary development. It prevents compression of the umbilical cord.4 Decreased amniotic fluid volume is frequently one of the first clues to an underlying fetal abnormality or maternal disease state.5 Most common quantitative measure for fluid volume used in clinical practice is AFI. It is calculated by dividing the uterus externally into 4 quadrants and using ultrasound to measure vertical diameter of the largest pocket in each quadrant in millimeter, which is then summed to calculate AFI.6. AFI ≤ 5cm is the accepted cut off for the diagnosis of oligohydramnios. Ante partum diagnosis of oligohydramnios by means of AFI accounted for 2.3% of pregnancies undergoing sonography after 34weeks.7 Sonogram – assisted diagnosis of oligohydramnios is associated with increased pregnancy intervention, still birth, fetal heart rate deceleration during labor and increased neonatal morbidity and mortality rates.7 Oligohydramnios can be an idiopathic finding in women who have low risk pregnancies and no medical or fetal complication.8 The present study was designed to study the outcome of pregnancies with AFI ≤ 5cm at or beyond 34weeks of gestation.
MATERIAL AND METHODS
This was a prospective case-control study conducted over a period of 22 months (November 2006 to August 2008) at department of obstetrics and gynecology, Basaveshwar Teaching and General Hospital, and Sangameshwar Hospital attached to Mahadeveppa Rampure Medical College, Gulbarga. The study consists of analysis of pregnancy outcome in 50 antenatal women with the ultrasound diagnosis of oligohydramnios (AFI ≤ 5) at or beyond 34 weeks of gestation compared with 50 controls with normal liquor (AFI > 5 and < 25) matched for other variables like age, parity and gestational age. Method of Collection of data • Women who have had 3 or more antenatal visits were considered as booked cases. • For all cases selected, thorough history was taken and complete examination was done and clinical evidence of oligohydramnios was looked for.
• The previous obstetric records and ultrasound reports were reviewed.
• Gestational age was calculated from their date of last menstrual period or from their first trimester ultrasound report.
• 50 patients with ultrasound diagnosis of oligohydramnios (AFI ≤ 5) were included in the study group. Amniotic fluid index was calculated by four quadrant amniotic fluid volume measurement technique.
• Oligohydramnios was defined as amniotic fluid index ≤5cm. The amniotic fluid volume is considered normal if amniotic fluid index is between 5.1 and 25cm.
• For each case, a control was taken with similar age, gravidity, parity and gestational age with amniotic fluid index of more than 5cm and less than 25cm.
Inclusion Criteria
a. Women with any order of parity
b. Singleton pregnancy
c. Gestational age ≥ 34 weeks d. AFI ≤ 5cm
Exclusion criteria
a. Multiple gestation
b. Gestational age less than 34 weeks and >40 weeks
c. AFI > 5cm
d. Ruptured membrane e. Pregnancy induced hypertension
f. Congenital anomalies
All the pregnant women in the study who went into spontaneous labor were allowed to deliver irrespective of gestational age with continuous fetal heart rate monitoring. Women not in labor with the gestational age between 34–38 weeks were closely monitored with biweekly NST and BPP, until they went into spontaneous labor. If they failed to go into spontaneous labor, they were induced at 38wks with dinoprostone gel or oxytocin drip depending on the Bishop’s score. NST was done for all patients. Variable deceleration was considered significant if it was below 70 bpm persisting for >60 seconds. Those who developed significant variable, repetitive late deceleration or other omnious FHR pattern with or without meconium stained liquor which persisted in spite of corrective measures like change in maternal position, hydration, O2 inhalation and stopping oxytocin were diagnosed as fetal distress and delivered by LSCS or by instrumental vaginal delivery. Amnioinfusion was not done in our study. Women with malpresentation and other obstetric indications were directly taken for cesarean delivery. All newborns were attended by pediatricians and endotracheal intubations and suctioning were done if liquor is meconium stained. Various outcome measures recorded were: induced Vs spontaneous labor, nature of amniotic fluid, FHR tracings, mode of delivery, and indication for cesarean section or instrumental delivery, Apgar score at one minute and five minutes, birth weight, admission to neonatal ward, perinatal morbidity and mortality. Early neonatal death was defined as the death of a fetus whose birth weight was 1000 grams or more, within first seven days of life. Fetal distress was an ill defined term used to express intrauterine fetal jeopardy, resulting from intrauterine fetal hypoxia. Non reassuring fetal heart rate pattern, significant variable and repetitive late deceleration were considered as fetal distress. Apgar score: Five minute apgar score < 7 was considered abnormal. IUGR was defined as a birth weight of less than 10th centile for gestational age. Low birth weight was defined as birth weight less than 2.5 kg at term. Preterm was defined as gestational age Englishhttp://ijcrr.com/abstract.php?article_id=504http://ijcrr.com/article_html.php?did=5041. Chamberlain PF, Manning FA, Morrison I, Harman CR, Lange IR. Ultrasound evaluation of amniotic fluid index. I. The relationship of marginal and decreased amniotic fluid volumes to perinatal outcome. Am J obstet Gynecol. 1984 Oct;150(3): 245-9.
2. Brace RA. Physiology of amniotic fluid volume regulation. Clin obstet Gynecol. 1997 Jun;40(2):280-289.
3. Wallenburg HC. The amniotic fluid I. Water and electrolyte homeostasis. J Perinat Med. 1977;5(5): 193-205.
4. Nicolini U, Fisk NM, Rodeck CH, Talbert DG, Wigglesworth JS. Low amniotic pressure in oligohydramnios-- is the cause of pulmonary hypoplasia? Am J Obstet Gyncol. 1989 Nov;161:1098-101.
5. Hill M. Oligohydramnios: Sonographic diagnosis and clinical implications. Clin obstet Gynecol. 1997 Jun; 40( 2):314-27.
6. Ott WJ. Reevaluation of the relationship between amniotic fluid volume and perinatal outcome. Am J Obstet Gynecol. 2005 Jun;192(6):1803-9.
7. Casey BM, McIntire DD, Bloom SL, Lucas MJ, Santos R, Twicker DM et L. Pregnancy outcome after antepartum di-agnosis of oligohydramnios at or beyond 34 weeks of gestation. Am J Obstet Gynecol. 2000 Apr; 182(4): 902-12.
8. Leeman L, Almond D. Isolated oligohydramnios at term: is induction indicated? J Fam Pract. 2005 Jan;54(1):25-32.
9. Halperin ME, Fong KW, Zalev AH et al. Reliability of amniotic fluid volume estimation from ultrasonogram ; intraobserver and interobserver variation before and after the establishment of criteria. Am J Obstet Gynecol. 1985 Oct;153(3):264-7.
10. Carroll BC, Burner JP. Umbilical artery Doppler Velocimetry in pregnancies complicated by oligohydramnios. J Reprod Med. 2000 Jul; 45(7):562-6.
11. Cunningham FG, Gant Norman F, Leveno KJ et al. Abnormalities of fetal membranes and amniotic fluid. Chapter 31 in William’s Obstetrics 21st edition, Mc Graw Hill 2001; 820-824.
12. Umber A, Chohan MA. Intravenous maternal hydration in third trimester oligohydramnios: effect on amniotic fluid volume. J Coll Physicians Surg Pak. 2007Jun;17(6):336-9.
13. Conway DL, Groth S, Adkins WB, Langer O. Management of isolated oligohydramnios in the term pregnancy: A randomized clinical trial. Am J Obstet Gynecol 2000;182:S21.
14. Ghosh G, Marsal K, Gudmundsson S. Amniotic fluid index in low risk pregnancy as an admission test to the labor ward. Acta Obstet Gynecol Scand. 2002;81(9): 852-5.
15. Voxman EG, Tran S, Wing DA. Low amniotic fluid index as a predictor of adverse perinatal outcome. J Perinatol. 2002 Jun;22(4):282-5.
16. Zhang J, Toendle J, Meikle S, Klebanoff MA, Rayburn WF. Isolated oligohydramnios is not assioated with adverse perinatal outcomes. BJOG. 2004 Mar;111(3);220-5.
17. Locatelli A, Zagarella A, Toso L, Assi F, Ghidini A, Biffi A. Serial assessment of amniotic fluid index in uncomplicated term pregnancies: prognostic value of amniotic fluid reduction. J Matern Fetal Neonatal Med. 2004 Apr;15(4):233-6.
18. Alchalabi HA, Obeidat BR, Jallad MF, Khader YS. Induction of labor and perinatal outcome: the impact of amniotic fluid index. Eur J Obstet Gynecol Reprod Biol. 2006 Dec;129(2):124-7.
19. Manzanares S, Carrillo MP, Gonzalez-Peran E, Puertas A, Montoya F. Isolated oligohydramnios in term pregnancy as an indication for induction of labour. J Matern Fetal Neonatal Med. 2007 Mar;20(3):221-4.
20. Danon D, Ben-Haroush A, Yogev Y, Bar J, Hod M, Pardo J. Prostaglandin E2 induction of labor for isolated oligohydramnios in women with unfavourable cervix at term. Fetal Diagn Ther. 2007;22(1):75-9.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareROLE OF TRANSFERRIN SATURATION, SERUM IRON AND TOTAL IRON BINDING CAPACITY INDICATING IRON-DEFICIENT ERYTHROPOIESIS IN SEVERE HOOKWORM INFECTION
English6973Govindarajalu GanesanEnglishObjective: Severe anaemia is reported to occur in severe hookworm infection in many studies. But so far detailed study of the role of percent transferrin saturation, serum iron and total iron binding capacity which indicate iron-deficient erythropoiesis 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 percent transferrin saturation, serum iron and total iron binding capacity which indicate iron-deficient erythropoiesis 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, Transferrin saturation, Serum iron, Total iron binding capacity, Upper gastro intestinal endoscopyINTRODUCTION
Severe anaemia is reported to occur in severe hookworm infection in many studies (1 to 17). But so far detailed study of the role of percent transferrin saturation, serum iron and total iron binding capacity which indicate irondeficient erythropoiesis and iron status was not done in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal endoscopy. Hence a detailed study of the role of percent transferrin saturation, serum iron and total iron binding capacity which indicate iron-deficient erythropoiesis and iron status was done in patients with severe anaemia due to hookworm infection diagnosed by doing upper gastro intestinal 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 Englishhttp://ijcrr.com/abstract.php?article_id=505http://ijcrr.com/article_html.php?did=5051. 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.
2. 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.
3. Yan SL, Chu YC. Hookworm infestation of the small intestine Endoscopy 2007; 39: E162±163.
4. Chao CC1, Ray ML. Education and imaging. Gastrointestinal: Hookworm diagnosed by capsule endoscopy. J Gastroenterol Hepatol. 2006 Nov;21(11):1754.
5. 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.
6. Genta RM, Woods KL. Endoscopic diagnosis of hookworm infection. Gastrointest Endosc 1991 July;37(4):476-8.
7. Anjum Saeed, Huma Arshad Cheema, Arshad Alvi, Hassan Suleman. Hookworm infestation in children presenting with malena -case seriesPak J Med Res Oct - Dec 2008;47(4) ):98-100.
8. 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. 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.
13. 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.
14. 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.
15. 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.
16. 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.
17. 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.
18. WHO. Iron deficiency anaemia: assessment, prevention, and control. a guide for programme managers. Geneva, Switzerland: World Health Organization, 2001. (WHO/ NHD/01.3.).
19. Sarita Modi, Bose Sukhwant Study of iron status in female medical students Indian Journal of Basic and Applied Medical Research; March 2013: Issue-6, Vol.-2, P. 518-526.
20. Crompton DW, Whitehead RR. Hookworm infections and human iron metabolism Parasitology. 1993;107 Suppl:S137-45.
21. 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.
22. Ahmed F, Khan MR, Karim R, Taj S, Hyderi T, Faruque MO, Margetts BM, Jackson AA. Serum retinol and biochemical measures of iron status in adolescent schoolgirls in urban Bangladesh. Eur J Clin Nutr. 1996 Jun;50(6):346-51.
23. Che?chowska M, Laskowska-Klita T, Leibschang J. . Concentration of ferritin, transferrin and iron as a markers of iron deficiency in healthy women in reproductive age]. Pol Merkur Lekarski. 2007 Jan;22(127):25-7. 24. Kaneshige E. Serum ferritin as an assessment of iron stores and other hematologic parameters during pregnancy. Obstet Gynecol. 1981 Feb;57(2):238-42.
25. Bakta and FX Budhianto S2 Hookworm anemia in the adult population of jagapati village, bali, indonesia Southeast asian j trop med public health vol 25 no. 3 september 1994
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareLEVEL OF SERUM CREATINE PHOSPHOKINASE IN ORAL SUBMUCOUS FIBROSIS - A BIOCHEMICAL STUDY
English7478Biju Baby JosephEnglish Shiny GeorgeEnglishContext: Oral squamous cell carcinomas develop from a premalignant lesion or condition, which are due to a variety of aetiological factors. Early detection of these are necessary to prevent them from developing into carcinomas which can increase the mortality and morbidity. There are a variety of possible aids like histopathology, Hstiochemistry and Enzyme assays in diagnosing these lesions. Histopathology has many limitations which can be overlookd by an enzyme assay technique. Keeping this in mind a study was planned to evaluate the association between serum creatine phosphokinase and a premalignant condition.
Aim and objective: To evaluate creatine phosphokinase level in patients with Oral Submucous Fibrosis and to compare it with the normal subjects
Methodology: Routine out patients visiting the department of oral medicine and radiology, coorg institute of dental sciences, Virajpet in the age range of 40-60 years old males. They were grouped and samples were collected and sent for analysis.
Result: We could not find any statistical significance in the study .
Conclusion: A multicentered study consisitng of a large sample is needed to emphasise the importance of creatine phosphokinase as a diagnostic biomarker in Oral Submucous Fibrosis
EnglishPremalignant lesions, Enzymes, Oral submucous fibrosisINTRODUCTION
Oral malignancy is widely recognized as the most common cancer in orofacial region.1 It ranks 5th in the world, and in South Asia it ranks 1st in males and 3rd in females among all other cancer. 2 The survival rate oral malignancies are less than 50 %, though treated, hence it is very important to recognise these malignancies at the earliest stage.3 The aetiology of these can be multifactorial and but are strongly related to life style and habits like tobacco chewing, and alcohol, however virus are also proved to be one of the aetiological factor 4 . The oral premalignant lesions and conditions more precisely Potentially Malignant Disorders(PMD) as given by World health Organization (WHO) have got the potential to change into malignancies, when undiagnosed earlier. Few of them are Oral Leukoplakia(OL) and Oral Submucous Fibrosis (OSMF), Oral Lichen Planus(OLP) Erythroplakia and Erythro-leukoplakia. Among these the most common ones are Oral Lichen planus and oral submucous fibrosis, both associated with habits.5 These lesions are clinically and histologically distinct, and have malignant potential. However not all of them transform in to malignant ones.The concept of premalignancy is more suitable to Indian subcontinent owing to the use of tobacco. The damage caused to the oral mucous membrane starts at very early age and added to this any deleterious habit act as adjuvant and pave way for premalignancy. The Potentially malignant disorders if diagnosed early can be treated well to prevent from being grown in to a full blown malignancy and better prognosis of treatment can be achieved when compared to treating a malignant ones.6 Detection of these potentially malignant disorders at the earlier stage and their intervention is very important in preventing them from being transformed in to higher stage. Identification of these depending upon the sites or habit are also important. An early detection all these help to improve the mortality and quality of life of the patient.7 Once the malignant changes have occurred then with our limited resource an impact can be achieved if the right priorities and strategies are established and implemented in treatment strategy. For this to happen an early detection is must.8 There are various diagnostic aids in detecting the premalignant lesions like vital staining , histopathology, VEL scope, Vizilite, saliva , biomarkers7 . Biomarkers help in detecting the earlier stages of malignant transformation and they reveal the early, intermediate and final cellular stage in these lesions9 . Markers like lactic dehydrogenase, phosphohexose isomerise has been found elevated in some cancers. The enzyme creatine phosphokinase is a hypothetize marker for cancer in lung and colon.7 Enzymes are preferred in diagnosis because of their substrate specificity and their activity can be quantified in the presence of other proteins. In each disesase state there is a consequent amount of tissue damage in the involved organ. By finding out the serum level of the enzyme it can act as a diagnostic biomarker.10 The diagnostic value creatine phosphokinase is well documented.It is seen in skeltal muscle, cardiac muscle.Increased levels are noted in myocardial infarction, in muscular dystrophy, in muscle trauma, and in intramuscular injections.Hence an elevation of total creatine phosphokinase in blood suggests muscle or skeltal disease.11 This is also substantiated in another study done by Paola b et al where they did study due to direct and indirect damage of muscle due to various factors. They concluded in a positive significance of creatine phosphokinase in direct muscle damage when compared to indirect damage12.
MATERIALS AND METHOD
Routine out patients visiting the department of oral medicine and radiology, coorg institute of dental sciences, Virajpet in the age range of 40-60 years old males.
METHOD OF COLLECTION
Age, gender, dental status of patient noted down. 20 Patients 20 control were taken after obtaining written consent , detailed case history was taken, and through clinical examination was done and lesions were identified , by experienced oral medicine specialist.
The patients were grouped in to two groups :Group1- having grade 1 –osmf.
Group 2- having grade 2- osmf.
All patient having areca nut chewing habits..
The Inclusion criteria were male patient of age 40-60, and patient willing for the study and treatment thereafter. Whereas the Exclusion criteria were ; Physically and mentally disabled and Patient with history systemic illness.
RESULT
The study had 20 controls and 20 patients in the age group of 40-60 ( table 1 and 2 ). The study was conducted in the Department of Oral Medicine and Radiology in out patient section of Coorg Institute of Dental Sciences. The study showed no statistical significance. The P value was greater (0.598 ). However the mean value showed a slight difference (Table 3 ) between case and control but are with in the normal range.
DISCUSSION
Oral cancer developing from a precancerous lesion is common.According to the literature the deleterious oral habits leads to potentially malignant disorders.The habits such as use of tobacco both in smoking and non-smoking, pan masala, Gutkha, and products which contain areccanut is the main causative agent for potentially malignant disorders. In an Indian preview use of areccanut is the most common agent. This contain certain chemicals which damage the mucosa .The most common damage clinically manifests in the form oral submucous fibrosis.2 Early detection of potentially maliganant disorders can prevent malignant transformation to certain extent. There are several studies done regarding the early detection methods of potentially maliganant disorders namely vital staining, histopathology, and detecting biomarkers. The aim of this study was to evaluate the significance of creatine phosphokinase in oral submucous patients and to compare it with healthy subjects. Oral submucous fibrosis is a precancerous condition characterized by juxtaepithelial inflammatory reaction and progressive fibrosis of the submucosal tissues ie lamina propria and deeper connective tissues(muscle layer). Since it involves the deeper layer as the condition progress the clinical sign is restricted mouth opening. The malignant transformation of oral submucous fibrosis is well documented13 Hence the early detection of this condition is of at most important. Even though it can be clinically diagnosed, the severity of dyspalsia cannot be judged. Hence an alternate method to detect the severity and dysplastic changes is necessary, which are reasonable for systemic involvement. A new enzymatic approach for diagnostic and prognosis of the disease is documented in a study has been done bySpoorthy et al 7 .The diagnostic and prognostics value of creatine phosphokinase as biomarker in other systemic disease are well documented. creatine phosphokinase is an enzyme which is released due to muscle damage in different systemic diseases. Hence this is used as biomarker to find out the extent of muscle damage or the progress of a disease. The importance of biomarkers in muscle damage is documented in a study done by Brancaccio et al. The author recommends to use these biomarkers for muscle stress, and damage12. In a study done by Ravi et al found appositive correlation between creatinie phosphokinase and potentially malignant disorders 7 . In a study done by Partovi et al to find out the impaired microcirculation in systemic sclerosis, found out that the these patients had abnormal elevation of creatine phosphokinase, and other factors14. The studies done by AZl Gani et al, in patients with acute myocardial infarction, found positive coorelation with these patients 15,16 But Joseph et al did their study on colon cancer patients to find out the significance of cretine phosphokinase and got a positive correlation 17. Arthur et al did their study on marathon runners to find the correlation between creatine phosphokinase and exercise. Their study was based on time gap and got a positive correlation between creatine phosphokinase and running18. Zarghami et al found the prognostic value is much less in ovarian cancers due to the drugs administered did not show any metabolism related values19. The exact mechanism for enzyme release is not clear, but some sort of muscle tissue damage can change the serum value of creatine phosphokinase which can be substantiated by the above studies. Since there is the release these enzymes the muscle damage can be assessed at very earlier in different diseases. Out of the various conditions studies done in patients with myocardial infarction showed more significance nevertheless colon cancers ,renal problems also showed significance. The significance of potentially malignant disorders like oral leukoplakia, oral submucous fibrosis showed statiscal significance e in a study done by Spoorthy et al.17,7 But the alteration of creatine phosphokinase level in a marathon runners as the study done by Arthur says it could be related to rhabdomyolysis which is due to over use of the muscle. In a patient developing oral submucous fibrosis due to excessive chewing over many years can be explained against the fact of over use of the buccal musculature. This is also substantiated by the study done by Dessem et al where he studied the muscle response to injury or over use over a long period of time, the levels of creatine phosphokinase are altered in different muscles in different parts of the body 20. The primary factor for muscle damage is due to proteolysis. IL 6, IL1, ANS TNF ALPHA are found increased in submucous fibrosis patients, which are factors which help in proteolysis.21,7 These cytokines are elevated due to activated T –lymphocytes present in the premalignant tissues7 . Keeping this view in mind we designed a study to find out the significance of creatine phosphokinase in oral submucous fibrosis patients. Our study had total 20 patients in the age group of between 40-60 male patient without any other systemic disease, who had habits of chewing of areca nuts. They had no clinical signs of anemia. We did not get a statistical significance between creatine phosphokinase to oral submucous fibrosis against as documented in other literature 7 (Table 1,2,and 3) However we could not trace a literature stating such an increase of creatine phosphokinase in oral submucous fibrosis. This could be due to the difference in pathophysiology of oral submucous fibrosis and other diseases like myocardial infarction and colon cancer, where in the creatine phosphokinase showed a significant correlation 16 But our study shows a mild difference in levels of creatine phosphokinase between normal subjects and oral submucous fibrosis patients.( Figure 1 ) The high range of P value(P value 0.598 ) could be substantiated by the reason that either too low sample, single centered study, and the subject’s severity of the condition of oral submucous fibrosis ie the dysplastic changes could be mild resulting in a no or subclinical muscle damage. In oral submucous fibrosis there is juxtaepithelial inflammatory reaction continued by activation of collagen production pathway leading to deposition of type 1 collagen fibres where as in myocardial infarction there is overuse of the cardiac muscle in a very short time period, which finally results in damage of the heart muscle. This damage causes the alteration in MB part of creatine phosphokinase enzyme. This is substantiated in the study conducted by Paola b et al on muscle damage from direct and indirect aetiological factors.12 Whereas in fibrosis there is reduction in blood supply in the region resulting in reduced nutrient flow, reduced immunity, to the region just as in systemic sclerosis as demonstrated by Partovi et al study14,22 Over a period of time there can be complete fibrosis and loss of activity of the muscle leading to improper diet, nutrition, minerals and thereby poor quality of life.
CONCLUSION
From this study we conclude that there is no definite underlying biochemical alteration with respect to enzyme creatine phosphokinase as a diagnostic marker for oral submucous fibrosis and this biomarker is not reliable.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholers who articles are cited and included in reference of this manuscript. The authors are also greateful to authors of 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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11. Willie L. Ruff, PhD, Roger Worrell, MD. Diagnostic Value of Creatine Phosphokinase (CPK) lsoenzymes in the Absence of Elevated Total CPK.Journal of the National Medical Association. 1979.71 (4).
12. Paola Brancaccio1, Giuseppe Lippi, Biochemical markers of muscular damage. Clin Chem Lab Med 2010;48(6).
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareCROWN LENGTHENING BY ORTHODONTIC FORCED ERUPTION - A CASE REPORT
English7983Maheaswari RajendranEnglish Jayshree Tukaram KshirsagarEnglish Golla Usha RaoEnglish Hema Jane ChristaEnglishAim: To increase the clinical crown height of the fractured tooth in the maxillary aesthetic zone for successful rehabilitation.
Objective: To utilise the orthodontic forced eruption technique in a single fractured anterior tooth to gain the required clinical crown height for ideal restoration.
Case Description: The article presents crown lengthening of a subgingivally fractured maxillary central incisor by means of orthodontic forced eruption for optimal restoration with the multi-disciplinary approach.
Conclusion: Although clinical crown lengthening can be done for subgingivally or gingivally fractured tooth with various methods, the orthodontic forced eruption technique is best suited in cases where optimal aesthetics is required.
EnglishCrown lengthening, Biologic width, Orthodontic forced eruption, GingivoplastyINTRODUCTION
Tooth fracture or advanced caries at or below the level of the crestal bone poses a periodontal and restorative challenge.(1) These teeth were doomed for extraction because of poor access for restoration. But on the long terms, tooth extraction is an expensive option with multiple disadvantages. (13) Extraction results in resorption of the alveolar bone, which makes aesthetics difficult to accomplish. (13) Alternatively, crown lengthening procedure has made retention and restoration of such grossly damaged teeth possible. (2)
Crown Lengthening:
Crown lengthening is the procedure which increases the supragingival tooth structure for both restorative and or aesthetic purposes.(4) Crown lengthening that is done for restorative (functional) purposes aims to gain sound tooth structure above the level of the alveolar crest to enhance the retention and resistance form of the tooth.(4) To restore a damaged tooth by crown lengthening, the coronal extent of the remaining tooth structure should have a minimum length of 3.5-4 mm from the alveolar crest or 1-2mm of sound tooth structure coronal to the epithelial attachment.(3) If the tooth structure is lesser than 3.5mm from the alveolar crest, the preparation needs to be extended subgingivally to obtain at least 1.25 mm of ferrule, and this causes a risk of impingement on the junctional epithelium and the connective tissue attachment.(3) In order to prevent this, crown lengthening has to be done. Crown lengthening can be done either surgically or orthodontically.
Surgical Crown Lengthening:
Surgical crown lengthening is the traditional method of treatment of a tooth with caries or trauma extending upto or apical to the alveolar crest. Surgical crown lengthening is done by gingivectomy or apically positioned flap with or without bone recontouring.(2) Gingivectomy will suffice if only 1-2mm of crown height needs to be increased and if the tooth has sufficient width of attached gingiva and has a probing depth of 4mm. (2,4)Apical repositioning of the flap with bone recontouring is done when more amount of crown has to be exposed. The main disadvantage of crown lengthening with apically positioned flap is that supporting bone from adjacent teeth is removed to achieve an even contour, which can compromise their function.(3) This procedure can also result in loss of the interdental papilla, opening of the embrasures, long clinical crowns and compromises the aesthetics, which the clinician is striving to achieve. (2,13)
Orthodontic Tooth Extrusion / Forced Eruption:
Orthodontic root extrusion was first introduced by Heithersay and Ingber. (8)This technique is based on principles of osteophysiology and orthodontics and it uses continuous force. (1) The objectives of orthodontic tooth extrusion include preservation of biologic width, exposure of sound tooth structure for optimal placement of restorative margins, and esthetics. (1). Orthodontic tooth extrusion can be done as a slow or rapid extrusion.(14) In slow orthodontic eruption, the periodontium – gingiva, periodontal ligament and alveolar bone also migrate coronally along with the tooth. The tension created by the light orthodontic force elongates the periodontal fibre bundles and induces osteoblasts to deposit new bone, which results in the coronal shift of the bone as the tooth moves occlusally. Once the desired crown length is achieved, ostectomy is performed in the particular tooth without causing alteration ofthe periodontium of the other surrounding teeth.(10) In rapid orthodontic extrusion, the alveolar bone is left behind temporarily and to prevent the bone from moving coronally, circumferential fiberotomy is performed. (14) Circumferential fiberotomy is the procedure where scalpel blade is used to severe the supracrestal connective tissue fibers around the tooth (15)The supracrestal connective tissue fibers of the tooth are stretched as the tooth is extruded. (1) These fibres are resected by supracrestal fiberotomy in order to remove the tensile stress on the alveolar crest, which in turn prevents the gingiva and bone from following the tooth. (1) Fiberotomy also maintains inflammation in the area near the marginal bone and this inflammation does not allow the marginal bone to follow the tooth coronally and the procedure is performed every 7-10 days. (5)
Orthodontic extrusion is not possible in:
a) Unfavourable axial tooth position.
b) Compromised periodontal health.
c) Short roots that would result in inadequate crown-toroot ratio (8)
d) Tapered roots.
e) Wide internal root form.
Orthodontic tooth eruption is the preferred mode of treatment to avoid the negative consequences of surgical crown lengthening, especially in aesthetic areas. Whenever orthodontic extrusion is decided as the means for crown lengthening, rapid extrusion is preferred to slow extrusion as it obviates the additional surgical procedure which is needed when a tooth is slowly extruded. It is an interdisciplinary treatment that requires the expertise of the endodontist, periodontist, orthodontist and prosthodontist.
CASE REPORT
A 36-year-old male patient was referred from the Department of Conservative Dentistry and Endodontics for crown lengthening of endodontically treated 11. On examination, it was found that the patient had Ellis class III fracture of 11 and the fractureline was present subgingivally. The gingiva was healthy with the probing depth of 2mm. IOPA radiograph revealed an intact root canal filling in 11 with normal bone architecture. There was no root fracture or periapical pathology in 11. Considering aesthetics and the amount of tooth structure available, the case was planned for rapid orthodontic extrusion of 11 along with supracrestal fiberotomy. Post space was prepared and the fabricated cast post and core was cemented with glass ionomer cement to enable orthodontic banding of the tooth. Subsequently, 11 was banded with Begg’s bracket and 0.016 inch Nickel titanium wire was tied within the bracket slot and secured with lockpin. The appliance was activated every 7 days and circumferential supracrestal fiberotomy was performed in 11 under local anesthesia after every activation. The appliance was activated till 4 mm of tooth structure was extruded. This was achieved in a span of one month and the tooth was stabilized in place for 4 months. On removal of the appliance, the marginal gingiva on the labial aspect was noted to be enlarged and unesthetic and the probing depth was 4 mm. Scaling and root planning was done in 11 but when the patient reported after 4 weeks, gingival hyperplasia was persistent with a probing depth of 4mm. Hence gingivoplasty was done on the labial aspect of 11 under local anasthesia to achieve an aesthetic gingival margin. On review after 2 weeks, the healing was satisfactory. Probing depth was 2mm and bone sounding measurement was 3 mm. The patient was then referred back to the Department of Conservative Dentistry and Endodontics for restoration of 11 with ceramic crown.
DISCUSSION
Crown lengthening is a procedure that is done to increase the clinical crown length to permit aesthetic restoration of the tooth without violating the biologic width. (11) It is mandatory that sound tooth structure be available coronal to the tooth’s attachment apparatus to optimally restore a tooth.(19) Several techniques are available for crown lengthening. Each technique has its unique indications, contraindications, advantages and disadvantages. This case describes the successful and optimal restoration of the tooth 11 that was fractured at the subgingival level. (10) As the tooth 11 was fractured at the subgingival level, there were three options for restoration of 11 – post and core with crown, surgical crown lengthening, orthodontic forced eruption. Whenever a tooth is prepared to receive a crown, the margins should remain on sound tooth structure for the restoration to be stable and have a good prognosis. This requires a ferrule of 1.25 to 2.5 mm. The fracture resistance of the restoration increases when the ferrule length is 1.5 to 2.0 mm.(18) However, a tooth with root canal filling and post and core demands for a ferrule of at least 2 mm to resist fracture. (17) Since the tooth was fractured at the subgingival level and the probing depth was 2 mm, placement of a subgingival crown margin to achieve the desired ferrule was not possible as it will violate the biologic width. So the first option of restoring the tooth using post and core with crown was eliminated. The second option was surgical crown lengthening with ostectomy. The advantage of this procedure is that the length of the crown can be immediately increased. But the major drawback is that crown lengthening would need to be performed from 13 to 23 to achieve an even aesthetic contour. This will necessitate unnecessary removal of supporting bone from several teeth. The third option was orthodontic forced eruption. The length of the root as measured from the radiograph was 14 mm. 4 mm of tooth was planned to be extruded and it was calculated that after 4 mm extrusion, adequate root length will still remain to provide favourable crown-to-root ratio of more than 1:1. (19) Crown-to-root ratio serves as an aid to predict the prognosis of the tooth.(12) Ideally the ratio should be 1:2 or a bare minimum of 1:1 in extreme cases. (6) When the ratio is higher, the crown portion of the prosthesis will have greater leverage and the root will have lesser resistance, which will ultimately affect the prognosis of the tooth. (6) The root form of 11 as noted from the intra oral periapical radiograph was broad and cylindrical and hence favourable for forced eruption. Generally there is a significant tendency for the roots to taper from the cervical margin to the apex, especially in the maxillary anteriors. (3) When the root has a marked taper, the cervical diameter becomes lesser as the root is extruded. (3) This will cause the crown restoration to have bulky unphysiologic cervical margins or crown will have a distinctly narrow cervical dimension causing excessively wide, unaesthetic embrasures. (3) The canal space of 11 was narrow and hence indicated for forced eruption. If the root canal is wider, the root structure between the root canal filling and the external root surface will be narrow. In such a scenario, crown preparation will result in much thinner root structure, which may result in fracture of the tooth. (14) The tooth 11 met all the criteria for crown lengthening by forced eruption. When faced with the option of slow and rapid extrusion, rapid extrusion was decided because extrusion can be done as rapid as 1 mm per week. (7,16) Forced eruption coupled with fiberotomy is the most preferred option when crown lengthening is required for a single tooth as it is easier, fast and cost effective. After 4 mm of crown was extruded, the tooth was stabilized in place for 4 months to allow for proper reorganization of periodontal fibres. This is because the periodontal fibers are stretched and obliquely oriented as the root is moved coronally and these fibres take about 6 weeks to 6 months to reorient themselves. (14) Also, in the 4 – 6 months period, bone remodeling and maturation occurs which prevent reintrusion of the tooth. (7) During fixed appliance treatment, there is an increase and change in the microbial load with a substantial increase in motile rods supragingivally and spirochetes subgingivally. (20) Hence, most of the patients treated with fixed orthodontic appliance experience moderate gingivitis and varying degrees of gingival hyperplasisa. The gingival hyperplasia can be managed nonsurgically and surgically. As the nonsurgical interventions such as scaling and root planning failed to resolve the hyperplasia, gingivectomy was done and physiologic gingival contour was obtained. After a healing period of 2 weeks ceramic crown was fabricated and cemented with glass ionomer cement in 11 and the patient’s smile was made aesthetically pleasing.
CONCLUSION
Multiple treatment options are available for restoring a tooth with gingival or subgingival fracture. An important criterion which the clinician has to bear in mind is preservation of the biologic width. Though the choice of treatment depends upon several tooth related factors and also the clinician’s preference, this novel multidisciplinary technique of forced eruption is the best choice when clinical crown lengthening is required in the aesthetic zone for a single tooth, provided the tooth has favourable root length and taper.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the authors whose articles are citied 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=507http://ijcrr.com/article_html.php?did=5071. Shyammohan A. Forced eruption: An adjunct to prosthodontic treatment planning. Indian J Stomatol. 2011; 2(4) : 260-62.
2. Liudvikas Planciunas, Alina Puriene, Grazina Mackeviciene. Surgical lengthening of the clinical tooth crown. Stomatologija, Baltic Dental and Maxiollofacial Journal. 2006; 8: 88-95.
3. Ayush Razdan Singh, Ruchita Verma. Crown lengthening versus forced eruption. Orthodontic Journal of Nepal .2011; 1(1) : 52- 55.
4. Marianne Ong, Shin-Chang Tseng, Hom-Lay wang. Crown Lengthening Revisited. Clinical Advances in Periodontics. 2011; 1(3).
5. CC Hung Biologic Width (III): Surgical Crown Lengthening 2012; https://hungdentalis.wordpress.com.
6. Gary Greenstein, John S Cavallaro Jr. Importance of Crown to root and Crown to Implant Ratio’s. Dent Today 2011Mar; 30(3):61-2,64,66 passim;quiz71,60. www.ncbi.nlm.nih.gov/ pubmed/21485881.
7. Monira Uddin, Natia Mosheshvili, , Stuart L Segelnick. A new appliance for Forced Eruption.NYSDJ 2006; 46-50.
8. Georgia K, Johnson, Joan E. Sivers. Forced eruption in crown lengthening procedures. J Prosthet Dent 1986;56(4):424-27.
9. Amit Smidt, Gleitman, Joseph Dekel, Mikhal Steinkeller. Forced eruption of a, solitary non-restorable tooth using mini-impants as anchorage: Rationale and Technique. Int J Prosthodont 2009; 22(5):441-446.
10. Rafael Scafde Molon, Erica Dorigatti de Avila, Joao Antonio, Chaves de Souza, Andressa Vilas Boas Nogueira, Rogerio M et al. Forced orthodontic eruption for augmentation of soft and hard tissue prior to implant placement. Contemp Clin Dent 2013; 4(2):243-47.
11. Ramya Nethravathy, Santhana Krishnan Vinoth, Ashwin Varghese Thomas. Three different surgical techniques of Crown lengthening: A comparative study. J Pharm Bioall Sci. (serial online) 2013 (cited 2014 APR 19); 5:14-6. Avail at http://www. ipbsonline.org/text.asp? 2013/5/5/14/113281.
12. Grossmann Y, Sadan A – The prosthodontic concept of crownto-root ration: A review of the literature. J Prosthet Dent 2005; 93:559-62.
13. Rob Veis. Forced eruption – Raising the root with gentle, continous force in a coronal direction. The Practice Building Bulletin 1993; 1(9) Chatsworth California.
14. Newman, Takei, Carranza. Editors. Carranza’s clinical periodontology. 11thed. New Delhi: Elsevier; 2012.
15. Jan Lindhe, Thorkild Karring, Niklaus P. Lang. Editors. Clinical Periodontology and Implant Dentistry ; 5th ed. Oxford: Blackwell Munksgaard; 2008.
16. .Ashu Sharma, G.R. Rahul, Poduval.T, Karunakar Shetty, Bhavna Gupta. Short Clinical crowns (SCC) – Treatment considerations and techniques. J ClinExp Dent 2012;4(4): e230-6.
17. Maduri R, Seshu K, Gash C.L. Multidisciplinary Management of a Fractured Premolar: A case Report with Follow up. Case Rep Dent 2012;2012:192912http://dx.doi.org/10 1155/2012/192912.
18. Kantheti Sirisha Yalawarthy N.S, Suneetha K. Management of crown root fractures : A novel technique with multidisciplinary approach. J NTR Univ Health Sci 2013; 2(1): 72-77.
19. Luis Antonio Felippe, Sylvio MonteiroJr, Luis Clovis Cardoso Vieira, EliotoAraujo, Re-establishing biologic width with forced eruption. QuitessenceInt 2003; 34(10).
20. Michael Florman, A softtissue maintenance during orthodontic treatment. www.rdhmag.com/index.html 2007; 27(10).
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241713EnglishN-0001November30HealthcareINDUCTION AND REGENERATION OF CALLUS FROM DIFFERENT EXPLANTS IN CITRUS RETICULATA (BLANCO.)
English8488Vishwanath WaghmareEnglish Narayan PandhureEnglishThe present work was focus on the induction of callus by introduced cotyledon, leaf, stem and shoot explants on MS mediumsupplemented with BAP, KIN, IAA, IBA and 2, 4-D in different concentration and combination. MS medium alone with BAP 1.0mg/l and 1.0 mg/l 2, 4-D induce highest percentage of callus, whereas combination of 2, 4-D alone with 0.5mg/l and 1.0mg/l KIN and combination of BAP 1.0mg/l, 1.5 mg/l, 2.0 mg/l, 2.5 mg/l and 3.0mg/l alone with 0.5 mg/l, 1.0mg/l, 1.5mg/l and 2.0 mg/l IAA and IBA were callus reported. Maximum percentage of callus was reported by leaf explant using 1.0 mg/l 2, 4-D combination
with 1.5 mg/l BAP. MS medium supplemented with above PGRs either alone or with different combination and concentration all the above explants of C. reticulata were potential capable to regenerated callus.
EnglishCitrus reticulata, Callus induction, Explant, Growth hormonesINTRODUCTION
Citrus is an important horticultural fruit crop, widely cultivated throughout the world for its fine flavor, test, vigor and nutritional quality. Under the cultivation of Citrus area Himalayan hill range North India to North China and Burma, Indonesia, Thailand and Caledonia of south range. According to the FAO total Citrus producer country in the world are 142 and its most production depends on Northern Hemisphere region about 70% of Citrus production in this area. It is considered as a topmost crop fruit of the world due to its high production, nutritional value, fruit products and use in citrus industry is known as a major fruit industry. In India Citrus after the Mango and Banana is third largest fruit crop cultivated for food and fed. It is mostly cultivated in 26 States in India Viz. Andhra Pradesh, Maharashtra, Punjab, Gujarat, Madhya Pradesh, Rajasthan, Karnataka, Orissa, Assam and Uttarakhand etc. Most popular cultivated Citrus veritiesare mandarin (C. reticulata), sweet orange (C. sinensis), lemon (C. aurantifolia). Nutritionally Citrus fruits demandable for their fragrance, containing flavonoids and phytochemicals in rinds and lots of edible juice, it is having high quantities of Citric acid from their characteristic of fine flavors and its biochemical provide health and benefits, being good sources of vitamin C, flavonoids, fiber, and folic acid (Chinelo et al, 2013). For the propagation practice Citrus varieties can be cultivation by both sexual and asexual propagation methods, generally it is cultivated from seed but there are some disadvantages such as seedling produced by plantlets cannot bear fruits before one decade old. Seedling and young plantlets may suffer from disease if unfavorable soil conditions and sometimes plantlets produced by seeds cannot true-true type or similar with the mother plant (Chaudhary M.I. 1994).When the propagation done by grafting, scion and budding etc., this is desire fruiting propagation depend on rootstock selection for disease resistance and hardiness. But these conventional methods of propagation having some barrier, there are more chances of transfer of pathogen plant to plant. As many commercial Citrus crops, subjected to various biotic stresses, virus and viroid’s have been recognised as serious problem limiting the vigour, yield and quality. Severe infections have resulted in the exclusion of some cultivars from commercial usage. (Santos et al., 1984) reported that viral diseases are major threats affecting citrus industry. The diseases are graft transmissible through grafting and infected bud sticks. Hence applied bioscience deals with tissue culture to rising pathogen free, stress resistance, high yield, improved quality and quantity of plants. The cell and callus cultures are extensively used for development of genetic variants in plant through the selection, screening and somaclonal variation. The in vitro techniques tried to induce variation throughout the year and an efficient to age limits of plant or seasonal variation. Currently it has widely accepted for crop improvement such as fruits, vegetable, cereals and medicinal plant. Therefore present research study aims to evaluate standardized protocol of in vitro regeneration of callus from different explant and development of variant through caulogenesis.
MATERIAL AND METHODS
Primary source of explant andsurface sterilization: Fruits of Citrus reticulata (Blanco) were collected from different localities of Marathwada region. These fruits were dissected for the seeds and the seeds were washed carefully in running tap water for 7 minutes and followed by distilled water. For the surface sterilization70% ethanol and 0.3 % mercuric chloride (HgCl2) were used. The healthy collected Seeds were surface sterilized with70% ethanol for 1 minute followed by0.3% Hgcl2 (three minutes) after that three subsequent rinses with sterilized glass distilled water, all these above process carried out in a laminar airflow. Sterilized seeds were dissected and removing the seed coat without any damages and aseptically inoculated in test tube as well as culture vessels.
Medium and storage condition: In the present research work MS medium (Murashige and Skoog, 1962) was used for all the experimental work such, germination of seeds, initiation of callus and regeneration of shoots from callus by using different explants of C. reticulata. MS medium fortified with 3% sucrose and gelled with 0.3%, Clerigel along with various concentrations of PGRs like BAP, KIN, IAA, IBA and 2, 4-D with different concentration and combination. After the adding of growth regulators the pH was adjusted 5.8. Then the media was steam sterilized under 15 psi pressures and 121° C temperature in an autoclave. After the autoclave these media was transfer to laminar air flow for solidified and inoculation of explant. For the incubation period culture vessels were sifted to incubation room at a constant 25 ± 0 C temperature for 30 Days and, a growth chamber with 16 hours of photoperiod of cool white fluorescent tubes light and 60 % relative humidity.
RESULTS
Sterilized seeds of C. reticulata were dissected and remove the seed coat without any damages and aseptically inoculated on MS medium along with various concentrations of PGRs for germination of seeds. After the 25 days these seeds were germinated and produce more than two seedlings it is considered as C. reticulata seeds have a polyembryonic. The present work was concentrated on induction of callus from cotyledon, leaf, stem and shoot explants these segments excised from in vitro grown seedling or plantlets. All these explants of C. reticulata regenerated callus when it was inoculated on MS medium Supplemented with optimum concentration of 2, 4-D either alone or in combination of BAP and KIN.
Effect of 2, 4-D on Initiation of callus Excised leaf, cotyledon, shoots and stem segments were introduced on MS medium supplemented with 2, 4-D at range 0.5-2.0 mg/l along with BAP 1.0 mg/l and Kin 0.5 mg/l for the induction the callus. When these explants were inoculated on MS medium along with BAP 0.5-2.0 mg/l combination with 0.5-2.0 mg/l IBA or IAA, able to induce callus but MS medium alone with KIN at various ranges of concentration and combination produce very low percentage of callus was reported (table 1). Leaf excised explant was inoculated on MS medium supplemented with 2, 4-D 1.2 mg/l either alone or combination with BAP 1.0 mg/l derived highest percentage of induction of callus, these calli observe brownish color and fibril in nature were also recorded. Leaf callus was transfer on MS medium supplemented with different optimized concentration and combination of BAP, KIN, IBA and IAA they do not shown regeneration of shoot activity. The cotyledon and shoot explant were inoculated on MS medium supplemented with 2, 4-D, BAP, KIN, IAA and IBA at different concentration develops callus, 2, 4-D 1.0 mg/l alone with 1.0mg/l BAP produce maximum percent of callus was recorded. These calli were derived from cotyledon and shoot tip explant, it must be regenerated by shoots also reported in the presence study; these callus was raised from cotyledon explant these are observed in greenish color and compact in nature.
Effect of BAP on Initiation of callus The leaf excised explant was inoculated on MS basal medium addition with 1.5 mg/l BAP in combination 1.0 mg/l IAA, or 1.5 mg/l IBA produce highest percentage of callus. But it was inoculated on MS contain KIN 1.0 mg/l 1.5, mg/l and 2.0 mg/l either alone combination of 1.0 mg/l 1.5 mg/l and 2.0 mg/l produce average percentage of callus was also observes. Cotyledon and shoot tip explant produce highest percentage of callus, when it was introduced on MS basal medium containing BAP 2.0 mg/l combination with 1.5 mg/l IAA and 1.0, 1.5 mg/l IBA. The callus produced by cotyledon explants, it was compact and yellowish and greenish in color observe, it is able to induce direct somatic embryos then later on shoot. These explants were introduced on MS medium supplemented 1.0 mg/l 2, 4-D in combination with different concentration of BAP and KIN produce maximum percentage of callus, but it cannot regenerate the somatic embryos and shoots. Nodal and stem explants were inoculated on MS medium containing 0.5 mg/l, 1.0 mg/l, 1.5 mg/l, and 2.0 mg/l 2, 4-D in combination with BAP induce highest percentage of callus. After the 21 day these calli were subculture on MS medium supplemented with different concentration and combination of BAP, IBA and IAA, result relevant to cotyledon explants shoot proliferation observed. Total biomass of callus was calculated such as fresh weight, dry weight and moisture content, gram per culture as shown (table 2).
DISCUSSION
The stem or nodal explants were developed highest percentage of callus on MS medium supplemented with 1.5 mg/l 2, 4-D alone with 1.0 mg/l BAP was recorded. That callus was raised from stem explant it is observed in yellowish color. The optimum concentrations of 2, 4-D at 1.0-1.5 mg/l were produced maximum percent of callus. Recently Isnaini and Riyanto (2014), similar results were reported that Citrus species have capacity regenerate callus from embryo, leaf, stem, nodal, shoot tip and cotyledons explants, out of that these calli derived from nodal segment, it was able to develop shoots by using optimum concentration and combination of BAP + IBA + NAA and 2, 4-D. But in present study shoot proliferation was achieved through cotyledon explant by using different concentration and combination of BAP + IBA + NAA as shown table 1. All the results on induction of calli were significantly associated with used optimized concentration from 2, 4-D. The callus induced by stem explant it was whitish in color observed in present study. These results summarized by, Chayanika et al, (2011) cotyledon explant of C. reticulata inoculated on MS basal medium contains 5 mg/l BAP + different concentration of NAA produce 80 % of shoots. Ibrahim M. (2012) also reported that cotyledon explant cultured on MS basal medium containing 4.0 mg/l BAP + 0.1 mg/l NAA induce callus, these callus produce shoots indirectly, when subculture on MS media containing 1-2 mg/l BAP + 0.1 mg/l NAA the after one month.
CONCLUSION
Present work was concluded that all the vegetative part of C. reticulata induce maximum percent of callus when the use of 2, 4-D above 1.0 mg/l either alone or in combination BAP. Callus derived from cotyledon and nodal region, those are able to regenerate shoot proliferation, when it was subculture on MS medium alone with BAP + IBA or IAA with optimized concentration.
ACKNOWLEDGEMENTS
Authors are grateful to Professor and Head, Department of Botany, Dr. Babasaheb Ambedkar Marathwada University, Aurangabad (M.S.), India for providing all necessary facilities and encouragement for the present research work. Authors are also thankful to Dr. Babasaheb Ambedkar Marathwada University Aurangabad, for awarded the University Scholar fellowship. 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=508http://ijcrr.com/article_html.php?did=5081. Chaudhary M. I. (1994). Fruit Crops, In: Malik M.N. (ed.), National Book Foundation, Islamabad.Horticulture, 422.
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