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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30General SciencesEGG PRODUCTION PERFORMANCE OF THREE VARIETIES OF GUINEA FOWLS IN HUMID TROPICS
English0106Onunkwo D. N.English Okoro I. C.EnglishAn investigation into the egg production performance of three varieties of Guinea fowls was studied. The experimental varieties were Pearl (Sake), Lavender (Hurudu) and Black (Angulu). Base populations of 180 guinea fowls were used to generate 144 F1 females comprising 48 birds per variety. Each variety was divided into three randomized replicates containing 16 birds per replicate. Data were collected fortnightly on egg production performance traits. Parameters collected for egg production included Body Weight (BWT), Body Weight Gain (BWG), Feed Intake (FI), Feed per Dozen Egg (FDE), Feed Efficiency (FE), Egg Number (EN), Percent Hen Day Production (% HD). Data collected were treated statistically. The Pearl, Lavender and Black varieties showed some similarities in the trend produced for some parameters. Body weight gain and mortality percent portrayed a decreasing trend as egg number increased, whereas, the daily feed intake, percent henday, and feed per dozen eggs tended to increase with an increase in egg number. The three varieties also demonstrated differences in such traits like feed efficiency, feed per dozen egg and body weight. These differences in phenotypic performance may suggest some level of genetic differences in these varieties and thus further research on the genetic characteristics of helmeted guinea fowl varieties is recommended.
EnglishEgg production, Guinea fowl, Performance, Humid tropicsINTRODUCTION
Guinea fowl (Numida meleagris) are indigenous to WestAfrica North of the Equatorial forest where there is an estimated population of about 4.7 million (FDLPS/RIM, 1991). It got the name ‘Guinea’ because it was believed to have originated from Guinea in West Africa. They are a common game bird in the Savanna Region of Nigeria. Guinea fowls are seasonal breeders which has been recognized as one of the major drawbacks to large scale Guinea fowl production. In the wild, production starts at 28-42 weeks with 15-20 eggs being laid each season while in captivity, production starts at 28-32 weeks with 50-100 eggs being produced in the first year and more eggs (180) are laid in the second year of production and laying may continue for 7 or more years (Ayorinde, 1990). Among domestic types which the peasant farmers have long identified and given local names based on their coloration are Pearl (Sake), Lavender (Hurudu), Black (Angulu) and White (Faren Zabi) (Ikani and Dafwang, 2004). The Pearl variety is the most common and probably the first developed from the Wild West African birds (Ikani and Dafwang, 2004). According to Ikani and Dafwang (2004), the advantages include that, Guinea fowls are more capable of coping with the effects of dry weather conditions prevailing in the Northern Guinea Savanna and Sahelian ecological zones than other domestic poultry; the over 50 million semi-domesticated guinea fowls in Nigeria constitute about 25% of the entire domestic poultry population in Nigeria making it variable source of animal protein which is socially acceptable. Body weight is an attribute of egg size. The poultry producer wants eggs of minimum possible size and weights that will maximize production of standard sized eggs at an economic rate and still maintain market carcass value at the end of the production period (Oke et al., 2004). Ayorinde et al. (1988) reported consistent reduction in body weight, which they attributed to increased body use of physiological reserve to meet the demand for egg production, Oke et al. (2004) reported initial gains in body weight which reduced and in some cases fluctuated with rise in egg production. Farooq et al.(2002), opined that feed consumption and its efficient utilization is one of the major concerns in commercial table egg production as feed cost is one of the major components of total cost of production. Better utilization of feed and avoiding unnecessary feed wastage could be the leading factors in minimizing total cost of production (Elwardanyet al., 1998).
MATERIALS AND METHODS
Location of Study
This study was carried out in the Teaching and Research Farm of Michael Okpara University of Agriculture, Umudike, located at about ten kilometers from Umuahia, the Abia State capital. Umudike bears the coordinate of 5°281 North and 70 321 East, and lies at an altitude of 122 meters above sea level. The environment of study was situated within the Tropical Rainforest zone and is characterized by an annual rainfall of about 2177 mm. The relative humidity during the rainy season is well over 72 %. Temperature ranged from 22 0 C - 36 o C with March being the warmest month, while July to October represents the coolest period with a temperature range of 22 0 C – 30 o C (Nwachukwu, 2006).
Acquisition and Mating of Base Population
One hundred and eighty adult guinea fowls of three varieties were procured from several markets in Zaria. The base population consisted of 36 adult males, and 144 adult females. Each variety had 12 males and 46 females each. These adults were quarantined for two weeks. A mating ratio of 1 male: 3 females were maintained and the mating scheme adopted was as shown below:
• Pearl male X Pearl female - Homozygous Pearl variant main cross
• Lavender male X Lavender female - Homozygous Lavender variant main cross.
• Black male X Black female - Homozygous Black variant main cross.
Experimental Animals and Management
The eggs laid by the base population were set and hatched at Kanem Hatcheries off Aba-Owerri Road, Aba. A total of two hatches which were one week difference resulted in 350 F1 keets. The keets were sexed by visualizing the vent and listening to the cry of the birds. The testicles of a male protrude when viewed via the vent whereas none is found in the vent of the females. More so, the males made “kee ke kee ke” sound whereas the females made “buck-wheat buck-wheat” or “put-rock put-rock” sound. All F1 male keets hatched were culled leaving only 165 F1 female keets which were used for the experiment. The keets were brooded for six weeks and subsequently reared until the 28th week when they started laying eggs. At the 28th week, 144 adult females were randomly selected out of the 165 females and wing-banded. The 144 adult females consisted of 48 females of Pearl, Lavender and Black each. Each variety was replicated three times, which gave a total of 9 replicates (B1, B2, B3, P1, P2, P3, L1, L2, and L3) for all the varieties, with 16 females per replicate. The guinea fowl varieties were raised in deep litter pens under natural daylight. Feed and water was provided ad-libitum. During the laying phase, layers mash containing 2900 kcal/kgME and 20.5 % CP according to Oguntona (1983) was introduced to the guinea fowl varieties. The nutrient composition of the layers diet is shown in table 1 below:
Data Collection and Analysis
Data collection started in April when the birds were at the 28th week of age and lasted for 18 weeks. The following parameters were measured for each variety according to Oke et al. (2004) and Obike et al. (2011).
Egg Production Parameters
• Body Weight (BWT): The initial body weight at the 26th week of age was measured and subsequently, fortnightly, using a 5 kg-top loading scale.
• Body Weight Gain (BWG): This was computed on fortnight basis as follows:
• Body Weight at Point of Lay (BWPL): This was measured as the initial body weight of the birds at the start of the experiment at the 28th week.
Body Weight at Final Lay (BWFL):
This was measured as the final body weight of the birds at the end of the experiment at the 46th week.
• Feed Intake (FI): This was determined as follows; Total feed given – left over.
• Feed per Dozen Egg (FDE): This was determined as follows:
STATISTICAL ANALYSIS
Data collected were subjected to Analysis of Variance (ANOVA) in Completely Randomized Design (CRD) using the general linear model described by Steel and Torrie (1980). The statistical model used is as shown below:
Significant means were separated using Duncan’s Multiple Range Test (Duncan, 1955). Pearson’s correlation test was done for the egg production parameters, internal egg quality parameters, and external egg quality parameters for the three varieties. A regression equation was derived through regression analysis in order to determine a predictive association between internal egg quality parameters and egg weight, external egg quality parameters and body weight, and egg production parameters and body weight. The regression equation was of the type
RESULTS AND DISCUSSION
The results are presented in Tables 2 and 3 below. The daily feed intake (DFI) recorded significant increases (P0.05) however was observed in mean BWG in the three varieties. Percent henday (HDP) varied significantly (P 0.05) was observed in Black. The Pearl variety maintained a decreasing trend. This might be due to the increasing use of its physiological reserve to meet egg production (Ayorinde et al. (1988) and little or nothing for bodyweight gain. The Lavender variety portrayed a decreasing trend up to week 38 and remained stable thereafter. The decrease may be due to some reasons as noted above for the Pearl. The stable trend however, implies that the Lavender gains and produces in an equal manner. The Black variety showed a nearly stable trend with three outstanding peaks. This observation shows that the Black gained or reduced in weight as much as it increased or reduced egg production. The outstanding peaks in Black were associated with reduced egg numbers. This might be due to non-genetic factors (Chineke, 2001) such as diseases (Downes, 1999) and other environmental factors such as stress from management, and climatic factors which probably affected its metabolism and feed conversion to egg. Significant differences (P0.05) was observed in Black variety. The three varieties showed an initial increasing trend and a terminal decreasing trend. Significant differences (PEnglishhttp://ijcrr.com/abstract.php?article_id=570http://ijcrr.com/article_html.php?did=5701. Adeyinka, F.D., Eduvie, L. O., Adeyinka, I. A., Jokthan, G.E. and Orunmuyi, M. (2007). Effect of Progesterone Secretion on Egg Production in the Grey Helmet Guinea Fowl (Numida meleagris galleata). Pakistan Journal of Biological Sciences, 10: 998-1000.
2. Asuquo, B.O. (1994). Some production parameters of Lohmann Brown broiler parent lines in the humid tropics. Nigeria Journal of Animal Production.
3. Austic, R.E. and Nesheim, M.C. (1990). Poultry production. Lea and Febiger, 13th ed. London.
4. Ayorinde, K. L. (1990). Problems and prospects of guinea fowl production in the rural areas of Nigeria. In: Rural Poultry in Africa (Proceedings of an International Workshop on Rural Poultry Development in Africa), (Ed. Sonaiya, E.B.), African Network on Rural Poultry Production Development, pp.106-115.
5. Ayorinde, K.L., Oluyemi, J.A., and Ayeni, J.S.O. (1988). Growth performance of four indigenous helmeted guinea fowl varieties (N.M. galleata pallas) in Nigeria. Bulletin of Animal Health Production, Africa. 36: 356-360.
6. Chineke, C.A. (2001). Interrelationships existing between bodyweight and egg production traits in Olympia Black Layers. Nigeria Journal of Animal Production. 28 (1): 1-8.
7. Downes, A. (1999). A guide to guinea fowl farming in Malawi. UNDP/Dept. of National Parks and Wildlife, Lilongwe, Malawi.
8. Duncan, D.B. (1955). Multiple Range Test. Biometrics. 11: 1-42.
9. Elwardany, A. M., Sherif, B. T., Enab, A. A., Abdel-Sami, A. M., Marai, I. F. M. and Metwally, M. K. (1998). Some performance traits and abdominal fat contents of three Egyptian indigenous laying breeds. First international conference on animal production and health in semi-arid areas, El Aris. September 1-3, 471-481.
10. Farooq, M., Mian, M. A., Durrani, F. R. and Syed, M. (2002). Feed consumption and efficiency of feed utilization by egg type layers for egg production.Livestock Research for Rural Development 14 (1).
11. FDLPS/RIM (1991). Nigerian National Livestock Survey Report. Federal Department of Livestock and Pest Control Services, Abuja Nigeria.
12. Gerstmayr, S. and Horsi, R. (1990). The relationship between bodies, egg and oviduct weight in laying hens. Journal of Animal Breeding and Genetics, 107: 149-158.
13. Ikani, E.I. and Dafwang, I.I. (2004). The production of guinea fowl in Nigeria. Extension Bulletin No.207 Poultry Series No. 8 National Agricultural Extension and Research Liaison Services, Ahmadu Bello University, Zaria, Nigeria.
14. Nwachukwu, E.N. (2006). Evaluation of growth and egg production potential of main and crossbred normal feathered, naked neck and frizzle chickens. Michael Okpara University of Agriculture, Umudike. PhD dissertation.
15. Obike, O.M., Oke, U.K. and Azu, K.E. (2011). Comparison of egg production performance and egg quality traits of Pearl and Black strains of guinea fowl in a humid rainforest zone of Nigeria International Journal of Poultry Science, 10(7): 547-551.
16. Oguntona, T. (1983). Current knowledge of nutrient requirements of the grey breasted helmet guinea fowl. In: The Helmet Guinea Fowl (Eds Ayeni, J. S. O, Olomu, J. M. and Aire, T.A.), Kainji Lake Research Institute, New Bussa, Nigeria, pp.121-128.
17. Oke, U.K., Herbert, U. and Nwachukwu, E.N. (2004). Association between bodyweight and egg production traits intock Research for Rural Development 16 (9).
18. SPSS (2007). Statistical Package for Social Sciences. SPSS Inc. 16.0 for windows.
19. Steel, R.G.D. and Torrie, J.H. (1980). Principles and procedures of statistics. A Biometrical Approach. Second edition, MC GRAW-Hill Book Coy. Inc. New York.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareCELL PHONE DEPENDENCE AMONG MEDICAL STUDENTS AND ITS IMPLICATIONS - A CROSS SECTIONAL STUDY
English0713Anuj MittalEnglish Vedapriya Dande RajasekarEnglish Lavanya KrishnagopalEnglishContext: The rising use of cell phone made people dependent on cell phone, to an extent that with usual disruption of services people feel disturbed. Cell phone dependence can be considered as a new diagnostic entity. Current literature proves that there is cell phone dependence among youth but not many studies highlight its implications and magnitude in developing Nations.
Methods and Material: A cross-sectional study was planned to evaluate dependence on cell phone among medical under graduate students and its implications. Total of 309 students studying in second to eighth semester had responded on self administered questionnaire.
Results: Among 309 participants, 131 were males and 178 were females. There was no significant difference between call patterns of males and females. Students were restless when they were unable to contact desired person (3.9+1.47) and when they forget to bring the cell phone (restlessness observed significantly among very frequent users). Total 54% students were angry with cell phone; the common reasons were software problems (29.3%), unavailability of network (23.4%), annoying messages and calls (22.8%). 25% students attend call while driving. False perception of ring was reported by 64.4% users and it was twice
more common among students with emotional bonding score greater than 18.
Conclusions: As observed unjustified use of cell phone may result in problems, therefore health education should be targeted to youth to prevent harmful effect of this great invention.
EnglishMobile phone, Dependence, False perception of ringINTRODUCTION
Currently cell/mobile phone is considered an important accessory, which has been carried by all. The charm of cell phone is more among youth and they spend a good amount of their pocket money on cell phone1 . This rising use of cell phone made people dependent on cell phone, to an extent that with usual disruption of services people feel disturbed. A study conducted among medical students reveals that 19% males and 18% females suffers from nomophobia (fear of being out of contact through cell phone)2 . According to psychiatrist3 cell phone dependence can be considered as a new diagnostic entity as it has properties of excessive use, withdrawal, tolerance and negative repercussions. Major studies done on problems arising due to cell phones are done in developed countries4,5,6,7. Present literature proves that there is cell phone dependence among youth but not many have highlighted its implications and magnitude in developing Nations. Realizing the urgency and importance of situation, present study is planned to evaluate dependence on cell phone among medical under graduate students and its implications. It also focused to assess relationship between dependence, duration of cell phone use and gender preferences.
MATERIALS AND METHODS
A cross-sectional study was planned and a research instrument was developed, which was pretested and validated to achieve study objectives. Considering findings of a study conducted among youth in Mumbai which reported that 58% of the respondents could not manage without a cell phone even for a day8 , minimum sample size for present study was estimated to be 290 with allowable error of 10% and 95% confidence interval. Additional 10% of sample was drawn considering attrition, so sample size was estimated to be 320. Sample was drawn out of 500 students randomly through attendance registers with help of Random Allocation Software. Students were given self administered questionnaire and assured that their confidentiality will be maintained, to get unbiased response. Total 320 students were selected for the study but three students didn’t consented to be part of study and six questionnaires were rejected as they were not completely filled. Out of 311 students two didn’t use cell phone so the final sample size was 309. Data collection was done during August 2011. After data collection, students were briefed regarding Do’s and Don’ts about cell phone use. The data thus collected was entered on Ms Excel and analyzed on SPSS 11.5 software. Chi square test, ANOVA (analysis of variance), post hoc test were applied to derive p values. Multiple logistic regression analysis was used to derive adjusted odds ratio.
RESULTS
Students were selected from second to eighth semester and their mean age being 20.2 years (range 17 to 26 years). Out of 309 participants, 131 were males and 178 were females. As students were having variation in use of cell phone they were divided into four categories: Occasional, regular, frequent and very frequent user (Table 1). There was no significant difference between call patterns of males and females, mean and SD (standard deviation) being 52.62+80.85 and 64.65+97.67 minutes per day. While males were more inclined to use SMS (short message service) with mean and SD of 75.86+115.35 which was significantly different (p=0.003) from females 47.74+56.48. Majority of students preferred call (51.1%) as mode of communication rest of them (48.9%) preferred sending SMS.
Emotional bonding
To assess emotional bonding for cell phone, students were asked to grade their feelings between score of zero to five (zero being calm and five being restless) for circumstantial problems encountered in day to day life. Students became restless when they were unable to contact desired person (3.9+1.47), while stress with other situations mentioned in table 2 were less. Though the score was higher among very frequent users as compared with occasional users but it was not significantly different except when individual forgot to bring his/her cell phone (Post hoc Tamhane test: p=0.024). Stress score was higher among males but it was not significantly different. Females becomes restless when person in front talks continuously over phone, this attitude was significantly different from males (p=0.009). Students preferred to call their friends (53.7%) and parents (40.8%). Call pattern was significantly different among males and females (pEnglishhttp://ijcrr.com/abstract.php?article_id=571http://ijcrr.com/article_html.php?did=5711. Mittal Anuj, Vedapriya Dande Rajasekar, Lavanya Krishnagopal. A study to assess economic burden and practice of cell phone disposal among medical students. J Clin Diagn Res 2013;7:657–60. PMID:23730640.
2. Sanjay Dixit, Harish Shukla, AK Bhagwat, Arpita Bindal, Abhilasha Goyal, Alia K Zaidi, et al. A study to evaluate mobile phone dependence among students of a medical college and associated hospital of central India. Indian J Community Med. 2010;35:339–41. PMID:20922119.
3. Bhatia Manjeet Singh. Cell Phone Dependence — a new diagnostic entity. Delhi Psychiatry Journal 2008;11:123-4.
4. Braune SA, Riedel J, Schulte-Monting J, Raczek J. Influence of a radiofrequency electromagnetic field on cardiovascular and hormonal parameters of the autonomic nervous system in healthy individuals. Radiat Res. 2002;158:352-6.
5. Eliyahu I, Luria R, Hareuveny R, Margaliot M, Meiran N, Shani G. Effects of radiofrequency radiation emitted by cellular telephones on the cognitive functions of humans. Bioelectromagnetics 2006;27:119-26.
6. Oftedal G, Wilen J, Sandstrom M. Mild Symptoms experienced in connection with mobile phone use. Occup Med (Lond) 2000;50:237-45.PMID:10912374.
7. Rubin GJ, Hahn G, Everitt BS, Cleare AJ, Wessely S. Are some people sensitive to mobile phone signals? Within participants double blind randomised provocation study. BMJ 2006;332:886-91.PMID:16520326.
8. Database on the Internet: Macro - market analysis and consumer research organization. A report on study of mobile phone usage among the teenagers and youth in Mumbai, April-May-2004 page 1-24. [Cited 2013 Oct 1] Available from:http://www.itu.int/osg/spu/ni/futuremobile/socialaspects/ IndiaMacroMobileYouthStud.y04.pdf
9. Kumar L, Chii K, Way L, Jetly Y, Rajendaran V. Awareness of mobile phone hazards among university students in a Malaysian medical school. Health 2011;3:406-15.
10. Zulkefly SN, Baharudin R. Mobile Phone use Amongst Students in a University in Malaysia: Its Correlates and Relationship to Psychological Health. European Journal of Scientific Research 2009;37:206-18.
11. Sonu H. Subba, Chetan Mandelia, VaibhavPathak, Divya Reddy, Akanksha Goel, Ayushi Tayal, et al. Ringxiety and the mobile phone usage pattern among the students of a medical college in south India J Clin Diagn Res 2013;7:205- 9. PMID:23542709.
12. Website- timesofindia.com [Internet]. Chennai: Times of India, Chennai, Bennet, Colman and Co. Ltd; c2013, [updated 2011 Sept 18; cited 2013 Oct 1]. Available from: http://articles.timesofindia.indiatimes.com/2011-09-18/chennai/30171796_1_mobile-phones-train-accident-hand-heldphones
13. Website– nbcnews.com [Internet]. Washington: NBC News, Washington;c2013 [updated 2009 March 3, cited 2013 Oct1]. Available from: http://www.nbcnews.com/ id/29494331/ns/us_news-life/t/train-crash-probe-focuses-cellphone-use/
14. Website- latintimes.com [Internet]. Newyork: Latin times, IBT Media;c2013, [updated 2013 June 30, cited 2013 Oct1]. Available from: http://www.latintimes.com/articles/6892/20130730/spain-train-crash-cell-phone-speedingderailment.htm
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcarePROCESS PERFORMANCE AND OUTCOME AS USEFUL CONSTRUCTS OF MEASUREMENT IN DEFINING THE QUALITY IN EYE CARE
English1418Akilan Arunkumar A.English C. A. K. YesudianEnglishObjective: The study was designed with an objective to understand quality in eye care by studying the relationships among process compliance and outcome in outpatient and inpatient ophthalmic processes.
Methods: The exploratory study focuses on finding out the relationship between process performance and treatment outcomes. It was based on primary and secondary data. Frequency distribution, chi square analysis, correlation and regression analysis were used to analyse the data.
Results: A strong association between the process conformance and outcome in terms of visual acuity was observed in cataract ((r = -.682, pEnglishProcess performance, Quality improvement, Quality in eye careINTRODUCTION
For years health care has been discussing about improving the quality of treatments, however, the system has failed in its ability to deliver quality healthcare to all consistently. A reason for this inefficiency may be the healthcare system focusing and acting on the parts than the whole. Taking a systems perspective, and orienting systems for the delivery and improvement of quality, are fundamental to progress and to meeting the expectations of the populations. Healthcare systems across the world have largely, realized this, and are in pursuit of improving the quality. Comparing to the other disciplines of medicine, Ophthalmology adopted quality assurance since 1980s. The first mention of quality assurance in ophthalmology appeared in medical journals in Australia, and USA in the 1980s (Carver, 1985). In the late 1990s, studies of the quality of life as outcome measures of ophthalmic conditions, and patients’ perspectives of their eye care were published. In India, more than 15 million people are visually impaired (Dandona et. al., 2003), with cataract (62.6 %) and refractive errors (19.7 %) as the leading causes of visual impairment (Jose, 2008). India has achieved a tremendous success in solving the problem of blindness, especially cataract, which was the high prevalence blinding disease. The number of cataract operations has increased five- fold over the last 20 years. Today, Indian eye care systems are promulgated as models for high volume eye surgeries. Although significantly reducing the prevalence of blindness to 1.0 percent, and reducing cataract blindness by 40 percent, there are alarming concerns about the quality of eye care (Limburg et.al, 2005). Dandona et al, (2003) estimates that the 3.5 million cataract surgeries performed in India in 2000 are to result in 0.3 million persons having irreversible blindness induced due to poor quality of surgeries. Policy makers and providers are shifting their focus from quantity to quality as the targets are achieved, and continuum of quantity is ensured. In the absence of nationwide data on outcome, these revelations pose great challenge to eye care providers. Eye care systems in India increasingly started deliberating on improving the quality of care over quantity in the last decade. Ravi Thomas (2000) points out that if outcomes and quality are ignored, the Indian eye care system is not only converting curable blindness to incurable, but also create adverse publicity to the national programme. Over the years, eye care has placed greater emphasize on post-procedural visual outcome as an indicator of quality. However, when poor quality is observed, the providers always get back to see what went wrong in the treatment process. In other words, the root cause analysis pertaining to a deficiency in the outcome always leads the providers to the see how the processes are being implemented. This underscores why processes becomes the center of attraction in any quality improvement initiative. In a system perspective, a process is defined as a sequence of interdependent and linked procedures. Activities of a hospital fully comprise of processes. Improving processes offers a tremendous opportunity for hospitals to improve the quality of patient services and overall organizational performance. Unmanaged processes produce random results and high amount of variation from the standard, since protocols or guidelines are not in place. In these cases, the quality of care differs from patient to patient. Therefore, a system-based approach to measure process variations and improve them consistently is required for better quality of services. While choosing indicators of measurement, outcome indicators are considered more stringent quality indicators than structural or process indicators because deviations from appropriate care should influence residents’ health outcome; however they are difficult to define and infer. On the other hand, process indicators are often easy to interpret. Many are also easy to enumerate and do not require adjustment. Donabedian (1983) notes, “outcomes are no more valid a measurement of quality than process, since validity resides not in the outcomes or processes themselves but the causal linkages between outcome and processes”. The core ideas behind this facet of total quality are that organizations are sets of interlinked processes, and that improvement of these processes is the foundation of performance improvement (James W. Dean, 1994).
MATERIALS AND METHODS
The study was designed with an objective to understand quality in eye care by studying the relationships among process performance in terms of compliance and outcome, in outpatient and inpatient ophthalmic processes. A causal chain linking interventions to outcome drawn from Donabedian’s theory is the basic framework of this study. The study explored the relationship between one factor with the other. Cataract and refraction were identified as the two processes under the study since one is an outpatient process and the other one is an inpatient process. In addition, these two processes constitute 3/4th of the patient load of any eye hospital. This study was conducted at a tertiary care eye hospital in South India. Excluding patients having co-morbidity, the valid samples included in the study were 323 and 343 from cataract and refractive error patients respectively; systematic random sampling was used to recruit respondents. Based on the process map, a tool to measure the level of compliance to process elements was developed. To improve the validity of the process tools, first, a process map was developed in consultation with the ophthalmologists, and later the process map was converted to a schedule. Ophthalmologists and experts evaluated and approved the tools. While developing this tool, standard protocols prescribed by the national and international eye care organizations were considered. The processes relating to the technical (clinical) aspects were grouped to the technical section and the processes relating to the functional aspects of the care delivery were grouped under functional section. Secondary data, such as process compliance, visual acuity was collected from the medical records of patients identified as samples over a period of six months. Data analysis was done using statistical analysis software SPSS 20.0. Frequencies and cross tabulation were used for descriptive analysis; correlations, and regression analysis were used in identifying relationships. Informed oral consent was taken from the patient to participate in this study and it was assured that participation in this study would not influence their care delivery.
RESULTS
Cataract treatment process
The frequency distribution of gender showed although the access to cataract treatment was equal, women have less access comparing men. A large majority of respondents (76%) were above the age of fifty. Patients operated under PHACO technique showed higher non-compliance (11.8%) as against respondents operated with small incision cataract surgery (4.8 %) for the criteria of patient selection (pEnglishhttp://ijcrr.com/abstract.php?article_id=572http://ijcrr.com/article_html.php?did=5721. Avedis Donabedian. Quality assessment and monitoring – Retrospect and prospect. Eval Health Prof 1983; 6: 363- 375.
2. Brook R, H.E. Mc Glynn, and Shekell. Defining and Measuring Quality of care: A perspective from US researchers, Int J Quality in Healthcare 2000; 12:281-95.
3. Carver AM. Development and implementation of a hospital- wide quality assurance program at the King Khaled Eye Specialist Hospital in Kingdom of Saudi Arabia. Aust Clin Rev 1985; 5:188-90.
4. Dandona L, Dandona R, Anand R, Srinivas M, Rajashekar V. Outcome and number of cataract surgeries in India: policy issues for blindness control. Graefes Arch Clin Exp Ophthal 2003; 31:23-31.
5. Eric D. Peterson, Matthew T. Roe, Jyotsna Mulgund, Elizabeth R. DeLong, Barbara L. Lytle et. al. Association between hospital process performance and outcomes among patients with acute coronary syndromes. JAMA 2006; 295:1912-1920.
6. Idvall E, Rooke L, Hamrin E. Quality indicators in clinical nursing: a review of the literature. JAN 1997; 25:6-17.
7. James W. Dean, Jr., David E. Bowen. Management Theory and Total Quality: Improving Research and Practice through, The Academy of Management Review 1994; 19(3): 392-418.
8. Jose R, Bachani D. Performance of cataract surgery between April 2002 and March 2003. NPCB-India 2008.
9. Limburg H, Foster A, Gilbert C, Johnson GJ, Kyndt M, Myatt M. Routine monitoring of visual outcomes of cataract surgery. Part 2: results from 8 study centres. Br J Ophthalmol 2005; 89: 50–52.
10. Thomas R. Surgical Techniques for a Good Outcome in Cataract Surgery: Personal Perspectives. Community Eye Health 2000; 13: 38–39.
11. Robert L Kane, Gardner J, Wright DD, Snell G, Sundwall D, et.al. Relationship between Process and Outcome in Ambulatory Care. Med Care 1977; 15: 961-965.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareCOMPARATIVE EFFICACY OF SYNTOMETRINE VERSUS OXYTOCIN IN ACTIVE MANAGEMENT
OF THIRD STAGE OF LABOUR
English1922Arunadevi V.EnglishObjective:
Postpartum hemorrhage is a major obstetrical complication and one of the important but preventable causes of maternal morbidity and mortality. The aim of the study is to compare the efficacy of syntometrine versus oxytocin in the active management of third stage of labor in reducing the risk of PPH and other adverse third stage outcomes.
Methodology:
This is a randomized prospective comparative study conducted from September 2008 to August 2009 at the department of Obstetrics and Gynecology, Institute of Social Obstetrics and Govt. Kasturba Gandhi Hospital for Women and Children, Chennai, on 300 patients. The patients were assigned to 2 groups at random of 150 patients in each group. All pregnant
women with singleton pregnancy of 20-35 years of age with no known risk factor for PPH were included. Exclusion criteria observed for patients with previous caesarean section, previous scarred uterus, multiple pregnancy, Cardiac patient, hepatic disorders, disorders of blood coagulation. The data was analyzed using t test and chi square test.
Results: The mean blood loss in syntometrine group was 120ml and oxytocin group was 171ml. The difference of mean blood loss between two group was 51ml, which is statistically significant (p=0.000).
Conclusion: It is concluded from this study that the use of syntometrine as part of routine AMTSL (Active Management of Third Stage of Labor) appears to be associated with a statistically significant reduction in mean blood loss when compared to Oxytocin.
EnglishSyntometrine, Oxytocin, Third stage of labor, Postpartum hemorrhageINTRODUCTION
Postpartum hemorrhage (PPH) is a nightmare to every obstetrician as it is sudden, frequently unpredicted and could be catastrophic. In the early decades of 20th century, PPH was the most common cause of maternal death (Thilaganathan et al1 – 1993). PPH is a major cause of maternal mortality worldwide with an overall prevalence of approximately 6%; Africa has the highest frequency of about 10.5%.2 PPH complicates 4% of vaginal deliveries and 6% of caesarean deliveries.3 About 14 million women suffer from severe PPH each year, and 140,000 of these die one in every 4 minutes.4
Excessive blood loss at delivery is defined as:
1. A loss in excess of 500 ml at vaginal delivery; 1000 ml at caesarean section or 1500ml at Caesarean hysterectomy (Prichard5 ).
2. 10% change in hematocrit between admission and postpartum period6
3. Need for an erythrocyte transfusion (Coomb)6 Primary PPH is loss of blood estimated to be > 500ml, from the genital tract, within 24hours of delivery 7. Secondary PPH is defined as abnormal bleeding from genital tract, from 24 hours after delivery until six weeks postpartum. Studies quote an incidence of PPH of around 5-10%.8,9
Etiological factors for PPH are as follows10:
1. Abnormalities of uterine contraction (Tone)
2. Retained products of conception (Tissue)
3. Genital tract abnormalities (Trauma)
4. Abnormalities of coagulation (Thrombin)
Uterine atony is the commonest of the numerous causes of PPH, accounting for 80-90% of cases.
Active Management of Third Stage of Labor (AMTSL) is an effective intervention to prevent PPH resulting from
uterine atony. AMTSL comprises the following series of interventions :
1. Administration of prophylactic uterotonic within 1 minute of delivery of the baby.
2. Controlled cord traction
3. Uterine massage after delivery of placenta.
AMTSL has been shown to reduce the incidence of PPH by approximately 60-70%.11,12,13 This study compares the efficacy of Syntometrine versus Oxytocin in AMTSL in reducing the risk of PPH.
MATERIALS AND METHODS
This randomized prospective case control study was conducted from September 2008 to August 2009, at Institute of Social Obstetrics and Govt. Kasturba Gandhi Hospital for Women and Children, Chennai on 300 patients, who were admitted in labor ward with no known risk factors for PPH. All patients included in the study delivered vaginally. The patients were assigned to 2 groups at random of 150 patients in each group. In group I, Syntometrine (5 IU Synthetic Oxytocin and 0.5 mg ergometrine maleate) and in Group 2 Oxytocin was administered i.m within 1 minute after delivery of the baby. This study was approved by Ethical Committee.
Inclusion Criteria:
1. Singleton pregnancy
2. No contraindication for oxytocin / syntometrine
3. No obstetric or other indication that could warrant abdominal delivery.
4. No known risk factor for PPH.
Exclusion Criteria:
1. Previous caesarean section
2. Previous scarred uterus
3. Multiple pregnancy
4. Cardiac patient
5. Hepatic disorders
6. Disorders of blood coagulationinal delivery
7. Past history of third stage complications
8. Known risk factor for PPH
9. Instrumental vaginal delivery
10. Absolute or relative risk factors for spontaneous vaginal delivery and hence posted for elective caesarean section.
Procedure: The delivery was effected with the patient at the edge of the table. Within 1 minute of delivery of the baby, either 10 units of injection oxytocin or 1 ampoule of syntometrine were given in a randomized order. The user will be unaware of the drug being given since all these drugs will be of the same color and ampoules will only be marked with appropriate numbers and no names will be mentioned. Once the placenta is removed, she was placed over a blood drape, which is a disposable, conical, graduated plastic collection bag. The amount of blood collected in the blood drape is measured. The average immeasurable blood loss due to episiotomy was taken as 50ml and the same is not included in the blood loss. Similarly when there was profuse bleeding following episiotomy, such patients were excluded from the study.
Results and Analysis
This study was commenced with 300 women and the outcome was analyzed using various parameters. The results were subjected to statistical analysis using the t test and chi square test. Most of patients in both groups were in age group of < 25 years. 70% of cases in group 1 and 62.7% of cases in group 2 were in age group < 25years. Only 5.3% in group 1 and 3.3% in group 2 were in age group > 30 years. 62.7% of women in group 1 and 60% of cases in group 2 were primigravida. 37.3% of cases in group 1 and 40% of cases in group 2 belonged to multigravida. All patients in our study group were booked cases, though they were selected at random basis. The mean blood loss in group 1 was 120ml and group 2 was 171 ml. The difference of mean blood loss between two group was 51ml, which is statistically significant ( p = 0.000). 2% of cases in group 2 and none of the case in group1 had blood transfusion, which is not statistically significant (0.082). None of the case in group 2 had side effects, whereas in group 1, 3.3% of cases developed adverse effects like nausea and vomiting. Only 2% of cases in group 2 had drop in hemoglobin level of 0.7 to 1 grams percent after delivery. The mean birth weight of the baby in both groups was 3.1 Kg.
Discussion
The synthetic form of the octapeptide, oxytocin is commercially available as Syntocinon or Pitocinon. It increases the frequency and strength of uterine contraction and augments retraction of uterus. Syntometrine injection is a clear, colorless solution and contains maleic acid as a buffer, pH3.2. Syntometrine combines the rapid uterine action of oxytocin with sustained uterotonic effect of ergometrine. The uterotonic effect of syntometrine lasts for several hours compared with only ½ to 1 hour when oxytocin is given alone.
When syntometrine is stored for prolonged periods of time, it must be kept at between 2 and 8o C and protected from light ( Hozerzeil et al14, 1994). Oxytocin is more stable in tropical climates. The efficacy of syntometrine has been shown to be significantly reduced when it is stored in a suboptimal environment (Chua15 et al 1993). The review by McDonald16 et al comparing syntometrine and oxytocin revealed that the use of intramuscular syntometrine was associated with reduced risk of PPH with a summary odds ratio of 0.74 (95% CI – 0.85) regardless of the dose of oxytocin used. Docherty and Hooper17 (1981) reported that oxytocin was associated with a 40% increase in mean blood loss, but absolute rate of PPH was not stated. Yuen et al18 (1995) reported a 40% reduction in risk of PPH and the need for repeated oxytocin injections in the syntometrine group compared to oxytocin and side effects were uncommon in both groups. The overall comparison of 10 units of intramuscular oxytocin with syntometrine still favors syntometrine. Edgardo Abalos19 stated that the use of syntometrine as part of AMTSL is associated with significant reduction in the incidence of PPH (blood loss 750 ml) irrespective of the dose. Since the prevention of maternal death from PPH is considered a fair price to pay for experiencing nausea, vomiting and hypertension ( Dwyer20 1994), syntometrine is now routinely used in most developed countries.
Conclusion
It is sad that inspite of tremendous advancement in medical science, women still die of PPH even in the developed countries. Active management should be the routine management of choice for women expecting to deliver a baby by vaginal route in a health care facility. The choice of drug depends on cost, facilities for storage and refrigeration, availability of trained personnel and assessment of trade off between benefits and side effects. The RCOG in the UK recommends that the oxytocics be offered routinely in the management of the third stage of labour in all women, as their administration reduces the risk of PPH by about 60%. The combination preparation syntometrine as part of routine AMTSL appears to be associated with a statistically significant reduction in risk of PPH, compared to oxytocin.
ABBREVIATIONS
PPH – Post Partum Hemorrhage
AMTSL – Active Management of Third Stage of Labour
Acknowledgement
Author acknowledges the enormous help received from the scholars whose article have been cited and incorporated in references. Author is also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this articles has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=573http://ijcrr.com/article_html.php?did=5731. Thilaganathan B et al, Management of the third stage of labour in women at low risk of postpartum hemorrhage. Eur J. Obstet Gynecol Reprod Biol. 1993. Jan: 48 (1): 19 –22.
2. Carroli G, Cuesta C, Abalos E, et al. Epidemiology of postpartum haemorrhage: a systematic review. Best Pract Res Clin Obstet Gynaecol 2008; 22: 999–1012.
3. Mousa H, Alffirevic Z. Treatment for primary PPH (Cochrane Review). The Cochrane Library, Vol. I. Oxford : Update software;2003.
4. Abouzahr C. Global burden of maternal death and disability. Br Med Bull. 2003;67: 1–11.
5. Pritchard JA, Baldwin RM, Dickey JC, Wiggins KM. Blood volume changes in pregnancy and puerperium. Am J Obstet Gynecol 1962; 84 (10); 1271–82.
6. Coombs CA, Murphy EL, Laros RK. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991; 69–76.
7. Prevention and management of postpartum hemorrhage; Royal College of Obstetricians and Gynaecologists (May 2009 with revision April 2011).
8. Fullerton G, Danielian PJ, Bhattacharya S: Outcomes of pregnancy following postpartum haemorrhage. BJOG. 2013 Apr 120 (5); 621–7.
9. Carroli G, Cuesta C, Abalos E, et al: Epidemiology of postpartum heamorrhage a systematic review. Best Pract Research Clinic Obstet Gynaecol. 2008 Dec; 22 (6); 999– 1012.
10. Schuurmans N. Mackinnon C, Lane C, Etches D. Prevention and Management of postpartum Hemorrhage. SOGCC. Clinical Practice Guidelines. No.88, April 2000.
11. Prevention and treatment of post partum haemorrhage : new advances for low resources settings. Joint – Statement. International Confederation of Midwives (ICM) International Federation of Gynaecology and Obstetrics (FIGO).
12. Prendiville WJP, Elbourne D, McDonald SJ. Active versus expectant management in the third stage of labour. Cochrane Database of Systematic Reviews 2009; Issue 3.
13. WHO recommendations for the prevention of postpartum haemorrhage. Geneva: World Health Organization; 2007.
14. Hozerzeil HV, Walker GJA and De Goeje MJ (1994) Oxytocin is more stable in tropical countries.
15. Chua, S. Arul Kumaran, S. Adaikan, G. et al., (1993). The effect of oxytocin stored at high temperatures on postpartum uterine activity. Br. J. Obstet, Gynaecol, 100,874–875.
16. McDonald S, Prendville WJ, Elbourne D, Prophylactic syntometrine versus oxytocin for delivery of the placenta. The Cochrane Database of Systematic reviews, Volume 1, 2001.
17. Docherty PW, Hooper M, Choice of an oxytocic agent for routine at delivery. J Obstet Gynaecol 1981; 2: 60.
18. Yuen PM, Chan NST, Yim SF, Chang AMZ,. A randomized double blind comparison of syntometrine and syntocinon in the management of third stage of labor. Br. J Obstet and Gynaecol 1995; 102377–380.
19. Ebardo Abalos. Evidence summary, Different interventions have been proposed for the management of third stage of labour. RHL. 20. Dwyer N (1994) Nausea is a fair price for preventing hemorrhage Br. Med J 308, 59.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareFUNCTIONAL ANNOTATION OF PROTOCADHERIN BETA GENES HYPERMETHYLATION AND THEIR SIGNIFICANCE IN NEONATAL SEPSIS
English2327Benet Bosco Dhas D.English Hiasindh Ashmi A.English Vishnu Bhat B.English Subhash Chandra ParijaEnglishBackground: Apart from genetic factors, epigenetic mechanisms like DNA methylation are now being established for their association with human diseases. Despite advance in medical research, sepsis still remains the major cause of neonatal mortality. In this study, the role of DNA methylation in neonatal sepsis was studied in an epigenome wide scale and the candidate genes were functionally annotated.
Methods: The methylation status was analyzed in babies with and without sepsis in epigenome wide scale using Illumina Infinium Human Methylation 450K methylation microarray. The microarray data was functionally annotated and interpreted for their
biological significance using the bioinformatics softwares and databases like DAVID v6.7, GeneMania, KEGG, etc.
Results: Functional annotation of methylation microarray data revealed that the protocadherin beta group of genes was hypermethylated in babies with neonatal sepsis. Protocadherin beta genes was found to be associated with calcium dependent cell to cell adhesion which is important in signaling pathways like leukocyte migration during sepsis.
Conclusion: DNA methylation might play critical roles in neonatal sepsis which was obvious from differential methylation of candidate genes like protocadherins, modifying the associated biological pathways.
EnglishEWAS, CpG methylation, Neonatal sepsis, Protocadherins, Leukocyte adhesion moleculesINTRODUCTION
Neonatal sepsis is associated with high mortality despite the advancement in medical field. Diagnosis of neonatal sepsis still remains one of the major problems. Researchers often came up with novel or improved diagnostic techniques but none predetermines the disease susceptibility or severity so as to help with the treatment and management of sepsis. Inherited genetic behavior of the host plays vital role in disease susceptibility and immune response against infections. Recent studies showed that human diseases or behaviors, not only depend on their genetic code but also non-genetic factors. DNA methylation, one of such epigenetic factor, is a heritable form of gene modification without any changes in the underlying nucleotide sequence. The changes in gene expression originated by hyper- and hypo- methylation of DNA and its association with disease physiology are still a mystery and no epigenome wide studies had been done so far in neonatal sepsis. In this study, an epigenome wide search was carried out to explore the differential methylation of candidate genes associated with neonatal sepsis.
MATERIAL AND METHODS
This study was conducted in the Department of Neonatology in a tertiary care referral hospital during the period of March to April, 2014. This study was approved by Institute Scientific Advisory and Human Ethics Committees. Six preterm newborns belonged to Dravidian population of South India were enrolled following inclusion and exclusion criteria for sepsis. Newborns of age less than 28 days and blood culture positive sepsis were re cruited as cases. Newborns with no sepsis and endured blood sampling for minor ailments were enrolled as controls. Babies with surgical conditions, congenital malformations, maternal history of infections / inflammations and Apgar score < 6/10 at five minutes were excluded.
Methylation Microarray
The detailed methodology has been described previously [1]. In brief, 200µL of peripheral venous blood was collected from the newborns and genomic DNA was extracted using QIAmp DNA Blood Mini kit (Qiagen, Hilden, Germany). The DNA was then subjected to heat based bisulfite treatment using EZ DNA methylation kit (Zymoresearch, USA). After bisulfite treatment, the DNA samples were amplified, fragmented by enzymes and hybridized to the Illumina Infinium Human Methylation450 BeadChip kits (Illumina, Inc., San Diego, CA). Then allele specific single-base extension and staining was performed, followed by imaging of BeadChips on Illumina BeadArray Reader and analyzed using Illumina’s BeadScan software (Illumina iScan scanner). Microarray data was processed and analyzed Illumina GenomeStudio v2011.1 (Methylatioin Module v1.9.0) and the statistical computing package R 3.0.2 (http://www.r-project. org). The microarray service was provided by Macrogen Inc., South Korea. The complete microarray data can be accessed from the public domain, Gene Expression Omnibus of NCBI (http://www.ncbi.nlm.nih.gov/geo/). The accession number is GSE58651.
Filtering of biologically insignificant CpGs
The statistically significant CpGs were filtered using the threshold values of difference in methylation level > 0.2 and p-value > 0.05. The significant CpGs filtered also included CpGs in sex chromosome, CpG-SNPs, CpGs in known repeats, non CpG methylation. The microarray data was further analyzed manually and filtered to remove these biased CpGs to find out the biologically significant and valid CpGs.
Gene Clustering Analysis
The differentially methylated genes identified through microarray data analysis were then subjected to clustering analysis in order to find out the biological roles. This was done with the bioinformatic online software DAVID v6.7 (Database for Annotation, Visualization and Integrated Discovery) (SAIC-Frederick Inc., Maryland, USA). The list of genes was selected from microarray data and pasted in the query dialog box, followed by selection of data type and clustering. The cluster with high enrichment score represents more biological value.
Biological Network and Pathway
Analysis The biological networks of the differentially methylated genes and their associated pathways were identified by GeneMANIA database (University of Toronto, Canada) which is based on the Cytoscape plugin. The false discovery rate (FDR) indicated the significance of analysis. The pathways regulated by the gene were identified and analyzed using KEGG (Kyoto Encyclopedia of Genes and Genomes) pathway database (Kanehisa Laboratories, Japan).
Gene Panel Analysis
The characteristics of the differentially methylated genes were analyzed using UCSC Genome browser (University of California, Santa cruz). The CpG islands in the genes and literatures involving the gene were analyzed for biological and clinical interpretation. The clinical significance of the genes was retrieved from the database, Online Mendelian Inheritance of Man (OMIM) developed by NCBI.
RESULTS
The newborns enrolled in our study were homogenous with regard to general demographic characteristics. All cases were positive for Klebsiella pneumoniae and similar sepsis risk factors like prematurity, premature rupture of membrane, etc.
Distribution of DNA methylation
The Illumina Infinium HumanMethylation450 is capable of analyzing about 4,85,350 CpGs throughout the genome. The distribution of DNA methylation level among the cases and controls were shown in Figure 1. The cases and controls were significantly distinguished both by hypomethylation and hypermethylation. Obviously the hypermethylation frequency of cases was predominantly higher compared to the controls.
The difference in methylation level of majority of the CpGs (4,73,081) among the cases and controls lied in the range of -0.1 to +0.1 (negative sign indicates hypomethylation and positive sign indicates hypermethylation). After filtering the CpGs for statistical and biological significance, 91 CpGs were found differentially methylated including 57 hypermethylated and 34 hypomethylated(Figure 2)
Figure 2: Graph showing the number of hyper- and hypomethylated CpGs.
Functional Location
The functional location of hypermethylated and hypomethylated CpGs are shown in Figure 3. Almost 40 % of the significant hypermethylated CpGs were found in the promoter region that includes TSS150, TSS 200 and 1st Exon, in contrast to 16 % of hypomethylated CpGs. Most of the hypomethylated CpGs were found in the gene body (65 %).
Figire 3: Functional location of significant hyper- and hypomethylated CpGs
Clustering Analysis
The differentially methylated 64 genes containing the 81 CpGs were subjected to bioinformatic analysis in order to find out the biologically significant genes and their functions. DAVID analysis was done to find out the functional gene clusters based on gene enrichment score among the differentially methylated genes. The complete details of DAVID analysis along with the corrected bonferroni values are shown in Figure 4. DAVID analysis revealed a cluster of protocadherin beta (PCDHB) genes that were differentially methylated with annotation score of 4.44.
Figure 4: Results of DAVID analysis showing significant gene clusters
Biological networks and functions
This cluster comprised of five biologically important PCDHB genes which were PCDHB11, PCDHB12, PCDHB5, PCDHB6, PCDHB16. PCDHB17 was also found to be included in the cluster but it is a pseudogene, which has no biological function. This cluster of genes was then analyzed for their biological roles and networks using GeneMania database (Figure 5).
Figure 5: Gene ontology annotation of PCDHB gene cluster.
(a) Physical interactions; (b) Co-expression; (c) Biological interactions
The network lines connecting the circles of genes, represents the relationship between them. The dark circles correspond to the genes in the cluster and brighter circle denotes related genes. Since PCDHB17 is a pseudogene, it was not found to be involved in physical and biological interaction, except that it is co-expressed. The biological functions of the genes were also found by GeneMania and the most important of them are listed in the table.
DISCUSSION
The significance of DNA methylation in relation with microbial infections is increasingly explored. The best example is abnormal methylation of DNA, especially in the promoters regions of underlying genes, that was induced by H. pylori infection in human gastric cancer cells [2]. Hypermethylation associated with H.pylori infection was found to occur in the genes such as E-cadherin gene – CDH1 [3], DNA repair gene – MLH1 [4], tumor suppressor genes like WWOX [5]. A recent study also showed methylation of LPS receptor gene, TLR4 in epithelial cells of intestine by commensal bacteria during non – inflammatory conditions [6]. Jelinek et al. observed that the gene PRV-1 which is expressed in neutrophils is epigenetically controlled by CpG methylation. During sepsis, PRV-1 expressing neutrophils increase significantly [7]. On the other hand, during endotoxin tolerance, TNF-α expression was found to be silenced via synergistic effect of DNA methylation and histone methylation, resulting in pro-inflammatory gene silencing associated severe systemic inflammation [8]. In contrast to these studies, Bierne et al., hypothesized that the pathogen itself can acts as epimutagens affecting the gene expression of host immune system in various infections with H.pylori, P.gingivalis, C. rectus and E.coli stating that the bacterial products like lipopolysaccharide may trigger these epigenetic changes [9]. In this study, we attempted to explore the genes that are differentially methylated in babies with sepsis through methylation microarray analysis. We found an immense variation in DNA methylation level in both extremes, hypo- and hyper-, among newborns with sepsis and without sepsis. This variation reveals that in sepsis, some CpGs are hypomethylated that may allow expression of genes and some are hypermethylated, suppressing the gene expression. Out of 4,85,350 CpGs analyzed in the whole epigenome, only 91 CpG sites belonging to 64 genes were found significantly varied among cases and controls. To our surprise, 35% of the significant CpGs (both hypo- and hyper-methylated) were found in the promoter region, giving hint to their association with gene expression. The functional analysis of these genes showed their association with sepsis pathophysiology. The functional clusters given by DAVID algorithm exposed the incredible fact of PCDHB hypermethylation in neonatal sepsis. Cadherin family of proteins play vital role not only in cell adhesion but also in cell recognition and sorting, maintenance of structural and functional cell polarity [10]. Protocadherins are calcium dependent cell-cell adhesion molecules, previously thought to be functional mainly in nervous system synapse organization. Recent studies showed that PCDHB genes were also expressed in peripheral blood cells and PCDHB10 gene was epigenetically regulated [11]. Hypermethylation of PCDHB genes found in our study, may restrain adhesion efficiency of leukocytes via suppressed expression of cell adhesion molecules. Leukocyte cell adhesion, an essential innate immune response is seized in healthy individuals by shear forces, but infection or inflammatory signals up regulate the expression of adhesion molecules leading to accumulation of leukocytes at the site [12]. In sepsis, suppression of leukocyte extravasation may exaggerate disease severity and poor outcomes like multiple organ dysfunctions [13]. The cell adhesion molecules (CAMs) play vital role in leukocyte migration during microbial infections. Differential expression of leukocyte adhesion molecules was found to be associated with varying biological functions of lymphocyte and monocytes in sepsis [14]. This varying expression of CAMs is mediated by nitric oxide produced by the enzyme, cytokine induced nitric oxide synthase [15]. We also found that oxidative stress regulators like AGER, SCARA3 were differentially methylated in sepsis cases. AGER gene encodes the receptor for AGE molecules which are the end products of advanced glycation capable of activating pro-inflammatory response [16]. Ying et al. have reported downregulation and hypermethylation of SCARA3 in prostate cancer [17].
CONCLUSION
Differential methylation of immune related genes regulates differential immune response during sepsis. Hypermethylation of protocadherin beta genes can be correlated with dysregulation of biological pathways like leukocyte migration. This understanding will help in the development of novel epigenetic based biomarkers and therapeutic targets for neonatal sepsis.
ACKNOWLEDGEMENTS
Authors thank Indian Council of Medical Research for providing research fellowship to the first author. 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.
ACCESSION NUMBER The complete microarray data can be accessed from the public domain, Gene Expression Omnibus of NCBI (http://www.ncbi.nlm.nih.gov/geo/). The accession number is GSE58651.
CONTRIBUTORSHIP: BBD, AH and VB designed the study. BBD and AH done data analysis and bioinformatics analysis. BBD, AH, VB and SCP prepared the manuscript. VB and SCP finalized and proofread manuscript.
CONFLICT OF INTEREST: The authors declare no conflicts of interest
SOURCE OF FUNDING: JIPMER Intramural research fund
Englishhttp://ijcrr.com/abstract.php?article_id=574http://ijcrr.com/article_html.php?did=5741. BB Dhas, Ashmi AH, Bhat BV, Kalaivani S, Parija SC. Comparison of genomic DNA methylation pattern among septic and non-septic newborns - an Epigenome wide association study. Genomics Data 2015;3:36–40.
2. Maekita T, Nakazawa K, Mihara M, Nakajima T, Yanaoka K, Iguchi M, et al.. High levels of aberrant DNA methylation in Helicobacter pylori-infected gastric mucosae and its possible association with gastric cancer risk. Clin Cancer Res 2006; 12: 989–995.
3. Chan AO, Lam SK, Wong BC, Wong WM, Yuen MF, Yeung YH, et al. Promoter methylation of E-cadherin gene in gastric mucosa associated with Helicobacter pylori infection and in gastric cancer. Gut 2003; 52: 502–506.
4. Yao Y, Tao H, Park DI, Sepulveda JL, Sepulveda AR. Demonstration and characterization of mutations induced by Helicobacter pylori organisms in gastric epithelial cells. Helicobacter 2006; 11: 272–286.
5. Yan J, Zhang M, Zhang J, Chen X, Zhang X. Helicobacter pylori infection promotes methylation of
6. Takahashi K, Sugi Y, Nakano K, Tsuda M, Kurihara K, Hosono A, et al. Epigenetic control of the host gene by commensal bacteria in large intestinal epithelial cells. J Biol Chem 2011; 286: 35755–35762.
7. Jelinek J, Li J, Mnjoyan Z, Issa JP, Prchal JT, AfsharKharghan V. Epigenetic control of PRV-1 expression on neutrophils. Exp Hematol 2007;35:1677–83.
8. El Gazzar M, Yoza BK, Chen X, Hu J, Hawkins GA, McCall CE. G9a and HP1 couple histone and DNA methylation to TNFalpha transcription silencing during endotoxin tolerance. J Biol Chem 2008;283:32198–208.
9. Bierne H, Hamon M, Cossart P. Epigenetics and bacterial infections. Cold Spring Harb Perspect Med 2012;2:1–24.
10. Halbleib JM, Nelson WJ. Cadherins in development: cell adhesion, sorting, and tissue morphogenesis. Genes Dev 2006;20:3199–214.
11. Ying J, Gao Z, Li H, Srivastava G, Murray PG, Goh HK, et al. Frequent epigenetic silencing of protocadherin 10 by methylation in multiple haematologic malignancies. Br J Haematol 2007;136:829–32.
12. Zarbock A, Ley K. Neutrophil adhesion and activation under flow. Microcirculation 2009;16:31–42.
13. Liu L, Kubes P. Molecular mechanisms of leukocyte recruitment: organ-specific mechanisms of action. Thromb Haemost 2003;89:213–20.
14. Mühl D, Woth G, Drenkovics L, Varga A, Ghosh S, Csontos C, et al. Comparison of oxidative stress and leukocyte activation in patients with severe sepsis and burn injury. Indian J Med Res 2011;134:69–78.
15. Benjamim CF, Silva JS, Fortes ZB, Oliveira MA, Ferreira SH, Cunha FQ. Inhibition of leukocyte rolling by nitric oxide during sepsis leads to reduced migration of active microbicidal neutrophils. Infect Immun 2002;70(7):3602–10.
16. Bierhaus A, Schiekofer S, Schwaninger M, Andrassy M, Humpert PM, Chen J, et al. Diabetes-associated sustained activation of the transcription factor nuclear factor-kappaB. Diabetes 2001;50:2792–808.
17. Yu G, Tseng GC, Yu YP, Gavel T, Nelson J, Wells A, et al. CSR1 suppresses tumor growth and metastasis of prostate cancer. Am J Pathol 2006;168:597–607.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareTHE STUDY OF PERIPHERAL NEUROPATHY AND AUTONOMIC NEUROPATHY PREVALENCE IN TYPE 2 DIABETES MELLITUS
English2833Bezwada Srinivasa RaoEnglish Madu Anu Radha M. D.English Matta Sree Vani M. D.EnglishBackground: Type 2 diabetes and its complications are major causes of morbidity and mortality with decreased quality of life. Distal symmetrical poly neuropathies affecting sensory more than motor nerves are common long term micro vascular complications. Prevalence of both peripheral and autonomic neuropathy increases with increased duration of type 2 diabetes. Tight glycemic control and lowering of glycosylated hemoglobin levels are associated with improvement of symptoms and slowing the progression of diabetic neuropathy.
Aim: The aim is to study the prevalence of peripheral neuropathy and autonomic neuropathy and their relation with duration of type 2 diabetes.
Materials and Methods: The present study enrolled 100 patients of type 2 diabetes with age > 30 yrs. Gestational and type1 diabetes patients were excluded from the study. Screening of neuropathy was done by monofilament and vibration tests. Nerve conduction studies were done to confirm neuropathy. Standard tests for autonomic dysfunction like orthostatic hypotension, pulse rate response to deep breaths test, hand grip and valsalva manoeuvre were performed.
Results: In this study, the prevalence of neuropathy was 57% in diabetic patients. Out of 57 patients with neuropathy, 25 patients (43.85%) had only peripheral neuropathy, 6 patients (10.53%) had only autonomic neuropathy and 26 patients (45.62%) had both peripheral and autonomic neuropathy. Prevalence of both peripheral and autonomic neuropathy increased with increased duration of type 2 diabetes.
Conclusions: The most common form is the distal symmetrical poly neuropathy than autonomic neuropathy. Both peripheral and autonomic neuropathies do not invariably coexist in diabetes. Peripheral and autonomic neuropathy increased with increased duration of type 2 diabetes.
EnglishAutonomic neuropathy, Glycosylated hemoglobin, Micro vascular complications, Nerve conduction studies, Symmetrical poly neuropathy, Type 2 diabetes mellitusINTRODUCTION
Disorders of the nervous system associated with diabetes have long been recognized by Rollo in 1978. Marchal de Calvi in 1864 first suggested that diabetes might be the cause rather than the effect of neuropathy.[1] International Diabetes Federation projects 285 million diabetics in 2010 to 438 million by 2030.The increased prevalence of diabetes in both developed and developing countries is associated with significant rise of health care costs. The prevalence of diabetic neuropathies is rising with global burden of type 2 diabetes. Diabetes and its complications are major causes of morbidity and mortality with decreased quality of life. The diabetic neuropathies are broadly classified into symmetric and asymmetric neuropathies. Symmetric neuropathies may be proximal or distal neuropathy, small or large fiber neuropathy and chronic inflammatory demyelinating polyradiculoneuropathy [CIDP]. Asymmetric neuropathy may be mono or poly neuropathy, radiculopathy and radiculoplexopathies. The most common diabetic neuropathy is predominantly sensory or sensorimotor poly neuropathy producing the typical stocking and glove pattern of sensory deficit in lower limbs. Features characteristic of a small fiber peripheral neuropathy include deficits in pain, temperature perception and dysesthesias are often described as like walking on pebbles or having cotton bunched up under the toes which predis pose to foot ulceration. Features of large fiber peripheral neuropathy include loss of position, vibration perception and deep tendon reflexes with nerve conduction abnormalities. Charcot joint or diabetic osteoarthropathy and foot ulcers are dreaded complications of diabetic neuropathy. Anorexia, weight loss, depression are prominent in neuropathies and the term diabetic neuropathic cachexia was coined by Ellenberg[2] to this syndrome. Treatment induced neuropathy due to improved glycemic control may initiate regenerating axonal sprouts which generates ectopic nerve impulses.[3] The majority of diabetic neuropathies affect 3rd and 6th cranial nerves. Facial paralysis due 7th nerve palsy occurs with increased frequency in diabetics. [4] Mono neuropathies occur due to focal ischemia, entrapment, compression or trauma to superficially placed nerves. When several nerves are involved simultaneously the condition is termed as mono neuropathy multiplex. The pathogenesis of diabetic neuropathy is multi factorial. Various mechanisms involved are genetic, ischemia, oxidative stress, over activity of polyol pathway, increased advanced glycation end products, deficiency of γ-linolenic acid, protein kinase C, growth factor deficiency and dysimmune mechanisms. Reduced endoneural capillary density [5] in capillary basement membrane [5] and significantly impaired total diffusion barrier are the pathological alterations that occur in peripheral nerves. Oxidative stress in diabetes may cause reduction in antioxidant enzymes as evidenced by increase in glycoxidation and lipoxidation products.[6] The key enzymatic scavengers like superoxide dismutase[SOD], catalase, reduced glutathione[GSH], glutathione peroxidase and ascorbic acid [7] are reduced in the peripheral nerves of diabetic patients. Glucose indeed a neurotoxin is central in pathogenesis. Glycation and formation of advanced glycosylation end products [AGE] followed by binding with its receptor [RAGE] results in generation of reactive oxygen species [ROS] and inflammatory response. Over activity of polyol pathway results in generation reactive oxygen species. Activation of Protein kinase C results in inhibition of Na, K–ATP ase which slows the conduction. Inhibition of protein kinase C will reduce oxidative stress. [8] Reduction in nerve growth factor will reduce and its administration will restore glutathione peroxidase and catalase.[9] Screening for diabetic neuropathy done by SWME (the l0-g Senimes-Weinstein monofilament examination) and vibration testing. Action potentials of muscle and sensory nerves elicited in nerve conduction studies confirms neuropathy. The autonomic nervous system subserves physiological functions of cardiac muscle, gastrointestinal smooth muscle and glandular tissues. Subclinical autonomic nerve damage has greater importance because of implications for mortality and morbidity.[11] Disturbances of autonomic nervous system in gastro intestinal system leads to abnormal esophageal motility, gastro paresis diabeticorum [10] with diminished gastric motility and delayed gastric emptying. Involvement of small intestine results in intermittent diabetic diarrhea which manifests as painless and frequent watery stools without weight loss. Parasympathetic denervation [11] of cardiac muscle in autonomic neuropathy causes tachycardia which is unresponsive to postural changes, six slow maximal deep breaths test and valsalva manoeuvre. When sympathetic denervation supervenes the heart rate slows to fixed unresponsive rate [12] similar to a denervated transplanted heart. In postural hypotension systolic fall of > 30 mm Hg or diastolic fall of > 20mm Hg on standing is due to sympathetic denervation of arterioles in splanchnic bed, muscles and skin. Autonomic dysfunction of genitourinary system causes difficulty in initiation of micturition, dribbling and urinary retention with over flow. Impotence is common in diabetes and incidence ranges from 30% to 75%.[13] Autonomic neuropathy causes impotence, retrograde ejaculation and absence of nocturnal erections. Gustatory sweating with profuse facial sweating usually beginning shortly after eating and extending to scalp and shoulder symmetrically is typically seen in diabetic autonomic neuropathy.[14] Management of diabetic neuropathy begins with tight glycemic control and lowering of glycosylated hemoglobin levels with oral hypoglycemic agents or insulin which reduces pain threshold and an improvement in motor but not sensory nerve conduction velocities. The tricyclic antidepressants, anticonvulsants like gabapentin, carbamazepine and tramadol are the agents of first line therapy in the treatment of neuropathic pain which is characteristically worse at night.
Aim of Study
The aim is to study the prevalence of peripheral and autonomic neuropathy in type 2 diabetic patients and their relation with the duration diabetes.
Materials and Methods
This is a prospective and observational study. Ethical clearance was obtained from the institution. Informed consent was taken from patients in their own language before collecting data. The present study enrolled 100 patients of type 2 diabetes with age > 30 yrs. Patients with type 1 diabetes and gestational diabetes were excluded from the study. The duration of the study was over a period of two years. Detailed clinical examination and routine blood investigations like hemoglobin, total leukocyte count with differential count, erythrocyte sedimentation rate, blood urea, serum creatinine, fasting blood sugar, postprandial sugar, glycosylated hemoglobin [HbA1C] levels were done. Screening of neuropathy was done by monofilament and vibration tests. Nerve conduction studies done to confirm neuropathy. Standard tests for autonomic dysfunction like fall of blood pressure in supine position, pulse rate response to deep breaths test, hand grip, and valsalva test were performed.
Results
The present study enrolled 100 patients of type 2 diabetes. The results of the study were shown in tables and figures given below. Fig. 1 below shows age and sex distribution in the study. Out of 100 patients, 64 patients were males and 36 patients were females. Male to female ratio is 1.7: 1. Out of 100 patients majority of patients (33%) were in the age group between 41-50 yrs followed by 26 patients (26%) in 51-60 yrs, 19% in 61-79 yrs, 15% in 31-40 yrs and 7% in 71-80 yrs age group.
. Out of 100 patients included in thestudy, only 57 patients showed evidence of neuropathy. Out of 57 patients with neuropathy, 25 patients (43.85%) had only peripheral neuropathy, 6 patients (10.53%) had only autonomic neuropathy and 26 patients (45.62%) had both peripheral and autonomic neuropathy. Out of 100 patients, 55 patients (55%) had diabetes < 5 yrs duration and 45 patients (45%) had diabetes > 5 yrs duration.
Fig. 3 below shows prevalence of peripheral neuropathy in relation to duration of type 2 diabetes. Out of 51 patients with peripheral neuropathy, 7 patients (13.7%) had diabetes < 5 yrs duration and 44 patients (86.3%) had > 5 yrs duration of diabetes.
Fig. 4 above shows prevalence of autonomic neuropathy in relation to duration of type 2 diabetes. In this study out of 32 patients with autonomic neuropathy, the duration of diabetes < 5 yrs in 8 patients (25%) and in 24 patients (75%) the duration of diabetes > 5 yrs. Table 1 below shows frequency of neuropathic symptoms and signs.
Fig. 5 below shows frequency of sensory and motor symptoms in the study. Out of 100 patients included in the study, 54 patients had only sensory symptoms, only motor symptoms in one patient and both sensory and motor symptoms were seen in 55 patients.
Fig. 7 below shows correlation of simple tests with nerve conduction studies in the study. In this study simple tests like monofilament, vibration tests and nerve conduction studies were done to confirm diabetic peripheral neuropathy. The study showed both monofilament and vibration tests were positive in 38 patients and nerve conduction studies were abnormal in 51 patients.
DISCUSSION
Diabetes and its complications are major causes of mortality, morbidity and decreased quality of life. The complications include both micro vascular (neuropathy, nephropathy and retinopathy) and macro vascular (atherosclerotic). Neuropathies are among the most common long-term micro vascular complications. The prevalence of diabetic neuropathies is rising with global burden of type 2 diabetes. Screening of diabetic neuropathy was done by monofilament tests, vibration tests and confirmed by nerve conduction studies tests. Autonomic dysfunction related tests were also done. With early detection and meticulous treatment of diabetes mellitus, neuropathic complications can be prevented along with decrease morbidity and mortality. In this study, out of 100 patients 64 patients were males and 36 patients were females. Male to female ratio is 1.7: 1. Majority of the patients 33% were in the age group between 41-50 yrs as shown in Fig 1. In this study of 100 patients with type 2 diabetes, prevalence of neuropathy was 57% which correlated with study done by Prasad Katulanda et al[15] and studies done in Malaysia and Saudi Arabia [16] which showed the prevalence of 59.1% and 54.3% respectively. Moreover peripheral and autonomic neuropathy do not invariably coexist in diabetes as per study by Tentolouris et al.[17] Out of 57 patients with neuropathy, 25 patients (43.80%) had only peripheral neuropathy, 6 patients (10.60%) had only autonomic neuropathy and 26 patients (45.60%) had both peripheral and autonomic neuropathy as shown in Fig 2. A population based study by Phillip et al [18] showed 73% prevalence of autonomic neuropathy in type 2 diabetes mellitus. The present study showed increased prevalence of both peripheral and autonomic neuropathy as the duration of type 2 diabetes increases. Out of 51 patients with peripheral neuropathy, 7 patients (13.7%) had diabetes < 5 yrs duration and 44 patients (86.3%) had > 5 yrs duration of diabetes as shown in Fig; 3. In the present study autonomic neuropathy was seen in 8 patients (25%) with < 5yrs duration of diabetes and in 24 patients (75%) with > 5yrs duration of diabetes as shown in Fig: 4. In this study, frequency of symptoms in peripheral neuropathy observed were shown in Table 1. Prevalence of sensory symptoms in this study correlated with study done by Schandry et al. [19] Out of 100 patients in the study, only sensory symptoms were observed in 54 patients, only motor symptoms in one patient and both sensory and motor symptoms were seen in 55 patients as per Fig 5. Risk factors of neuropathy like uncontrolled diabetes in 58 patients, >5yrs duration of diabetes in 42 patients, diabetic retinopathy in 14 patients, alcoholic in 35 patients, history of smoking in 29 patients and low high density lipoprotein[HDL] cholesterol in 16 patients observed were shown in Fig: 6. The frequency of symptoms observed in relation to autonomic neuropathy in this study were shown in Table:2. In this study , monofilament and vibration tests in type 2 diabetic patients were positive in 38 patients but nerve conduction studies were positive in 51 patients as per Fig. 7 Nerve conduction studies not only confirms but also identifies subclinical peripheral neuropathies which may be helpful in treatment planning.
CONCLUSION
The prevalence of diabetes is increasing dramatically in both developed and developing countries. Neuropathies are common long-term micro vascular complications and the most common form is the distal symmetrical poly neuropathy affecting sensory more than motor nerves. Prevalence of both peripheral and autonomic neuropathy is increasing with increased duration of type 2 diabetes. Both peripheral and autonomic neuropathies do not invariably coexist in diabetes. Tight glycemic control, lowered glycosylated hemoglobin levels with effective treatment by oral hypoglycemic agents or insulin are associated with improvement of symptoms and slowing the progression of diabetic neuropathy. Diabetes and its complications are major causes of mortality, morbidity and decreased quality of life. Limitations of the study: Patients < 30 yrs and Type 1 diabetes mellitus patients were not included in the study.
ACKNOWLEDGEMENT
Authors are thankful to Postgraduate students in Department of Medicine for their co-operation in the study. Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors/ editors/ publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=575http://ijcrr.com/article_html.php?did=5751. Marchal de Calvi CJ. Recherchessur les accidents diabetiques P Asselin, 1894\
2. Ellenberg M. Diabetic neuropathic cachexia. Diabetes 1974;23:418-423.
3. Tesfaye S, Malik R, Harris N, et al. Arterio-venous shunting and proliferating new vessels in acute painful neuropathy of rapid glycaemic control (insulin neuritis). Diabetologia 1996; 329-335.
4. Korczyn AD. Bell’S palsy and diabetes mellitus. Lancet 1971;1:108-109.
5. Malik RA, Newrick PG, Sharma AK, et al. Microangiopathy in human diabetic neuropathy : relationship between capillary abnormalities and the severity of neuropathy Diabetologia 1989; 32 : 92-102
6. Baynes JW, Thorpe SR. Role of oxidative stress in diabetic complications : a new perspective on an old paradigm. Diabetes 1999; 48:1-9.
7. Jennings PE, Chirico S, Lunec J, et al, Vitamin C metabolites and microangiopathy in diabetes mellitus. Diabetes Res 1987; 6: 151-154.
8. Matinez – Blasco A, Bosch – Morell F, Trenor C, et al. Experimental Diabetic neuropathy: role of oxidative stress and mechanisms involved. Biofactors 1998; 8: 41-43.
9. SampathD, Jackson GR, Werbach – Perez K, et al., Effects of nerve growth factor on glutathione peroxidase and catalase on PC 12 cells J N eurochem 1994; 62: 2476-2479.
10. Kassander P. Asymptomatic gastric retention in diabetics (gastroparesis deabeticorum). Ann Intern Med 1958; 48 : 797-812.
11. Ewing DJ, Campbell IW, Clarke BF, Heart rate changes in diabetes mellitus. Lancet 1981; 1: 183-186.
12. Lloyd-Mostyn RH, Watkins PJ. Defective innervations of heart in diabetic autonomic neuropathy. BMJ. 1975; 3 : 15- 17.
13. Mc Culloch Dk, Campbell IW, Wu FC, et al. The prevalence of diabetic impotence. Diabetologia 1980; 18 : 279-283.
14. Stuart DD. Diabetic gustatory sweating. Ann Intern Med 1978; 89 : 223-224.
15. The prevalence, patterns and predictors of diabetic peripheral neuropathy in a developing country, Diabetology and Metabolic Syndrome 2012, 4:21, Prasad Katulanda, Priyanga Ranasinghe, RanilJayawardena, Godwin R Constatine, M H R Sheriff and David R Matthews.
16. Explorative study on diabetes neuropathy among type II diabetic patients in UniversitiSains Malaysia Hospital, SalwaSelim Ibrahim Abougalambou, Ayman SelimAbougalambou, Discipline of Clinical Pharmacy, School of Phar-maceutical Sciences, UniversitiSains Malaysia (USM), Malaysia, King Abdhullah Medical City, Saudi Arabia.
17. Peripheral neuropathy does not invariable coexist with autonomic neuropathy in diabetes mellitus by N. Tentolouris, S. Pagoni, A. Tzonou, N. Katsilambros, First Department of Propaedeutic Medicine, Athens University Medical School, ‘Laiko’ Epidemiology, Athens University Medical School, Athens, Greece.
18. A population-based study by Philip A. Low, MD, Lisa M. Benrud-Larson, PHD, David M. Sletten, Tonette L. OpferGehrking, Stephen D. Weigand, MS, Peter C. O’Brien, PHD, Guillermo A. Suarez, MD and Peter J. Dyck, MD.
19. R Schandry, M Lobisch, Importance of sensory symbptoms in identifying patients with diabetic peripheral neuropathy, published in Practical Diabetes International, January/February 2007.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareEFFECT OF PROBLEM BASED LEARNING ON MOTIVATION OF NURSING STUDENTS
English3438Juliana Linnette D SaEnglishAbstract body: Motivation is critical for students to achieve successful learning outcomes. Among the various teaching – learning strategies, PBL is one such approach that fosters motivation to learn.
Objective: To determine the effect of problem-based learning among undergraduate nursing students in terms of motivation to learn, in comparison with the traditional teaching, in the Indian context.
Methods: A quasi-experimental study using a pre- test post- test control group design was adopted.The PBL on antenatal care was used for the experimental group and the traditional lecture-based teaching was used for the control group.Using convenience sampling, 90 students were assigned to the experimental group while 73 were assigned to the control group. They were BSc Nursing students who were undergoing the Obstetrical and Gynecological Nursing in India. The Motivation to Learn Scale (MLS) developed by the author was used to collect data prior to the intervention and after the intervention.
Results: There was a statistically significant difference between the PBL group and the traditional teaching group in the mean gain score on motivation for learning, with the PBL group having a higher mean gain.
Conclusion: PBL was shown to be more effective than the traditional teaching in improving the motivation of the undergraduate nursing students.
EnglishProblem based learning, motivation, Nursing students, Evaluation, Teaching methodINTRODUCTION
Motivation is one of the significant psychological concepts that is related to the successful outcome of education (1). A wide range of motivators that inspire students to direct their learning to the desired end exists. Motivating students in the classroom and providing them with opportunities for clinical practice are critical factors in the teaching-learning process. Learning is most effective while solving a problem hands-on which is of immense value to the needs of the learner. Student-centered approaches to teaching and learning are increasingly being adopted to motivate students to learn better. Students must primarily consider education as personally relevant to their interests and goals for being motivated to learn. Problem- based learning (PBL) is one such approach that has enhanced motivation of the students as they are made to work on ill- defined, complex real-world problems that have no single right answer. PBL has many advantages. It enables the students to develop essential skills like problem-solving and self-directed life-long, and above all it fosters motivation to learn (2-3). Researchers have reiterated the fact that one of the most widely accepted merits of PBL is the ability to motivate or remotivate students by freeing them from rote learning (4). Other studies have also shown that PBL results in higher motivation and better attitudes towards learning (5). Literature abounds with various explanations on the complex subject of motivation that is viewed from a variety of theoretical perspectives. Some of the theories are Hierarchy of Needs Theory (6), Social Cognitive Theory (7-8), Goal Theory (9) and Self-Determination Theory (10). Motivation is considered being either intrinsic or extrinsic. When students enjoy learning for its own sake, they are considered being intrinsically motivated. Such students have the driving force to perform well, and they will succeed. On the other hand, extrinsically motivated students only aim is to attain a desired grade to get a job or to acquire academic qualification for their perceived benefit. It was evident from the results of the study on self-efficacy, intrinsic motivation and extrinsic motivation as predictors of cognitive engagement. This study reported that self-efficacy and intrinsic motivation had a correlation with academic identification, and they were also predictors of meaningful cognitive engagement. On the other hand, extrinsic motivation was predictor to shallow engagement in learning tasks. Motivational beliefs is a well–documented determinant for the quality of learning achievement (11). Other researchers have arrived at the conclusion that instructional materials that are challenging give student choices and promote autonomy and self-determination that will have a positive effect on students’ motivation (10, 12). A study on problem-based learning among 36 first-year students reported that during their first exposure to PBL, the achievement and motivation of students improved. Besides there was a noticeable change in their learning preference (13). It was also evident in another investigation done on the medical students’ motivation to commit themselves to studying in PBL health sciences curriculum on the basis of their attendance at tutorial meetings. Commitment to study in the PBL was a potent determinant of achievement (14). The effects of problem-based learning as compared to the traditional lecture method was reported in the Cardiorespiratory Nursing Section of the Adult Health Nursing Course. The students in the PBL group had higher motivation towards learning as compared to students in the lecture group. Besides, they gained much more knowledge than those in the traditional lecture method. However, there was no significant difference in the attitudes towards learning between the two groups (15). PBL has various forms. Researchers studied the effect of these forms, in comparison with conventional teaching. One such study is the Taiwanese experimental study, where a comparison of the learning-effectiveness was made between a peer-tutored PBL and conventional teaching of nursing ethics. A sample of 142 senior nursing students was randomly assigned to the two groups. It resulted in a significant difference between the two groups in satisfaction with self-motivated learning and critical thinking (16). In India, no investigations of this kind in nursing have been reported so far. Therefore, as part of a larger study, this study aimed at determining whether PBL was effective in improving motivation for learning in the context of the Indian setting particularly among the undergraduate nursing students.
MATERIAL AND METHODS
The study aimed at determining the effectiveness of a problem-based learning package on antenatal care developed for training of undergraduate nursing students in colleges in South India. A quasi-experimental pre-test post-test control group design was used. The study was conducted in three selected nursing colleges using nonprobability convenient sampling. Students who were available during the data collection were selected for the study. The experimental group consisted of 90 subjects while the control group had 73 subjects, who were in the third year B.Sc. Nursing program, and had Obstetrics and Gynecological Nursing as one of their courses. The Motivation for Learning Scale (MLS) was developed by the researcher and was used for collecting data on motivation for learning. The evidence of content validity was based on the judgement of six educational experts, calculated in terms of percentage of agreement on content adequacy, relevance and appropriateness of the items. Each item had three alternatives, for which experts assigned ranks 1,2 and 3 to each of the alternatives, from least motivation to highest motivation. On the basis of expert opinion, three items were dropped from the 58- item draft scale. The 55-item scale was validated a second time and was pretested on 20 undergraduate nursing students. The average time they took to complete the scale was 40 minutes. This scale was to be found clear and hence no modification was considered necessary. The construct validity of the scale was based empirically on the data obtained from 574 nursing students drawn from all the four years of the BSc nursing program, using a factor analysis approach. Items with factor loadings of less than 0.30 were omitted, which resulted in retaining 35 items under six components/ factors. These six factors were ‘mastery’ (19 items), ‘resource management strategies: effort regulation’(3 items), ‘self-regulation’ (4 items), ‘goal-oriented commitment’(3 items), ‘self-determination/autonomy’(3 items) and ‘task value’(3 items). The construct validity of the 35 item MLS was also determined by correlating the scores obtained on the MLS with that of the Motivated Strategies for Learning Questionnaire (MSLQ) developed by Pintrich (1991) (17) . The Pearson Correlation Coefficient computed was 0.784 on a sample of 89 nursing students. The Cronbach alpha computed from a sample of 132 subjects was 0.708, indicating that the MLS was reliable. The MLS had items with three alternatives, with the scores ranging from 1 to 3. An example of an item from the scale is given below:
I learn better by:
a. Gathering factual information
b. In-Depth analysis of the subject
c. Rote (memorization)
The option ‘b’ was rated as 3, while ‘a’ was rated as 2, and ‘c’ was rated as 1.The scores for the MLS was devised by summing up the ratings on all items, resulting in a minimum possible score of 35 and a maximum possible score of 105. Ethical Consideration: Prior to data collection, administrative permission was sought from the Heads of the Colleges of Nursing. After that, the researcher explained the purpose of the research, to the course coordinators. Later, the purpose of the study was explained to the students, and they were assured confidentiality and anonymity of the data that would be collected. The consent was taken for participating in the study. A pilot study was conducted in two nursing colleges; one for the experimental group and the other for the control group. No modification was made in the design, as it was found to be feasible. For data collection, the MLS was administered to the students during a scheduled lecture hour, on the first day prior to the intervention. The experimental group underwent the PBL approach for the learning unit on antenatal care, which was integrated into the existing traditional approach. The control group, however, underwent the traditional approach of teaching which was predominantly lecture-based. The students in the experimental group, to start with, were introduced to training by PBL approach, because they had no previous experience of PBL. After the initial training, the PBL package was adopted for the students. The five problems/ situations that were utilized for the PBL approach was conducted over a period of one month, using the seven-step approach. Where in the first session was the brainstorming session and the second session was the regrouping sessions The post-test was conducted at the end of the intervention on the 30th day.
RESULTS
The data were analyzed using the statistical package for social sciences (SPSS) version 21.0. The mean, median, range and standard deviation was computed to describe the motivation for learning scores while inferential statistics was used for comparison of the motivation scores between the experimental and the control group. Whether or not there was a significant difference between the pre-test and the post – test was determined by computing the independent t test. The results in Table 1 indicate that the mean scores in both, the pre-test (88) and the post-test (87.8) were apparently higher in the control group in comparison to that of the experimental group. The mean score for the experimental group was 84.14 and 85.37 respectively. Comparison Between Experimental and Control Groups The independent sample t-test computed between the mean pre-test MLS scores of the experimental and control groups revealed that the two groups differed significantly, prior to the intervention t(161)=3.58, pEnglishhttp://ijcrr.com/abstract.php?article_id=576http://ijcrr.com/article_html.php?did=5761. Dearnley C, Matthew B. Factors that contribute to undergraduate student success. Teach Higher Educ 2007; 12(3): 377-91.
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11. Zimmerman BJ, Schunk DH. (Eds.) (2001). Self-regulated learning and academic achievement: theoretical perspectives (2nd ed.). Mahwah, NJ: Erlbaum.
12. Hidi S, Harackiewiez JM. Motivating the academically unmotivated: A critical issue for the 21st Century. Review of Educational Research 2000;70(2): 151-79.
13. Marjorie M. CORE elements of student motivation in problem-based learning. New Directions for Teaching and Learning 1999; 78: 49-58.
14. Van Berkel HJM, Schmidt HG. Motivation to commit oneself as a determinant of achievement in problem-based learning. Higher Educ 2000;40:231-42.
15. Hwang SY, Kim MJ. A comparison of problem-based learning and lecture-based learning in an adult health nursing course. Nurse Educ Today. 2006 May;26(4):315-21.
16. Lin CF, Lu MS, Chung CC, Yang CM. A comparison of problem-based learning and conventional teaching in nursing ethics education. Nurs Ethics. 2010 May;17(3):373-82.
17. Pintrich, PR, Smith, DAF, Garcia T, McKeachie WJ. A manual for the use of motivated strategies for learning questionnaire (MSLQ). National Center for Research to Improve Postsecondary Teaching and Learning, University of Michigan, Ann Arbor, MI.1991.
18. Cooke M, Moyle K. Students’ evaluation of problem-based learning. Nurse Educ Today. 2002 May;22(4):330-9.
19. Galand B, Bentein K, Bourgeois E, Frenay M. (2003). The impact of a PBL curriculum on students’ motivation and self-regulation. In Bedard, Pedagogical innovation in higher education and its impact on student learning and motivation. Symposium conducted at the Biennial Conference of the European Association for Research on Learning and Instruction. Padora, Italy, August 2003.
20. D’Sa JL and Bhaduri A. Acceptability of a problem-based learning approach in a baccalaureate nursing programmea pilot study. International Journal of Nursing Education. 5(1): 92-96.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareA COMPARATIVE STUDY BETWEEN ELECTRICAL STIMULATION IN ADDITION TO PASSIVE STRETCHING THAN ALONE PASSIVE STRETCHING ON SPASTICITY IN PATIENTS WITH SPASTIC DIPLEGIC CEREBRAL PALSY CHILDREN
English3944Ghazi Sharique AhmadEnglish Md Haider AliEnglish K. Sambhu NathEnglish Md SarfrazEnglishAim: An electrical stimulation and passive stretching were used to reduce spasticity in spastic diplegic cerebral palsy children patient.
Methodology: Intervention for four weeks which consisted of 30 minutes of electrical stimulation of antagonistic muscles and 30 seconds of passive stretching of the agonist muscles (bicep brachi) 3 times per week of spastic diplegic child patients. Pre and
Post treatment Spasticity of the bicep brachi was measured using the modified Ashworth scale.
Results: The mean value 1.43 of Group A post treatment was compared to the mean value 1.93 of Group B post treatment then the P value found to be 0.0057.
Conclusions: Spasticity of diplegic cerebral palsy children are greatly reduced by using electrical stimulation combined with passive stretching. This suggests that electrical stimulation with passive stretching are more reliant to reduce spasticity than alone passive stretching.
EnglishElectrical stimulation, Muscle spasticity, Diplegic cerebral palsyINTRODUCTION
Cerebral palsy is an “umbrella term covering a group of non-progressive, but often changing, motor impairment syndromes secondary to lesions or anomalies of the brain arising in the early stages of its development1 . The traditional definition of cerebral palsy is a non progressive impairment in movement or posture caused by injury or anomaly of the developing brain2 . CP is classified by the types of motor impairment of the limbs or organs, and by restrictions to the activities an affected person may perform3 .There are three main CP classifications by motor impairment: spastic, ataxic, and athetoid / dyskinetic.3 Additionally there is a mixed type that shows a combination of features of the other types. These classifications also reflect the areas of the brain that are damaged3 . Spastic cerebral palsy, or cerebral palsy where spasticity (muscle tightness) is the exclusive or almost-exclusive impairment present, is by far the most common type of overall cerebral palsy, occurring in upwards of 70% of all cases4 . People with this type of CP are hypertonic and have a neuromuscular mobility impairment (rather than hypotonia or paralysis) stemming from an upper motor neuron lesion in the brain as well as the corticospinal tract or the motor cortex4,5. Spasticity as defined by Lance (1980) is “a motor disorder characterized by a velocity dependent increase in muscle tone with exaggerated tendon jerks, resulting from hyper excitability of stretch reflex as one of the component of upper motor neuron syndrome”.6,7,8 The upper limb adopts an adducted posture at the shoulder and a flexed posture at the elbow and wrist, with the fingers flexed into the palm. In patients with no functionally useful voluntary limb movement, spasticity can maintain an abnormal resting limb posture leading to contracture formation. In the arm, severe flexion deformity of the fingers and elbow may interfere with hand hygiene and dressing, as well as affecting self-image.9,10 Numerous studies say that the effectiveness of stretching depends upon the frequency and duration of the applied stretch11,12,13. This raises the question as to whether the effectiveness of stretch can be enhanced with electrical stimulation7. Functional electrical stimulation (FES) or neuromuscular electrical stimulation (NMES) is the application of continuous current of electricity administered through a surface electrode at the nerve or motor point of a muscle to elicit a muscle contraction.14,15 Many authors have employed that use of functional electrical stimulation and have achieved success in terms of improved upper extremity function. Electrical stimulation has been shown to have positive effects on motor performance.16, 17 , 18 It has also been claimed that spasticity reduction with electrical stimulation is achieved without any muscle weakness or paralysis. It was found that electrical stimulation may increase sensory inputs into the central nervous system and so accelerate nervous plasticity and lead to faster improvement19,20. It has been proposed in various studies that neuromuscular electrical stimulation enhances motor recovery with reduction in spasticity, increase in range of movement of joints and strengthening of muscles, and prevention or correction of contractures.21,22 Electrical stimulation of the antagonistic muscles may improve the efficacy of stretching by providing an additional stretch to the agonistic muscles. It may also reciprocally inhibit the stretched muscle.7 The explanation of these results is that When electrical stimulation is added to passive stretching, is more effective than alone passive stretching for decrease in spasticity in patients with cerebral palsy.7 Therefore, it is predicted that in the current study, Patients with elbow flexors spasticity with Grade between 2- 4 in Modified Ashworth Scale of cerebral palsy children would show greater reduction of spasticity with application of electrical stimulation and passive stretching.
METHODS
Subjects
A total of 30 patients with spastic diplegic cerebral palsy patients, with stage 2 - 4 modified aswarth scale, age 3-5 years were selected. All participants were on phase of medication, tested after an overnight abstinence of at least 12 hours from their usual medication regimen. All participants were naive with respect to the experimental design.
Study design
The study has two groups (Group A and Group B). Each group was 15 patients of both the genders of cerebral palsy. Group A received neuromuscular electrical stimulation to elbow extensors (triceps) and passive stretching of elbow flexors (biceps). And Group B patients received only passive stretching to elbow flexors (biceps). Both the groups were trained for thrice a week for 4 weeks. The approximate duration of each session is 30minutes. All the subjects received a total of 12 sessions.
Instrumentation
The procedure included the Electrostim T electrical muscle stimulator and Modified Ashworth scale. Electrostim T is a modern solid state and a portable surface electrical muscle stimulation unit. It offers both Faradic and Galvanic currents with a various available waveforms like: Plain Faradic: faradic pulses of 0.7ms with a pulse repetition frequency of 40 cycles per second and Surged Faradic: faradic pulse of 0.7ms pulse duration with a repetitive frequency of 40 cycles per second. Surge rate varies from 0.8 to 3 seconds with a fixed rest time of 0.5 seconds. Electrical muscle stimulation is the elicitation of muscle contraction using electrical impulses. The electrical impulses with a short duration of less than 1ms duration is known as faradic type current and is used to strengthen weak muscles, relax spastic muscles.24 Faradic type current is usually surged for treatment purposes to produce a near normal titanic like contraction and relaxation of the muscle.15,24 The current is surged so that intensity of successive impulses increases gradually reaching a peak and then falls either suddenly or gradually.14,15,24 Modified Ashworth Scale is used to grade spastic hypertonicity. It is basically a subjective, 5 point ordinal scale.42 This scale remains a gold standard scale by which other tests are validated. It has been shown to have good intrarater reliability (0.84) and good interraterreliability(0.83)42
Procedure
The patients were diagnosed to have spastic diplegic cerebral palsy and who fulfilled the above inclusive and exclusive criteria were selected. The attendant of entire subject signed an informed consent approved by ethical committee of Bachcha Hospital, Katihar, Bihar, India. A closed environment with least possible distraction was selected as site for data collection. General demographic data was taken. The research designs used were pre and post experimental design for the study. The selected subjects were randomly assigned into one of the two groups A and B.7,23 Each group consists of 15 patients of both the genders and in the age group between 2 to 5 years. Group A: they received neuromuscular electrical stimulation to elbow extensors (triceps) and passive stretching of elbow flexors (biceps). And Group B: they received only passive stretching to elbow flexors (biceps) Both the groups were trained for thrice a week for 4 weeks. The approximate duration of each session is 30minutes. All the subjects received a total of 12 sessions. A portable, surface electrical muscle stimulation unit (Electrostim T) is used in the study. The experimental methods used are non-invasive and pose no hazards to the health of the patient.21
Treatment Intervention
The technique for application of passive stretching was based on passive range of motion therapeutic exercises by Kisner and Colby.29 The passive range of motion consists of moving the elbow passively and holding it in position for 60 seconds. The procedure of passive stretching is given in every treatment session in all the patients, both in group A and B.25 The assessments of spasticity using Modified Ashworth Scale of elbow flexors were carried out at the commencement of the treatment session (pre-treatment). These assessments are also carried out at the end of 4th week (post treatment) on all the patients. The subjects who were included in the research are the patients of spastic diplegic cerebral palsy affecting the elbow flexors muscle i. e biceps with a grade ranging from 2-4. The subjects who are not having normal tactile and pain sensation are not included in the research. In the group A, combination of electrical stimulation and passive stretching is used. The subject is placed in the sitting position and electrical stimulation is given to the elbow extensors i. e triceps brachii for 30minutes in a single session and thrice a week which is followed by passive stretching of the elbow flexors. The triceps is stimulated by placing an active electrode over its motor point of the tendon at the elbow. The therapist was explained the procedure of the stimulation to the participant so that he can be familiarize with the apparatus. A two channel electrical stimulator is applied to the antagonist muscle (triceps) of the subjects of Group A through square 2.5 cm surface electrodes. A stimulator with surging is used to produce near normal tetanic like contraction and relaxation of the muscle and it will be more comfortable which in its self may reduce the tone. The stimulation frequency used is 40 Hz and pulse duration 0.7ms which produces a smooth and comfortable contraction. The rest time is 0.5 sec with a surge rate ranging from 0.8 to 3 sec. The intensity is set according to the subject tolerance and it should produce a visible contraction. The current amplitude will be adjusted according to the subject comfort. During the application of the electrical stimulation the subjects were positioned with elbow semi flex so that biceps is not in lengthened position as recommended by Benton (1981) and therefore to reduce the amount of stimulation required attaining a forceful contraction. After the stimulation, three brief stretches are applied to the elbow flexors for 60sec with a 1 min rest in between the three stretches.13 In the Group B, passive stretching to the elbow flexors for thrice a week is given. Neither the subjects of both the groups received any other form of treatment for spastic diplegic cerebral palsy. At the end of 4 weeks outcome measures are collected immediately after the last intervention by therapist.13,25
Statistical Analysis
A pretest-posttest experimental group design is used for the study. The pretest treatment values of modified aswarth scale on day 1 and post treatment values on day 5 was taken. The data was analyzed using the SPSS 18 Software. Paired T- test applied for comparison of pre test treatment values and post test treatment values within and each groups respectively. The results were taken to be significant if pEnglishhttp://ijcrr.com/abstract.php?article_id=577http://ijcrr.com/article_html.php?did=5771. A. Hussain R. Saadi et al. Maternal and foetal risk factors of cerebral palsy among Iraqi children: A case control study. 2012:2(3): 350-358.
2. Walraich, M, Droter, D et al. Developmental behavioural peditric, Evidence and practice. 2008: 14 : 483-517.
3. C. Rethelfsen SA et al. Classifiation systems in cerebral palsy.” Orthop Clin North Am. 2010 oct: 41 (4): 457–67.
4. Stanley F et al. Cerebral Palsies: Epidemiology and Causal Pathways. London, United Kingdom: MacKeith Press; 2000.
5. J. Maheshwari. Essential Orthopaedics. 4th edition: 222
. 6. Allison Brashear, Elie. P Elovic; Spasticity: Diagnosis and management; Demos medical publication.
7. Khalili, Mohammad A; Hajihassanie, Abdulhamid; Electrical simulation in addition to passive stretch has a small effect on spasticity and contracture; Journal of Physiotherapy; 2008; 54, 3; ProQuest Nursing and Allied Health Source.
8. Kuen-Horng Tsai et al. Effect of single session of Prolonged muscle stretch on Spastic muscle of stroke patients;
9. Bipin B Bhakta; Management of Spasticity in Stroke; Rheumatology and Rehabilitation; British Medical bulletin; 2000: 56: 476-485.
10. Sommerfeld DK et al.Spas ticity after stroke: Its occurrence and association with motor impairments and activity limitations. Stroke. 2004; 35: 134-140.
11. Lesley Wiart et al. Stretching with children with Cerebral Palsy, what do we know and where are we going;Pediatric PhysTher 2008; 20: 173-178.
12. Tamis Pin et al. The effectiveness of passive stretching in children with cerebral palsy; Developmental Medicine and Child Neurology 2006, 48: 855-862.
13. Carolyn Kisner, Lynn Allen Colby, Therapeutic Exercise: Foundations and Techniques, Jaypee, 4th Edition.
14. Sheila Kitchen, Sarah Bazin; Clayton’s Electrotherapy; Saunders; 1996.
15. John Low and Ann Reed; Electrotherapy Explained : Principles and Practice; 3rd Edition; Elseiver; 2003.
16. Juan Nicolás Cuenca and Eric Lazar; Functional Electrical stimulation in stroke.
17. Lourenção MI et al. Analysis of results of functional electrical stimulation on hemiplegic patients’ upper extremities using the Minnesota manual dexterity test. IntRehabil Res. 2005; 28: 25-31.
18. Liberson WT et al. Functional electrotherapy: stimulation of the peroneal nerve synchronized with the swing phase of the gait of hemiplegic patients. Arch Phys Med Rehabil. 1961; 42: 101–105.
19. Susan R O Sullivan and Thomas J Schmitz; Physical Rehabilitation: Assessment and Treatment; Jaypee Brothers; 4lh Edition, 2001.
20. C. R. W.Edwards et al. Davidson’s Principles and Practice of Medicine; Churchill Livingstone; 18th edition ; 2000.
21. Barbara M Doucet; High vs. low electrical stimulation frequencies for motor recovery in hemiplegia; December. 2004.
22. A. Pandayan et al. Electrical stimulation of wrist extensors in post stroke hemiplegia; Stroke journal of American Heart Association 1999 : 30 :1384 – 1389.
23. S.R.A Akinbo et al. Comparison of the effect of Neuromuscular electrical stimulation and Cryotherapy on Spasticity and hand function in patients with spastic cerebral palsy; Nigeria medical practioner; 2005(6): 51: 128-132.
24. Sheila Kitchen, Sarah Bazin; Electrotherapy; Evidence based practice; 11th edition, 2002.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareCORRELATES OF AGE AT MENARCHE AMONG UNMARRIED GIRLS IN UT CHANDIGARH
English4552Dinesh KumarEnglish N. K. GoelEnglish Sonia PuriEnglish Nancy GuptaEnglishBackground: Age at menarche is an important factor in health planning and reproductive health of females. Studies have indicated that girls are attaining puberty earlier than in the past.
Objectives: To explore age at menarche and factors determining it among unmarried girls.
Methods: This community based cross-sectional study was conducted in Rural, Urban and Slum strata of UT Chandigarh ,during April 08 to March 09 in total duration of 12 months .Stratified Multistage Random Sampling Design with probability proportional to size (PPS) was utilized. 744 respondents were selected and interviewed by personal interview method to collect desired information.
Results and Discussion: The study showed, Maximum respondents 282 (37.9%) were found in the age group 13-15 years followed by 240 (32.3%) in the age group 16-18 years. Maximum number of respondents attained menarche between 13-14 years of age. Mean age at menarche was found to be varying significantly according to type of family (P< 0.001), home environment (P < 0.001), menstrual problems (P=0.03) and menstrual cycle (P=0.001). Respondents whose home environment was not religious, attained menarche significantly earlier (PEnglishMultistage random Sampling, MenarcheINTRODUCTION
The age of menarche varies from 9-18 years with the average age in the United States being about 12 years and 8 months whereas in India it is around 12 years1-4.Several studies have documented the importance of environmental factors in the timing of menarche in girls. Sociocultural, environmental, nutritional, and life style related factors are among some potential correlates of age at menarche apart from genetic factors. Eveleth and Tanner (1990)5 , in their review of the sexual development of adolescents worldwide, found that the timing of menarche varies greatly across cultures. A variety of other factors including family conflict, stress and nutrition have also been found to influence the age of menarche. Detailed account of correlates of age at menarche is available in the study by AYATOLLAHI ET AL6 in Iran. With the advancement in modern communication technology, age at menarche is likely to be influenced by exposure to mass media also. There is a need for investigating factors associated with variations in the menarcheal age. The manner in which a girl learns about menstruation and its associated changes may have an impact on her response to the event of menarche. Menstruation is still regarded as something unclean or dirty in Indian society7 . Without prior knowledge, the first menstruation is often horrifying and frightening experience to them8 . Unmarried girls are prone to various reproductive health related problems. Although menstruation is a natural process, it is linked with several misconceptions, ignorance and practices among young girls, which sometimes results into adverse reproductive health outcomes and may adversely affect their daily routine and quality of life9 . Unmarried girls are prone to various menstrual problems like pain and discomfort, heavy bleeding, absence of menstruation and some symptoms related to fluctuating hormone levels like depression, breast tenderness and slight, temporary weight gain. Menstruation disorders are also responsible for emotional, physical, behavioural and dietary practice changes10. Kushwaha and Mittal11 studied the knowledge and attitude of adolescents, but their study was confined to out- of school adolescents attending some training program only and does not reflect their knowledge status in the general community. Despite the fact that menstruation is closely associated with reproductive health matter of females, community based research among unmarried girls on this particular topic has been relatively unexplored. This study aims to explore the various factors determining the age of menarche in adolescent unmarried girls in UT, Chandigarh, The place characterized by high population growth due to increasing migratory population
MATERIALS AND METHODS
744 respondents were selected from different wards/ strata by using Stratified Multistage Random Sampling Design with probability proportional to size (PPS) .Only those unmarried girls who have already attained menarche to find extent of their menstrual problems, perceptions beliefs practices and restrictions and who/ their parents were willing to participate in the study were included.
House-to-house surveys were conducted to collect the desired information. Respondents were interviewed individually in privacy. Interview schedule was finalized after conducting a qualitative survey to explore relevant questions and to get insight of the problem. A well-trained team of female investigators of the department were involved in data collection. Informed consent following Ethical Guidelines of World Medical Association Declaration of Helsinki12 was taken. In case of respondents below 18 years of age, consent from her parents was taken.
STATISTICAL METHODS:
Data analysis was done by using SPSS-12 Software.
RESULTS
Table 1 Maximum respondents (37.9%) were found in the age group 13-15 years followed by 240 (32.3%) in the age group 16-18 years. Overall mean age of respondents was found to be 16.84 years. Maximum respondents 304 (40.9%) were studying in 10th standard while 82 (11.0%) were illiterate and 68.1% were already dropped from their respective schools mostly before 5th standard. Maximum numbers of respondents were from Hindi medium followed by English and Punjabi medium. Respondents were mostly from nuclear families (80.8%). Parents were from different educational categories. Fathers of 119 (16.0%) respondents and mothers of 187(25.1%) were either illiterate or just literate Majority of mothers 433 (58.2%) were house-wives whereas fathers of only 30(4%) were unemployed. Respondents represented different socio economic classes (29.4%) low, (48.9%) middle and (21.6%) of high socio economic status. Mean family size was found to be (5-15±1.67). Table 2 Maximum number of respondents274 (36.8%) attained menarche between 13-14 years of age. Table 3 Majority of respondents 572 (76.9%) were exposed to TV. Against the usual hypothesis of high degree of exposure to internet in highly urbanized city of Chandigarh, it was found to be only among 75 (10.1%) respondents. A total of 448 (60.2%) respondents were having prior knowledge regarding menstruation before attaining menarche and most of these respondents (46.8%) got this knowledge from their mothers followed by their friends (28.3%) and elder sisters (25.9%). Overall mean age at menarche was found to be 13.02 ± 1.13 years. Medium of education, literacy status of mothers were found not to be significantly associated with menarcheal age. Mean age at menarche was found to be varying significantly according to type of family (P< 0.001), home environment (P < 0.001), menstrual problems (P=0.03) and menstrual cycle (P=0.001. Respondents whose home environment was not religious attained menarche significantly earlier (PEnglishhttp://ijcrr.com/abstract.php?article_id=578http://ijcrr.com/article_html.php?did=5781. Ghiri P, Bernardini M, Vuerich M, Cuttano AM, Coccoli L et al. Adrenarche, pubertal development, age at menarche and final height of full-term, born small for gestational age (SGA) girls. Gynecol Endocrinol 2001; 15: 91-97.
2. Khadilkar VV, Stanhope RG, Khadilkar V. Secular trends in puberty. Indian Pediatr 2006; 43: 475-478.
3. Chumlea WC, Schubert CM, Roche AF, Kulin HE, Lee PA, Himes JH et al. Age at menarche and racial comparisions in US Girls. Pediatrics 2003; 111:110-113.
4. Acharya A, Reddaiah VP, Baridalyne N. Nutritional status and menarche in adolescent girls in an Urban resettlement colony of South Delhi. Indian J Community Medicine.2006; 31:302-303.
5. Eveleth PB, Tanner JM: Worldwide variation in human growth 1976. Cambridge University Press, 1976:213-9.
6. Ayatollahi SMT, E Dowlatabadi, SAR Ayatollahi. Age at menarche and its correlates in Shiraz, Southern Iran. Irn J Med Sci 199; 24(1and 2):20-25.
7. Kamaljit K., Balwinder Arora, Gurmeet Kahlon Singh, N.S. Neki. Social Beliefs and Practices associated with Menstrual Hygiene among Adolescent Girls of Amritsar, Punjab, India. JIMSA April-June 2012 Vol. 25 No. 2
8. H. Tiwari, R. Tiwari, U.N. Oza. Age at Menarche and its Association with Age at Marriage and Age at First Birth. IJCM Vol. 30, No. 1, January-March, 2005.
9. Suman sangita Nayak, Dr.P.K. Mishra. Menstrual Health And Hygiene Education Among Adolescent Girls In Rural Areas By Providing life Skill Education: An Intervention. Life skills education for adolescent reproductive and sexual health issues, 2011.
10. Dinesh Kumar, N.K.Geol, Sonia Puri, Rambha Pathak, Sandeep Singh Sarpal et al. Menstrual Pattern among Unmarried Women from Northern India. J Clin Diagn Res. 2013 Sep; 7(9): 1926–1929.
11. Kushwaha SS, Mittal A. Perceptions and Practice with Regard to Reproductive Health Among Out-of- School Adolescents, Indian Journal of Community Medicine (2007); 32(2):141–43.
12. World Medical Association Declaration of Helsinki: Recommendations guiding physicians in biomedical research involving human subjects 2006 version.
13. Nair P, Grover VL and Kanan AT. Awareness and Practices of Menstruation and Pubertal Changes Amongest unmarried Female Adolescents in Rural Area of East Delhi. Indian Journal of Community Med (2007); 32(2):156-57.
14. Dasgupta A, Sarkar M. Menstrual Hygiene: How Hygienic is the Adolescent Girl. Ind J Community Med 2008; 33(2):77-80.
15. AR Dongre, Deshmukh P.R. and BS Garg. The effect of community-based health education intervention on management of menstrual hygiene among Rural Indian Adolescent Girls. Dr Sushila Nayar School of Public Health, Mahatma Gandhi Institute of Medical Sciences, Sewagram - 442 102, India.
16. Shiela W, Malathy K, Premila S. Menstrual and gynecological disorders in 500 school girls in Madras City. J Obstet Gynaecol India 1993;43: 940-5.
17. Richa Kushwaha. Socio-cultural and Nutritional aspects of menarche among adolescent girls. M.Sc Nutritional Sciences, Dissertation,University of Allahabad, 2004.
18. Khanna A, Goyal RS, Bhawsar R. Menstrual practices and reproductive problems: a study of adolescent girl in Rajasthan. J Health Management 2005; 7:91-107.
19. HK girls with menstrual problems rarely seek medical help: February issue of Hong Kong Medical Journal 2009-02-06 19:15:33.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareEFFECTIVENESS OF COMPUTER AIDED TEACHING, AS COMPARED TO TRADITIONAL BOARD TEACHING, AMONG MEDICAL UNDERGRADUATES OF UDAIPUR
English5355Jarinabanu T.English K. PrabhakaranEnglishIntroduction: Even though it is a well known fact that computer aided teaching methods like power point presentations are far more advanced, popular and superior to traditional teaching methods like board teaching, there is always a constant debate among medical teachers and students about the best method for medical undergraduates. So an attempt has been made to find out the student’s perspective, the popular teaching methods among them, the reasons for the popularity, the students view of advantages and disadvantages of board and computer aided teaching through a student feedback.
Aims and Objectives: To compare the effectiveness of computer aided teaching with board teaching through a student feedback, to find out the advantages, disadvantages of computer aided teaching and board teaching through a student’s perspective and finally to find out the student’s preference of best teaching tool for them.
Materials and Methods: 98 medical undergraduate students belonging to first year MBBS course of GMCH, Udaipur formed the subjects for the current study. All the students were given a standard MEU questionnaire used for microteaching for collecting their feedbacks.
Results: 95.92% preferred computer aided teaching method like power point presentation for understanding difficult concepts/ topic where as only 4 students that is 4.08% of students preferred board teaching. 97 students out of 98 that is, 98.98% of students mentioned that, maximum interest was generated in the topic, when both power point presentation and board teaching methods were combined together. 83 students out of 98 students that is, 84.69% preferred a combined teaching method for regular anatomy lectures.
EnglishComputer aided teaching, Power point presentation, Board teachingINTRODUCTION
Even though it is a well known fact that computer aided teaching methods like power point presentations are far more advanced1,2, popular and superior to traditional teaching methods like board teaching, there is always a constant debate among medical teachers and students about the best method for medical undergraduates. All standard Medical education technology workshops1,2 world over insist on computer aided teaching methods rather than board teaching method because of its greater advantages and fewer limitations. In the recent times computer aided teaching has become a necessary tool for teaching medical undergraduates, especially due to decreased course period for MBBS. Though board teaching has certain advantages for small groups, the computer aided (like PowerPoint) teaching has a lot more advantages for both small groups as well as larger group teaching, mainly because of its speedy coverage of topics, concept building methods, striking and actual depiction of clinical pictures, Real Gross Anatomy pictures, Animations like showing mechanism of Drug action and so on. After all, it is evolution of teaching methods which has finally given rise to computer Aided teaching methods starting from black board. In this study we have tried to compare the effectiveness of board teaching and computer aided teaching in a class room setup for medical undergraduates.
An attempt has been made to find out the student’s perspective, the popular teaching methods among them, the reasons for the popularity, the students view of advantages and disadvantages of board and computer aided teaching through a student feedback. AIMS AND
OBJECTIVES
1. To compare the effectiveness of computer aided teaching with board teaching through a student feedback.
2. To find out the advantages and disadvantages of computer aided teaching and board teaching through a student’s perspective.
3. To find out the student’s preference of best teaching tool for them.
MATERIALS AND METHODS
98 medical undergraduate students belonging to first year MBBS course of GMCH, Udaipur formed the subjects for the current study. All the students were given a standard MEU questionnaire used for microteaching for collecting their feedbacks, once during their first year. Permission from Human ethics committee was taken for conducting the study. The students were taught some topics using board alone, some topics with Computer Aided tools like PowerPoint and some topics using both board as well as power point. The questionnaire dealt with various issues like advantages and disadvantages of board teaching, computer aided teaching, combined board and computer aided teaching, reasons for the same. It also dealt with popularity of the any single or combined teaching methods and the reasons for the same. It also dealt with teaching method/s which generated greater interest in the subject or topic taught. The questionnaire also contained questions pertaining to teaching methods which made them easier to understand and comprehend difficult concepts. The study design is of descriptive comparative type. The feedback questionnaire was collected from all the students during lecture hours and the percentage of responses calculated.
DISCUSSION
In the current study we found that 94 out of 98 students that is, 95.92% preferred computer aided teaching method like power point presentation for understanding difficult concepts/topic where as only 4 students that is 4.08% of students preferred board teaching (Table no.1). Supporting our result a study undertaken in people’s medical sciences state that, majority of students, understand and retain better if taught by power point,3 stressing the importance of power point in the current scenario. This proves that computer aided teaching that is power point presentation is more effective than board teaching in making students understand difficult concepts/topic 97 students out of 98 that is, 98.98% of students mentioned that, maximum interest was generated in the topic, when both power point presentation and board teaching methods were combined together. Only 1.02% of students mentioned that computer teaching alone generated interest in the topic and 0% for board teaching alone for generating interest (Table no.2) there by emphasizing that a combined teaching method to be more interesting. 83 students out of 98 students that is, 84.69% preferred a combined teaching method for regular anatomy lectures, whereas 9 students that is 9.18% preferred computer teaching alone and only 6 students that is 6.12% preferred board alone (Table. 3). An earlier study4 done in King George medical university showed that 70.37% of students preferred a combination of power point presentation and traditional methods supporting our outcome. This proves that the best teaching tool according to students is a combination of power point presentation and board teaching. This is also supported by yet another study undertaken in Dehradun5 .
CONCLUSION
1. Computer aided teaching that is power point presentation is more effective than board teaching in making students understand difficult concepts/topic.
2. Maximum interest was generated in the topic, when both power point presentation and board teaching methods were combined together.
3. The best teaching tool according to students is a combination of power point presentation and board teaching.
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=579http://ijcrr.com/article_html.php?did=5791. Medical Education-Principles and Practice. 2nded. Pondicherry: NTTC JIPMER Alumni Association; 2013.
2. Principles and Practice of Medical Education Technologies workshop manual. Ahmedabad: MCI Regional training Centre NHL Municipal Medical College; 2013.
3. Hanmant S. Amane, Silpa N. Kaore, Suresh V Vasvani. Evaluation of existing teaching methods used for lecture classes in pharmacology. Int J Pharm Bio Sci 2013;4(1):193-198.
4. Jyoti Chopra, Anita Rani, Archana Rani, R.K. Deewan, A.K. Srivastava and P.K .Sharma. Student’s reflection on teaching methodology in Anatomy. AJMS 2014;5(1):47-51.
5. Sukhendu Dutta. Application of computer aided teaching in conventional lecture class. SEJME 2011; 5(2):60-63.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareAN EPIDEMIOLOGICAL STUDY OF DETERMINANTS OF DEFAULTER UNDER REVISED NATIONAL TUBERCULOSIS CONTROL PROGRAM IN OLD CITY OF HYDERABAD
English5662Pisudde P. M.English Sushma KatkuriEnglish Nithesh KumarEnglish Taywade M. L.EnglishIntroduction: In India TB report 2014 it was stated that, out of the estimated global annual incidence of 8.6 million TB cases, 2.3 million were estimated to have occurred in India till 2012. As per WHO, Tuberculosis prevalence per lakh population has reduced from 465 in year 1990 to 230 in 2012. Defaulting from treatment has been one of the major obstacles to treatment management and an important challenge for TB control. To ensure treatment adherence, Directly Observed Treatment - Short Course (DOTS) is a main strategy. It becomes imperative to understand the determinants of default under DOTS so that necessary actions can be taken up to prevent defaults under the program. Hence, the present study was undertaken to study the determinants of default under DOTS.
Material and methods: Case control study was carried out in “Bhavani Nagar” urban slum area of Hyderabad in old city and study subject were selected. Study duration was from 1st January 2011 to 31 December 2012 and data was collected from June 2013 to July 2013 by interviewing study subjects. The data collected was entered and analyzed using epi_info 6.04d. The study has been conducted after being approval from Institutional Ethical Committee.
Results and conclusion: The odds of getting default were 2.4 times more when the study subjects belongs to OBC caste but was not found statistically significant. The risk of getting defaulter was 3.2 times more in study subjects studied less than higher secondary when compared with study subjects studied more than equal to higher secondary but was not found statistically significant. Major reason for defaulting was disappreance of the symptoms i.e. 33.3%, followed by intolerance of drugs(26.1%). It was found that having nuclear family is one of the determinant for defaulting. It was also seen that old cases of TB were associated with defaulting this may be due to the drugs intolerance or due to the disappearance of symptoms or their adherence
to treatment requires more counseling. Defaulting was also found significantly associated with DOTS provider who were from
the health department.
EnglishCase control study, Tuberculosis, DefaultersINTRODUCTION
India is the second-most populous country in the world one fourth of the global incident Tuberculosis (TB) cases occur in India annually. In India TB report 2014 it was stated that, out of the estimated global annual incidence of 8.6 million TB cases, 2.3 million were estimated to have occurred in India till 2012. India’s TB control programme is on track as far as reduction in disease burden is concerned. There is 42% reduction in TB mortality rate by 2012 as compared to 1990 level. Similarly there is 51% reduction in TB prevalence rate by 2012 as compared to 1990 level. These estimations were based on Revised National Tuberculosis Control Program (RNTCP) data, prevalence surveys in India conducted between 2007-2010, National Annual risk of tuberculosis infection(ARTI) surveys and mortality surveys conducted in 2005. Tuberculosis prevalence per lakh population has reduced from 465 in year 1990 to 230 in 2012. In absolute numbers, prevalence has reduced from 40 lakhs to 28 lakhs annually. Tuberculosis incidence per lakh population has reduced from 216 in year 1990 to 176 in 2012. [1] Defaulting from treatment has been one of the major obstacles to treatment management and an important challenge for TB control.[2,3] Inability to complete the prescribed regimen which is quite common in selfadministered treatment[4], is an important cause for treatment failure, relapse, acquired drug resistance and on-going transmission of infection[5]. The consequences of default could be disastrous particularly in the context of intermittent Short Course Chemotherapy (SCC) regimens. Directly Observed Treatment - Short Course (DOTS) is a main strategy under RNTCP to ensure treatment adherence, wherein each dose of treatment is given under the observation of a health worker. The adoption of DOTS has given impressive results with higher treatment success being reported from developing[6]and industrialized countries[7]. Yet, default continues to occur in certain situations and is a matter of concern. The challenges encountered while implementing DOTS vary from place to place depending on the geographic terrain, demographic structure and socio-cultural milieu. The major thrust of RNTCP is achieving a cure rate of more than 85%[6]. Strict adherence to Directly Observed Treatment is likely to minimize defaults and is therefore essential for the desired treatment success as shown in study at Bangalore[7]. It becomes imperative to understand the determinants of default under DOTS so that necessary actions can be taken up to prevent defaults under the program. Hence, the present study was undertaken to study the determinants of default under DOTS.
AIMS AND OBJECTIVES
The present study was undertaken to study the determinants of default under DOTS programme
MATERIAL AND METHODS
Present Case control study was carried out in “Bhavani Nagar” urban slum area of Hyderabad in old city. A “case” was a defaulter TB patient who received anti-TB treatment for one month or more from any source and had not taken anti-TB drugs consecutively for two months or more. All cases which defaulted during 1st January 2011 to 31 December 2012 at Bhavani Nagar area using RNTCP definition were included in the study. The “control” was a case of tuberculosis that has completed treatment during 1 January 2011 to 31 December 2012 and was not a defaulter at any point of time. The Quantitative data was collected for the study purpose from June 2013 to July 2013. The quantitative data was collected by interviewing the defaulters and the persons who have completed the treatment in predesigned and pre-tested questionnaire after taking informed consent. The socioeconomic status(SES) was based on the different ration card provided by state government which mentions the Below poverty line(BPL) and Above poverty line(APL) family. The data collected was entered and analyzed using epi_info 6.04d. The study has been conducted after being approval from Institutional Ethical Committee. The defaulters in the study area were interviewed after informed about the importance of the treatment. If any problem detected, defaulter was counseled for referral.
RESULTS
Table 1 above shows that, maximum numbers of study subjects were from below age of 40 years(86.6%), similar were in cases and controls. Age was not found to be significantly associated with defaulters. Male and female study subjects were approximately equally affected in both cases and controls. Study subjects belonging to OBC caste were more in cases(53.3%) and the general caste were more in controls(73.3%). The odds of getting default were 2.4 times more when the study subjects belongs to OBC caste but was not found statistically significant. Study subjects doing household works and those doing labour work were 53.3% and 46.7% in the cases respectively where as in controls 60% were doing household work and 40 % were in labour. It can be observed from the above table maximum number of study subjects were belonging to Below Poverty Line(BPL) i.e 80% and 20% were in Above Poverty Line(APL) and study subjects were similar in cases and controls both. In above table 1 it can be observed that 26.7% and 73.3% study subjects were from joint and nuclear family respectively in cases and in controls it was vice versa. It was observed that the odds of becoming defaulters was 0.13 times less when the study subject belong to nuclear family compared to joint family and was found statistically significant(p 0.05) In the above table 1, it can be observed that 20% study subjects were tobacco consumers in cases and there were no tobacco consumer in the control group. It can be observed from above table that 6.7% study subjects were consuming alcohol and 20% were of the study subjects in control groups were consuming alcohol group and was not having any significance in determining the defaulters. Most of the study subjects in cases were referred by health workers and other (80%) while the in controls they were 73% and there was no significance. Above table shows that among the cases group 26% study subjects migrated while no study subjects migrated in the control group. In above table 1, it can be seen that only 6.7% study subjects in the cases were diagnosed in private hospital while all of the study subjects were diagnosed in government hospital. Above table shows that old TB study subjects were 40% and 13.3% in the cases and control group respectively. Odds of getting defaulter of 4.3 times more in old study subjects compared to newly diagnosed TB and the association was found statistically significant(P < 0.05). Above table 1, shows that in cases group pulmonary and extra pulmonary TB diagnosed study subjects were 46.7% and 53.3% respectively while they were 80% and 20% in respectively in control group. Above table shows that in category of TB, study subjects were 60% in cat I and 40% in cat II in cases group and 86.7% and 13.3% in cat I and cat II respectively in control group. Above table 1, shows that DOTS providers in the cases group were personals in the health system(66.7%) and volunteers were 33.3%. While in control group DOTS providers were personals in the health system(6.7%) and volunteers were 93.3%. The odds of getting defaulter was 28 times more if the DOTs provider was the personal from the health system compared to volunteer and was found statistically significant(p Englishhttp://ijcrr.com/abstract.php?article_id=580http://ijcrr.com/article_html.php?did=5801. Central TB division, DGHS, Ministry of Health and Family welfare. TB India 2014, RNTCP Status Report. New Delhi; 2014.
2. Snider DE Jr. An overview of compliance in tuberculosis treatment programmes; Bull Int Union Tuberc 1982; 57: 247-52.
3. Brudney K, Dobkin J. Resurgent tuberculosis in New York City: human immunodeficiency virus, homelessness, and the decline of tuberculosis control programs; Am Rev Respir Dis 1991; 144: 745-79.
4. Davidson BL. A control comparison of directly observed therapy vs self-administered therapy for active tuberculosis in the urban United States. Chest 1998; 114: 1239-43.
5. Weis SE, Slocum PC, Blais FX, King B, Nunn M, Matney GB et al; The effect of directly observed therapy on the rates of drug resistance and relapse in tuberculosis; N Engl J Med. 1994; 330: 1179-84.
6. Khatri, G.R., Frieden, T.R.; The status and prospects of tuberculosis control in India; Int J Tuberc Lung Dis 2000; 4(3): 193-200.
7. Sophia Vijay, VH Balasangameswara, PS Jagannatha, VN Saroja, P Kumar. Defaults among tuberculosis patients treated under DOTS in Bangalore city : a search for solution. Ind. J Tub., 2003, 50,185
8. Frieden TR, Fujiwara PI, Washko RM, Hamburg MA. Tuberculosis in New York City-turning the tide. N Engl J Med. 1995 Jul 27;333(4):229-233.
9. Chandrasekaran V, Gopi P, Subramani R, Thomas A, Jaggarajamma K, Narayanan P. Default during the intensive phase of treatment under DOTS programme. Indian J Tuberc 2005;52:197-202.
10. Chatterjee P, Banerjee B, Dutt D, Pati RR, Mullick AK. A complete evaluation of factors and reasons for defaulting in tuberculosis treatment in the state of West Bengal, Jharkhand and Arunachal Pradesh. Indian J Tuberc, 2003,50:17-22.
11. Yeung MC, Noertjojo K, Leung CC, Chan SL, Tam CM. Prevalence and predictors of default from tuberculosis treatment in Hong Kong Hong Kong Med J 2003;9:263-68.
12. Comolet TM, Rakotomalala R, Rajaonarioa. Factors determining compliance with tuberculosis treatment in an urban environment, Tamatave, Madagascar Int J Tuberc Lung Dis 1998; 2(11):891–897.
13. Daniel OJ, Alausa OK. Default from tuberculosis treatment programin Samagu, Nigeria. Nigerian J Medicine2006; 15(1): 63-70.
14. Jaggarajamma K, Muniandy M, Chandrasekaran V, Thomas SG, Gopi PG, Santha T. Is migration a factor leading to default under RNTCP. Indian J Tuberc 2006;53:33-36.
15. Jaggarajamma K, Sudha G, Chandrasekaran V, Nirupa C, Thomas A, Santha T et al. Reasons for non-compliance among patients treated under revised national tuberculosis control programme(RNTCP), Tiruvallur district, South India. Indian J Tuberc 2007; 54:130-135.
16. Santha T, Garg R, Frieden TR, Chandrasekaran V, Subramani R, Gopi PG et al. Risk factors associated with default, failure and death among tuberculosis patient treated in a DOTS programme in Tiruvallur district, South India, 2000. Int J Tuberc Lung Dis. 2003 Feb;7(2):200-1.
17. Balasubramanian R, Garg R, Santha T, Gopi P, Subramani R, Chandrasekaran Vet al. Gender disparities in tuberculosis: report from a rural DOTS programme in south India. Int J Tuberc Lung Dis 2004; 8(3):323–332.
18. Jakubowiak WM, Bogorodskaya EM, Borisov ES, Danilova DI, Kourbatova EK. Risk factors associated with default among new pulmonary TB patients and social support in six Russian regions. Int J Tuberc Lung Dis 2007; 11(1):46– 53.
19. Chatterjee P, Banerjee B, Dutt D, Pati RR, Mullick AK. A complete evaluation of factors and reasons for defaulting in tuberculosis treatment in the state of West Bengal, Jharkhand and Arunachal Pradesh. Indian J Tuberc, 2003,50:17-22.
20. Tekle B, Mariam DH, Ali A. Defaulting from DOTS and its determinants in three districts of Arsi Zone in Ethiopia. Int J Tuberc Lung Dis 2002; 6(7):573–579.
21. Gopi PG, Vasantha M, Muniyandi M, Chandrasekaran V, Balasubramanian R, Narayanan PR. Risk factors for nonadherence to directly observed treatment (dot) in a rural tuberculosis unit, South India. Indian J Tuberc 2007; 54:66-70.
22. Chang KC, Leung CC, Tam CM. Risk factors for defaulting from anti-tuberculosis treatment under directly observed treatment in Hong Kong. Int J Tuberc Lung Dis 2004; 8(12):1492–1498.
23. Hasker E, Khodjikhanov M, Usarova S, Asamidinov U, Yuldashova U, Werf MJ. Default from tuberculosis treatment in Tashkent, Uzbekistan; Who are these defaulters and why do they default? BMC Infectious Diseases 2008; 8:97.
24. Zellweger JP, and Coulon P. Outcome of patients treated for tuberculosis in Vaud County, Switzerland. Int J Tuberc Lung Dis 1998; 2(5): 372-77.
25. Santha T, Garg R, Frieden TR, Chandrasekaran V, Subramani R, Gopi PG et al. Risk factors associated with default, failure and death among tuberculosis patient treated in a DOTS programme in Tiruvallur district, South India, 2000. Int J Tuberc Lung Dis. 2003 Feb;7(2):200-1.
26. da Silva Oliveira VL, da Cunha AJLA, Alves R. Tuberculosis treatment default among Brazilian children. Int J Tuberc Lung Dis 2006; 10(8):864–869.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareCLINICOPATHOLOGICAL AND IMMUNOHISTOCHEMICAL PROFILE OF MAMMARY PAGET DISEASE
English6366Salma BhatEnglish Rohi WaniEnglish Samina KhandayEnglish Sheema SheikhEnglish Ruby ReshiEnglish Humaira BashirEnglishMammary Paget disease (MPD) is a rare manifestation of the nipple-areola complex that is often associated with an underlying in situ or invasive carcinoma. MPD is very often hormone receptor negative. However, unlike ER and PR, Her 2 neu receptor is overexpressed in the vast majority of Mammary paget disease. In this study we have evaluated the clinicopathological and immunohistochemical aspects of this disease. In this retrospective study, all cases of mammary Paget disease referred to the Department of pathology, Government Medical College Srinagar from 2006 till 2013 were evaluated. Collective data were analysed by descriptive statistical analysis methods.There were 19 cases of Mammary paget disease reported from 2006 to 2013. All but one of the MPD cases were associated with an underlying ductal carcinoma .The underlying breast malignancy was high grade with a significant proportion having axillary nodal involvement. One patient had underlying DCIS. On IHC , only two cases of MPD were ER and PR positive. There was a single triple negative MPD case. Conversely Her2 neu was strongly positive in sixteen cases of MPD .The same immunohistochemical spectrum was shared by underlying breast carcinoma including DCIS.
MPD is often associated with extensive underlying malignancy which is of high grade and is frequently Her2 neu positive with a resulting poor prognosis. Therefore for patients with clinical suspicion of MPD breast examination, mammography and even biopsy are highly recommended.
EnglishMammary Paget disease, Ductal carcinoma, Her2 neuINTRODUCTION
MPD has been recognised as a distinct entity for over 120 years.MPD is diagnosed in 0.5%-5% of all breast cancer patients.1 The association of MPD with underlying breast carcinoma was described originally in 1874 by Sir James Paget.2 The clinical appearance of Mammary Paget disease is usually a thickened, sometimes pigmented, eczematoid, erythematous weeping or crusted lesion with irregular borders.3 Usually the lesion is limited to the nipple or extended to the areola and in advanced cases it may also involve the surrounding skin. It is often associated with underlying DCIS and/or invasive ductal carcinoma. Approximately,50% of these patients present with an associated palpable mass in the breast.4 In cases where mass is palpable, invasive carcinoma is likely to be found. On the other hand patients presenting without a clinical mass more likely have DCIS.5 The prognosis for MPD with an underlying palpable mass is poorer than mammary carcinoma without Paget disease. By contrast, the prognosis for Paget disease with minimal intrinsic in situ carcinoma is excellent.6 MPD occurs most commonly in post-menopausal women but may be observed even in younger and adolescent population.7 MPD is very often hormone receptor negative, because the underlying carcinoma tends to to be poorly differentiated. Unlike ER and PR ,Her2 neu is overexpressed in the vast majority of MPD.8 Over expression of Her 2 neu is the result of Her2 neu gene amplification.9 The Her 2 protein has a growth stimulating effect, furthermore it enhances the motility of tumour cells by the interaction of the membrane expressed neoprotein and a motility factor resulting in chemotaxis and invasion of epidermis by the Paget cells.10 Generally in many cases there is a correlation between positive stain ing for Her 2 oncoprotein of Paget cells and underlying in situ or invasive carcinoma.11 Patients with MPD and underlying IDC tend to have greater chance of lymph node metastasis , lower hormone receptor expression and higher Her2 expresssion compared to those without Paget disease.12
MATERIAL AND METHODS
In this descriptive retrospective study, all Paget biopsied samples referred to the department of pathology ,Government medical college, Srinagar since 2006 till 2013 were evaluated. The Inclusion criteria was 1)Mastectomy patients. 2)Had histologically confirmed IDC/DCIS with Paget disease. The tumour was characterised on the basis of histology, tumour grade, regional lymph node status, ER, PR and Her 2neu expression (positive vs negative).
Observations
There were 19 cases of MPD reported from 2006 to 2013. All but one of the MPD cases were associated with ductal carcinoma .The underlying breast malignancy was high grade with a significant proportion having axillary nodal involvement. One patient had underlying DCIS. On IHC , only two cases(10.5%) of MPD and underlying ductal carcinoma were ER and PR positive.There was a single triple negative MPD case. Conversely Her2 neu was strongly positive in sixteen cases(84.2%) of MPD .The same immunohistochemical spectrum was shared by underlying breast carcinoma including DCIS.
DISCUSSION
MPD is a rare disorder of the nipple-areola complex that is often associated with an underlying in situ or invasive carcinoma.6 The clinical appearance of MPD is usually a thickened, sometimes pigmented eczematoid, erythematous weeping or crusted lesion with irregular borders.3 Two theories have been proposed to explain the pathogenesis of MPD. The Epidermotropic theory which is the most accepted theory suggests that Paget cells originate from ductal cancer cells that had migrated from the underlying breast parenchyma. This theory is supported by the predominance of Breast cancer markers found in Paget disease.13 Although there are few articles in which MPD is reported in men, all of our 19 cases were women.14 The mean age of our patients was 60 years which was consistent with the findings of Chen,C-Y et al15 where the mean age at diagnosis for MPD was 60 years. In our study, all MPD cases were unilateral and more prevalent on left side. Not even a single case of bilateral MPD was seen in our study which is otherwise also extremely rare16 Mammary Paget disease is characterised by Paget cells. Paget cells are large cells with clear cytoplasm and eccentric, hyperchromatic nuclei found throughout the epidermis.17(Fig. 1)
Patients with Mammary Paget disease have a high incidence of an underlying breast carcinoma.18 The associated carcinoma can be either carcinoma in situ or invasive cancer.19 We found underlying duct carcinoma in 94.7%of cases which was comparable to a study by Lioyd et al where breast cancer was seen in 82%-92% of MPD cases.20 Caliskan M et al also observed in their study that MPD had underlying IDC in 93.8% of MPD cases.21 All the underlying breast tumours were high grade which was comparable to studies by Lester T et al where 93% of the MPD associated tumours had high nuclear grade.22 Axillary lymph node involvement was seen in 68.4% of MPD with underlying IDC. This was 44% in a study by Kothari AS et al.23 There are reports of positive lymph nodes even without any underlying malignancies.21,24 On immunohistochemical evaluation, 84.2%(16 cases) showed strong positivity for Her2 neu(Fig. 2).
Sek P et al and Fu W et al reported Her 2neu positivity of Paget cells in 86% and 93% of cases respectively.11,25 The same immunohistochemical profile was shared by the underlying breast carcinoma including DCIS(fig 3).Two cases(10.5%) of MPD and associated ductal carcinoma was ER and PR +ve and Her2 neu –ve.In a study by Liegl B et al, ER positivity was seen in 10% of MPD cases.26 There was a single case with triple –ve immunohistochemical profile of the ductal carcinoma and Paget component.
CONCLUSION
MPD is often associated with extensive underlying malignancy which is difficult to assess accurately either clinically or mammographically. The underlying disease is of high grade and is frequently Her2neu positive with a resulting poor prognosis. Therefore for patients with clinical suspicion of MPD breast examination, mammography and even biopsy are highly recommended. Furthermore, larger studies of MPD and prospective follow-up of patients with ductal carcinomas may be useful in elucidating the molecular characteristics that are associated with greatest risk of developing MPD.
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=581http://ijcrr.com/article_html.php?did=5811. Kollmorgen DR, Varanasi JS, Edge SB, Carson WE 3rd. Paget’s disease of the breast: a 33-year experience. J Am Coll Surg. 1998;187:171-177.
2. Paget J. On the disease of the mammary areola preceding cancer of the mammary gland. St. Bartholomew Hosp. Rep. 1874;10:87-89.
3. Karakas C. Pagets disease of the breast.J carcinog 2011;10:31.
4. Kanitakis J. Mammary and extramammary Paget›s disease. J Eur Acad Dermatol Venereol 2007;21:581-90.
5. Yim JH, Wick MR, Philpott GW, Norton JA, Doherty GM. Underlying pathology in mammary Paget›s disease. Ann Surg Oncol 1997;4:287-92.
6. Sakorafas GH, Blanchard K, Sarr MG, Farley DR. Paget›s disease of the breast. Cancer Treat Rev 2001;27:9-18.
7. Martin VG, Pellettiere EV, Gress D, Miller AW. Paget›s disease in an adolescent arising in a supernumerary nipple. J Cutan Pathol 1994;21:283-6.
8. Elzbieta Marczyk,Anna kruczak,Aleksandra Ambicka et al.The routine immunohistochemical evaluation in Paget disease of the nipple.Pol J Pathol 2011;4:229-235.
9. Tanskanen M, Jahkola T, Asko-Seljavaara S, et al. Her2 oncogene amplification in extramammary Paget’s disease. Histopathology 2003; 42: 575-579.
10. Schelfhout VR, Coene ED, Delaey B, Thys S, Page DL, De Potter CR. Pathogenesis of Paget›s disease: epidermal heregulin-alpha, motility factor, and the HER receptor family. J Natl Cancer Inst 2000;92:622-8.
11. Sek P, Zawrocki A, Biernat W, Piekarski JH. HER2 molecular subtype is a dominant subtype of mammary Paget›s cells. An immunohistochemical study. Histopathology 2010;57:564-71.
12. Ling H, Hu X, Xu X-L, Liu Z-B, Shao Z-M (2013) Patients with Nipple-Areola Paget’s Disease and Underlying Invasive Breast Carcinoma Have Very Poor Survival: A Matched Cohort Study. PLOS ONE 8(4).
13. Sandoval Leon AC, Drews- Elger K, Gomez Fernandez CR et al. Paget’s disease of the nipple.Breast Cancer Res Treat.2013;141(1):1-12.
14. Fouad Dina. Paget›s disease of the breast in a male with lymphomatoid papulosis: a case report. Journal of Medical Case Reports 2011; 5:43.
15. Chen CY.,Sun L-M and Anderson B-O. Paget disease of the breast: changing patterns of incidence, clinical presentation, and treatment in the U.S. Cancer. 2006 Oct 1;107(7):1448-58.
16. Xie B, Zheng H, Lan H, Cui B, Jin K, Cao F. Synchronous bilateral Paget›s disease of the breast: A case report Oncol Lett. 2012 Jul; 4(1):83-85.
17. Marques-Costa, JC; Cuzzi, T; Carneiro, S; Parish, LC; Ramos-e-Silva, M (May–Jun 2012). «Paget›s disease of the breast.». Skinmed 10 (3): 160-5.
18. M Muttarak, B Siriya, P Kongmebhol, B Chaiwun, and N Sukhamwang.Paget’s disease of the breast: clinical, imaging and pathologic findings: a review of 16 patients Biomed Imaging Interv J. 2011 Apr-Jun; 7(2): e16.
19. Goro Amano,Mioko Yajima,Yasunori Moroboshi, Yoshiki kuriya and Noriaki Ohuchi. MRI Accurately Depicts Underlying DCIS in a Patient with Paget’s Disease of the Breast Without Palpable Mass and Mammography Findings. Jpn. J. Clin. Oncol. (2005) 35 (3):149-153.
20. Lioyd J and Flanagan AM. Mammary and extramammary Paget’s disease. J Clin Pathol. Oct 2000; 53(10): 742-749..
21. Caliskan M, Gatti G, Sosnovskikh I, et al. Paget’s disease of the breast: the experience of the European Institute of Oncology and review of the literature. Breast Cancer Research and Treatment 2008;112(3):513-521.
22. Lester T1, Wang J, Bourne P, Yang Q, Fu L, Tang P. Different panels of markers should be used to predict mammary Paget’s disease associated with in situ or invasive ductal carcinoma of the breast. Ann Clin Lab Sci. 2009 Winter;39(1):17-24.
23. Kothari AS., Beechey-Newman N, Hamed H, Fentiman IS, D›Arrigo C, Hanby AM, Ryder K. Paget disease of the nipple: a multifocal manifestation of higher-risk disease. Cancer. 2002 Jul 1;95(1):1-7.
24. Siponen E1, Hukkinen K, Heikkilä P, Joensuu H, Leidenius M Surgical treatment in Paget›s disease of the breast Am J Surg. 2010 Aug;200(2):241-6.
25. Fu W1, Lobocki CA, Silberberg BK, Chelladurai M, Young SC Molecular markers in Paget disease of the breast.J Surg Oncol. 2001 Jul;77(3):171-8.
26. Liegl B,Horn LC,Moifar F.Androgen receptors are frequently expressed in mammary and extramammary Paget’s disease.Mod Pathol 2005Oct;18(10):1283-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareA RARE CASE OF LYMPHOEPITHELIOMA OF BASE OF TONGUE-NON NASOPHARYNGEAL LYMPHOEPITHELIOMA
English6770Surendra M.English Siva Sankar KotneEnglish P. B. Ananda RaoEnglish P. Ravindra KumarEnglishBackground: Lymphoepithelioma (Squamous cell carcinoma with associated lymphoid stroma) commonly occurs in nasopharynx. It occurs rarely at other sites like oropharynx, laryngo-hypopharynx and salivary glands. Lymphoepitheliomas of base of tongue are less than 1% in head and neck region.
Case Report: We present a rare case of 65years old male patient with lymphoepithelioma of base of tongue with bilateral cervical level II lymph nodes and immunohistochemistry showing positivity for cytokeratin and negativity for leucocyte common antigen. Patient is also a known Hansen’s disease, which was treated 10 years back and has left lower limb amputated for chronic venous ulcer.
Treatment Guidelines: Treatment course was planned as per stage with radical radiotherapy with concurrent chemotherapy. Wider volume (CTV) was given to cover distant regional spread as the tumour is locally aggressive.
Conclusion: Lymphoepitheliomas are radiosensitive tumours with higher rates of locoregional tumour control, achieved with concomitant chemo radiotherapy in all head and neck sites.Distant metastasis was seen in patients with lymph node involvement and was a cause of poor prognosis. Non nasopharyngeal lymphoepithelioma can be planned better than nasopharyngeal tumours as in the later, organs at risk are near by.
EnglishLymphoepithelioma, Hansen’s disease, CTV (clinical tumour volume)INTRODUCTION
Head and neck cancer is one of the most common cancers world wide accounting for5 to10%, more than 90% tumours are squamous cell carcinomas. Lymphoepithelioma (squamous cell carcinoma associated lymphoid stroma) occurs primarily in the nasopharynx ,rare in other sites such as upper aerodigestive tract including the major salivary glands1 , oral cavity2 , oropharynx ,larynx3 , hypopharynx, etc. Lymphoepithelioma5 is an undifferentiated carcinoma with a prominent reactive lymphoplasmocytic infiltrate morphologically indistinguishable from nasopharyngeal carcinoma. Microscopically lymphoepithelioma shows a rather prominent squamous cell carcinoma component in about half of the cases and sometimes lymphoepithelioma exhibit such a dense lymphoplasmocytic infiltrate that it mimics malignant lymphoma. Lymphoepithelioma are aggressive tumours with a propensity for regional lymphnode and distant metastases.
CASE REPORT
We present a rare case of 65 year old male patient who came with bilateral level II cervical lymphnode swelling and odynophagia. Videolaryngeo scopy showed an ulceroproliferative growth over base of tongue on the left side. Biopsy was taken and it showed features of lymphoepithelioma/ undifferentiated nasopharyngeal carcinoma of base of tongue. Upper gastrointestinal endoscopy shows growth base of tongue and impaired mobility of right vocal cord. Patient had history of Hansen’s disease 40 years back which then treated. Patient had right lower limb below knee amputation for chronic venous ulcer 15 years back. Regular systemic examination was normal. Immunohistochemistry revealed the tumour to be positive for cytokeratin and negative for leucocyte common antigen excluding lymphoma. Ultrasonography abdomen is normal. CT scan of head and neck showed growth of tongue and level II cervical LN.
TREATMENT GUIDELINES
Treatment was planned with definitive chemoradiotherapy. Patient was immobilized in a thermoplastic mask in supine position. Radical RT of 6600cGy in 33fractions and five fractions per week and 200cGy per fraction was delivered to wider volume (CTV) to cover the primary site and lymphnodal area as the tumour is locally aggressive with a chance of distant metastasis . Spinal cord was spared after 44Gy. 5 cycles of cisplatin based chemotherapy were given for radiosensitization for tumour kill.
DISCUSSION
Lymphoepithelioma is a clinicopathologic entity that was described simultaneously but independently by Schminke and Regaud in 1921. In 1929, Ewing concurred that LE should be considered a separate category of nasopharyngeal carcinoma; he noted that the distinguishing feature of these tumors was their radiosensitivity. It has been firmly established that the lymphocytes in the lymphoid stroma are neither neoplastic nor integral to the carcinomatous process. In 1978, the World Health Organization published a histologic typing system for nasopharyngeal carcinoma based on the appearance of the malignant epithelial cells. In this system, all three categories of nasopharyngeal tumors can be associated with a lymphoid stroma. Oropharyngeal LE is a rare disease. Between 1960 and 1983, only 13 cases of oropharyngeal LE were seen at the Mayo Clinic. At the Institut Gustave-Roussy, 18 patients were treated who had undifferentiated carcinoma of the nasopharyngeal type (UCNT) located in the tonsillar fossa; these 18 cases were identified in a retrospective pathologic review of 2262 patients with carcinoma of the tonsillar region. The report does not state whether a lymphoid stroma was present in these cases. Twenty-four of the 34 patients in the report had oropharyngeal LE. Outside of Waldeyer’s tonsillar ring, mucosal nonnasopharyngeal LE is even rarer. At the Mayo Clinic, 4 cases of laryngohypopharyngeal LE were seen between 1907 and 1984. Micheau et al. identified 3 cases of laryngeal LE in a review of 2430 laryngectomy and pharyngectomy specimens. Ferlito reviewed the pathologic specimens of 2052 laryngohypopharyngeal neoplasms and found only 1 case of LE of the hypopharynx. Patients with nonnasopharyngeal LE have a high incidence of lymph node metastasis and a propensity for distant metastasis. Our locoregional treatment strategy for patients with nonnasopharyngeal LE will be to irradiate all the primary tumors.
CONCLUSION
Nasopharyngeal lymphoepithelioma of base of tongue is a rare entity with good response to treatment. Here we are reportin g a case with cured Hansen’s disease also. Now the patient is in follow up and doing well.
Englishhttp://ijcrr.com/abstract.php?article_id=582http://ijcrr.com/article_html.php?did=5821. Zbaren P, Borisch B, Lang H, Greiner R. Undifferentiated carcinoma of nasopharyngeal type of the laryngopharyngeal region. Otolaryngol Head Neck Surg 1997: 117: 688– 693.
2. Chow1, Chow, Lui, Sze, Yuen, Kwok; Lymphoepitheliomalike carcinoma of oral cavity: Report of three cases and literature review; Int. J. Oral Maxillofac. Surg. 2002.
3. Merz H, Marnitz S, Erbersdobler A, Goektas O. Schminckes tumour, Carcinoma of the base of the tongue, a case report. Case rep oncol. 2010;3(1):77–82
4. Klijanienko J, Micheau C, Azli N, et al. Undifferentiated carcinoma of nasopharyngeal type of tonsil. Arch Otolaryngol Head Neck Surgery 1989: 115: 731–734.
5. SUN Xiao-nan, XU Jing, YANG Qi-chu, HU Jian-bin and WANG Qi; Lymphoepithelioma-like carcinoma of the submandibular salivary gland: a case report; Chinese Medical Journal 2006. 119(15):1315–1317.
6. Dubey P, Ha CS, Ang KK, et al. Nonnasopharyngeal lymphoepithelioma of the head and neck. Cancer 1998: 82: 1556–1562.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareBENIGN OVARIAN TUMOURS IN A TERTIARY CARE HOSPITAL IN NIGER DELTA, NIGERIA: A 10 YEAR HISTOPATHOLOGICAL STUDY
English7174Udoye Ezenwa PatrickEnglish Kotingo Ebikabowei LuckyEnglishObjectives: To determine the relative frequencies, types, subtypes and age distribution of Benign ovarian tumours and to compare the results with other local and international studies.
Methodology: A 10 year retrospective analysis of Benign ovarian tumours diagnosed in the Anatomical Pathology Department of University of Port Harcourt Teaching Hospital from January 1998 to December 2007.
Results: Out of a total of 7529 surgical specimens received in the department within the study period, 166 (2.2%) were ovarian tumours. Of these 166 ovarian tumours, 128 (77.1%) were benign neoplasms. These 128 benign ovarian tumours formed 1.7% of the total surgical specimen received. The most common histological group was the germ cell tumours (67.2%), followed by surface epithelial tumours (25.8%) and sex cord-stromal tumours (7%). All the germ cell tumours seen were benign cystic teratoma, 86 (67.2%). The lowest age at which benign ovarian tumours occurred in this study was 4years while the highest age was
82years. Benign ovarian tumours peaked in the 21 – 30 years age range, followed by 31- 40 years age range.
Conclusion: Ovarian tumours are more commonly benign in our environment with germ cell tumours being the most common histologic group unlike in Caucasians where surface epithelial tumours are more predominant. Benign cystic teratoma is very common in our locale unlike in Europe, North America and some parts of Asia where surface epithelial tumours are more common.
EnglishBenign ovarian tumours, Cystic teratoma, Neoplasms, Histologic typesINTRODUCTION
The ovaries are female reproductive organs which are normally paired and located at both sides of the uterus, behind the broad ligaments and in front of the rectum1 . Each ovary is covered by a single layer of modified mesothelium known as surface, coelomic or germinal epithelium2 . All primary ovarian tumours tend to originate from one of the four structures that make up the composite ovarian organ notably the surface epithelial cells, the germ cells, the sex cords and the specialized ovarian stroma1,2. Interestingly, no other organ gives origin to a wide range of histogenetic tumours as the ovaries3,4. Benign cystic tumours of the ovaries are the fourth most common gynecological causes of hospital admissions5 . Worldwide figures show that about 80% of ovarian neoplasms are benign, occurring mostly in the 20 – 45 years age range2 . There is likelihood of increase in the incidence of ovarian tumours in the developing countries because of decreasing fertility rate and increasing use of ovulation induction drugs, among other factors, which thus calls for greater effort in the study of this tumour in these regions6 . No previous work has been done exclusively on the histopathological pattern of benign ovarian tumours in the University of Port Harcourt Teaching Hospital. In view of this and the need to have a comprehensive literature on ovarian tumours in Africa which will help us reappraise our dependence on western data, this study was carried out. The purpose of this study was to show the histopathologic pattern and age distribution of benign ovarian tumours and how they compared to results from other centres locally and outside Nigeria with the hope that this work would contribute to the literature on ovarian tumours in this country.
METHODOLOGY
This is a retrospective study based on histopathologically proven cases of benign ovarian neoplasms seen at the department of Anatomical Pathology of University of Port Harcourt Teaching Hospital over 10years. The original request forms and histopathology reports for all the ovarian neoplasms seen within the study period were retrieved and relevant clinical information and biodata were obtained. Clinical information and biodata unavailable on the request forms were obtained from the case files. The original slides of the entire benign neoplastic lesions were also retrieved and reviewed using the simplified version of W.H.O classification of ovarian tumours2 . Fresh sections of the missing slides were also taken from the tissue blocks and stained with Haematoxylin and Eosin, then reviewed. The results obtained were analyzed using simple descriptive statistical methods. Cases of benign ovarian tumours with incomplete biodata or those with missing slides and blocks were excluded. Ethical committee clearance: This study was duly approved by the ethics committee of the University of Port Harcourt
Teaching Hospital.
RESULTS
A total of 7529 surgical specimens were received in the department within the study period, 166 (2.2%) were ovarian tumours while 128 (1.7%) were benign ovarian neoplasms. Of these 166 ovarian neoplasms, 77.1% (128) were benign. The most common histologic group was the germ cell tumours which constituted 67.2% of all the benign ovarian tumours. Benign ovarian tumours were seen between the ages of 4years and 82years in this study and occurred mostly (41.4%) in the third decade (21 - 30years) followed by the fourth decade (31 - 40years) 23.4%. Frequencies for other age ranges are shown in Table 1. All the 86 germ cell tumours seen in this study were Benign cystic teratoma (BCT). BCT was also the most common histologic subtype of the benign ovarian tumours and occurred most in the 21- 30years age range. The surface epithelial tumours 25.8% were the second most common histologic group and were seen most in the 31- 40years age range. Serous cystadenomas (14) were the most common subtype of the surface epithelial tumours and also formed the second most common histologic subtype of all the benign ovarian tumours (10.9%). Other subtypes of surface epithelial tumours and their relative frequencies are also shown in Table 3. The sex cord-stromal tumours (9) were the least occurring histologic group of benign ovarian tumours forming only 7%. Eight out of the nine sex cord-stromal tumours were ovarian fibroma which occurred most in the 11 – 20 years age range.
DISCUSSION
In this study, benign ovarian tumours constituted 1.7% of the total surgical specimen received in the department over the study period, a figure which may suggest that these neoplasms are relatively uncommon in our locale.
Abbreviations
BCT: Benign cystic teratoma
W.H.O: World Health Organization
ACKNOWLEDGEMENTS
The authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. We also acknowledge Prof. S. O. Nwosu of the Department of Anatomical Pathology, University of Port Harcourt Teaching Hospital who supervised this work, a dissertation for the award of Fellowship of the National Postgraduate Medical College of Nigeria, 2011.
Source Of Funding No external source of funding.
Conflict Of Interest None declared.
Englishhttp://ijcrr.com/abstract.php?article_id=583http://ijcrr.com/article_html.php?did=5831. Rosai J. Ovary. In: Rosai and Ackerman’s Surgical Pathology. 9th ed. (Vol. 2). New Delhi: Mosby; 2004. p. 1649-709.
2. Ellenson LH, Pirog EC. The female genital tract. In: Kumar V, Abbas AK, Fausto N, Aster JC, editors. Robbins and Cotran Pathologic Basis of Disease 8th ed. Pennysylvania: Saunders; 2010. p. 1005-61.
3. Greenwald EF. Ovarian tumours. Clin Obstet Gynecol 1975; 18(4): 61-84.
4. Salzer H, Denison U, Breitenecker G, Speiser P, Obermair A. Ovarian carcinoma. ACO Manual 1993; 2: 5-7.
5. Yasmin S, Yasmin A, Asif M. Frequency of benign and malignant ovarian tumours in a tertiary care hospital. JPMI 2006; 20: 393-7.
6. Odukogbe AA, Adebamowo CA, Ola B, Olayemi O, Oladokun A, Adewale IF, et al. Ovarian cancer in Ibadan: characteristics and management. J Obstet Gynecol 2004; 24(3): 294-7.
7. Jibrin P. A ten year histopathological review of ovarian tumours in Calabar [dissertation]. National Postgraduate Medical College of Nigeria, 2001.
8. Akhiwu WO. Histopathological analysis of ovarian tumours seen in the University of Benin Teaching Hospital: A ten year retrospective study 1987-1996 [dissertation]. National Postgraduate Medical College of Nigeria, 1999.
9. Onyiaorah IV, Anunobi CC, Banjo AA, Abdulkareem AA, Nwankwo KC. Histopathological pattern of ovarian tumours seen in Lagos University Teaching Hospital: A ten year retrospective study. Nig Qt J Hosp Med 2011; 21(2): 114-8.
10. Doh AS, Shasha W. A clinicopathologic study of ovarian tumours in Yaoundé, Cameroun. West Afr J Med 1994; 13(4): 196-7.
11. Murthy DP. Ovarian tumours in Papua, New Guinea: relative frequency and histological features. PNG Med J 1985; 28(1): 14-22.
12. Gatphoh ED, Darnal HK. Ovarian neoplasm in Manipur. J Indian Med Assoc 1990; 88(12): 338-9.
13. Pilli GS, Suneeta KP, Dhaded AV, Venni VV. Ovarian tunours: a study of 282 cases. J Indian med Assoc 2002; 100(7): 420, 423-4, 447.
14. Katchy KC, Briggs ND. Clinical and pathological features of ovarian tumours in Rivers State of Nigeria. East Afr Med J 1992; 69(8): 45-9.
15. Lancaster EJ, Muthuphei MN. Ovarian tumours in Africa: a study of 512 cases. Cent Afr J Med 1995; 41(8): 245-8.
16. Briggs ND, Katchy KC. Pattern of primary gynecological malignancies as seen in a tertiary hospital situated in the Rivers State of Nigeria. Int J Gynecol Obstet 1990; 31: 157- 61.
17. Baker TR, Piver MS. Etiology, biology and epidermiology of ovarian tumour. Semin Surg Oncol 1994; 10: 224-6.
18. Babarinsa IA, Akang EEU, Adewale IF. Pattern of Gynecological malignancies at the Ibadan cancer registry (1976- 1995). Nig Qt J Hosp Med 1998; 8(2): 103-5.
19. Moller H, Evans H. Epidemiology of gonadal germ cell cancer in males and females. APMIS 2003; 111(1): 43-6. Discussion 46-8.
20. Ahmad Z, Kayani N, Hasan SH, Muzafar S, Gill MS. Histological pattern of ovarian neoplasm. J Pak Med Assoc 2000; 50(12): 416-9.
21. Bukhari U, Memon Q, Memon H. Frequency and pattern of ovarian tumours. Pak J Med Sci 2011; 27(4): 884-6.
22. Sharma I, Sarma U. Dutta UC. Pathology of ovarian tumour: a hospital based study. Valley Int J 2014; 1(6): 284- 6.
23. Mabogunje OA, Nirodi NS, Harrison KA, Edington GM. Teratomas in adult Nigerians. Afr J Med Med Sci 1980; 9(3-4): 151-8.
24. Akang EE, Odunfa AO, Aghadiuno PU. A review of teratomas in Ibadan. Afr J Med Med Sci 1994; 23(1):53-6.
25. Di Bonito L, Patriarca S, Delenchi M, Alberico S. Ovarian tumours: anatomohistopathological contribution to their interpretation. Eur J Gynecol Oncol 1988; 9(4): 324-30.
26. Junaid TA. Ovarian neoplasms in children and adolescents in Ibadan, Nigeria. Cancer 1981; 47(3): 610-14.
27. Tavassoli FA, Devilee P. Tumours of the ovary and peritoneum. In: Pathology and Genetics of tumours of the breast and female genital organs. Lyon: IARC; 2003. p. 113-202.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524178EnglishN-0001November30HealthcareA SURVEY ON DOCTOR'S EXPECTATION FROM MEDICAL REPRESENTATIVE IN KARNATAKA STATE
English7582Ankush C.English Virendra S. L.English Kiranshanker K.English Sreedhar D.English Manthan J.English Muragundi P. M.English Udupa N.EnglishThe aim of present study was to know to the effectiveness of personal selling in perception of doctors and to find out exactly what doctors expect from medical representative.A self-administered questionnaire was distributed to 200 doctors. Both open end and close end questions were included in the questionnaire. Results obtained from the study were informative. Doctors find the services rendered by medical representative useful. Today, providing information on price and discounts and availability of drugs are most important services rendered by medical representatives. So it was concluded from the study that
many doctors are price sensitive today and want drugs at less price for their patients
EnglishPersonal selling, Perception, Medical representativeINTRODUCTION
Marketing and selling are important functions of any business.The American Marketing Association define marketing as: “Marketing is an organizational function and a set of process for creating, communicating, and delivering value to customers and for managing customer relationships in ways that benefit the organization and its stake holders”.1 It is hard for many to believe, but when compared to economics, production and operations, accounting and other business areas, marketing is a relatively young discipline having emerged in the early 1900s2.Good marketing is a result of careful planning and execution. Marketing practices are continuously being refined and reformed in virtually all industries, including the pharmaceutical industry, to increase the chances of success. But marketing excellence is still rare and difficult to achieve.As we go back to the history of pharmaceutical marketing, it reveals that the first pharmaceutical sales representative appear on the scene in 1850s in the United States.3 Unfortunately there is no solid evidence to show when and how the pharmaceutical sales representatives appeared in the Indian pharmaceutical market. Sales representative in pharmaceutical marketing are called as Medical representative. They promote the company product to the customer that is physicians. Promotion is a method utilized to tell the customers about product, place and price. Promotion has two basic elements 1) to provide information about product 2) to persuade potential customers4 .Selling may be defined as the process of analyzing potential customers’ needs and wants, and assisting them in discovering how such needs and wants can best be satisfied by the purchase of a particular product, services or idea5 . The focus of selling thus is on the needs and wants of customers rather than on the features of a product. A pharmaceutical sales representative has to perform four crucial tasks6 . Even a slight improvement of in effectiveness of anyone of these will lead to a significant increase in results. These four crucial tasks are:-
1. Detailing
2. Monitoring
3. Sampling
4. Retailing (retail booking)
Detailing is singularly the most important task that a representative has to perform. Ethically speaking, effective detailing with the help of a proper visual aid is the only way to increase prescription generation7 . It is said that the pharmaceutical companies often use effective methods of influence in combination with misleading “logic”. Promotion can influence prescribers more than we thought possible. Frequent exposure to promotion correlates with more expensive, less appropriate prescribing.8 As we know, personal selling is a crucial determinant factor of success in pharmaceutical marketing. Till date nothing has replaced the profession of personal selling in pharmaceutical industry and in other industries too. The pharmaceutical sales representatives play a critical role in the development and sustainability of the business through the selling of products and services. Pharmaceutical representatives are trained in traditional ways and because of this they are doing detailing in traditional ways. But expectations of doctors have been changed over a period of time. Pharmaceutical companies spend huge amount and time for such promotional activities; hence it is essential to know what doctors are currently expecting from medical representative so that money of company and efforts of medical representatives will not go waste. The present was carried out to analyze the perception of doctors towards medical representative in Karnataka, India. The following objectives were framed to study.
OBJECTIVES OF THE STUDY
1. To find out the effectiveness of personal selling in perception of doctors.
2. To find out exactly what doctors expect from medical representative.
METHODOLOGY
Survey Design
A mail questionnaire was prepared to collect data from doctors. Mail questionnaire were sent to 10 doctors for testing the response rate of doctors. After waiting for 20 days another reminder mail was sent to each and every previous doctor. After waiting few more days it was decided personal interview will be more appropriate.
QUESTIONNAIRE DESIGN
Questionnaires were typed in Microsoft word and then converted to PDF format for ease of printing. Size of paper used was A4 and 200 copies of questionnaire for doctors were printed. Each copy consisted of two pages (front and back). Total 10 questions were included in questionnaire.
TYPES OF QUESTIONS
Both open end and close end questions were included in the questionnaire. In case of close ended questions respondents were asked to tick ( Ö ) most appropriate answer and in few questions respondents were asked to give number in order of preference.
DOCTOR LIST
Karnataka medical council registration data base was used to identify MBBS doctors in Bangalore; approximately 20 thousand doctors were identified. Then by using random number generator from www.random. org 1400 MBBS doctors were selected. 800 BDS doctors, 600 ophthalmologists, 400 orthopedics, 400 MD and 400 Surgeons were identified using www.yellowpages.com and www.doctorduniya.com and like this doctor list was prepared. That sum up as 4000 doctors total.
SAMPLE SIZE
200 doctors from above doctor list of 4000 were selected. In those 4000 doctors, 1400 were MBBS that means 35% so to maintain same percentage 70 MBBS doctors were randomly selected from list of 1400 doctors by using random number generator from www.random.org , likewise 40 BDS, 30 ophthalmologists, 20 orthopedic doctors, 20 MD and 20 MS were selected after randomization.
SAMPLING TECHNIQUE
Doctor
Stratified randomized sampling technique was used for sampling of doctors. They were stratified according to their qualification as mentioned above and then randomization was done in each stratum and 200 doctors were selected
DATA COLLECTION
Data was collected from respondents in Bangalore (Capital of Karnataka)
DURATION OF STUDY
The duration of the study was 6 months
DATA PRESENTATION
Tables, Pie charts, Bar diagrams etc.
DATA ANALYSIS AND INTERPRETATION
Analysis and interpretation of the data has been carried out to deduce the conclusions with the aid of appropriate statistical tools.
RESULTS AND DISCUSSION
SURVEY OF DOCTORS
Out of 200 doctors who participated in the survey 35% were MBBS, 20% were BDS, 15% were Ophthalmologists,10% were Orthopedics, 10% were MD and 10% were MS.
Doctors were met personally, interviewed and their responses were noted in questionnaire. Except questions in questionnaire some other questions were also asked by the author to doctors and many interesting facts came out, they are discussed with some of the questions below.
SURVEY RESULTS
Question 1: Do you feel medical representatives are useful to the medical profession?
Survey indicated almost all (99.00%) of the respondents feel that representatives perform a useful service to them (table). Only one MD and one MS mentioned that representatives perform no useful service to them.
Question 1 (a): If yes then why?
71.71% respondents respond to all option. Among rest 28.28% price information and discounts got most response (10.10%), followed by information about drug use (8.58%), information about availability of drugs (6.06%) and at last distribution of samples (4.04%). Two respondents did not respond to any option. If we see point wise price information that means one point for every response, price information and discounts got most points and became first ranker followed by information about availability of drugs on second rank, information about drug use on third rank and providing samples got least points and attained fourth rank. When asked why doctors need price information and discounts as priority majority of doctors told they wants drug at less price for their patients because if patients will get medicines at lower price than they are more likely to come to the same doctor. So it was concluded from the study that many doctors are price sensitive today and want drugs at less price for their patients.
Question 1 (b): If no please write what are the alternatives to MR, in your opinion?
Two respondents told the same answer. The answer was emailing of literature and information. But when asked do they check mail every day, the answers were negative.
Question 2: Generally how many representatives you see in one day?
Most of the respondents (86.86%) said that they see 6 to 10 medical representatives daily. A small number (4.54%) said they see more than 10 medical representatives while 8.58% respondents said they see less than 5 medical representatives a day. One MD and one MS told they are not entertaining medical representatives. It can be concluded with this survey that MD and MS have less time so many of them (actually well experienced doctors) have a tendency to see less than 5 medical representatives. Interview revealed that young doctors and students are more likely to entertain medical representatives than experienced doctors.
Question 2(a): What should be the interval between visits in your opinion?
Majority of respondents (61.11%) said for them ideal interval is 21 to 30 days, a significant percentage of respondents (22.22%) said, less than 20 days is the ideal interval. Few respondents (15.65%) said that ideal interval should be more than 30 days. It was noted that majority of this 15.65% were experienced doctors having experience more than 10 years. It is also interesting to note that young less experienced doctors and students wants to meet more medical representatives to enhance their knowledge.
Question 3: To what extent these medical representatives influence your choice of drugs in prescribing?
More than half the number of respondents (52.52%) said that they are influenced very little by Medical representatives in their choice of drugs in prescribing. 18.68% indicated ‘Quite a bit’, a smaller percentage (15.65%) mentioned ‘Very much’ and 13.13 percentage of respondents were of the opinion that they are not at all influenced by the medical representatives. It was observed from the survey that majority of well experienced doctors responded to ‘very little’ and ‘not at all’. Young and new doctors are likely to be more influenced by medical representatives than old and experienced ones
Question 4: In your opinion what should be the minimum qualification of MR?
The most frequent answer was bachelor in pharmacy (65.15%). Next answer was diploma in pharmacy (27.77%), next comes science graduates (6.06%) and a insignificant percentage of respondents (1.01%) told that matriculation should be the minimum qualification. Author asked question to all of the respondents who responded to ‘Bachelor in pharmacy’ that why they want B. Pharm as minimum qualification for medical representative, few doctors told that it is a waste of time for them to meet medical representative who do not have product knowledge, meeting them is just a formality but whenever they meets a medical representative having B.Pharm degree it is easy for them to ask questions and get answers. When asked the medical representative having diploma in pharmacy also can perform the same, majority were unconvinced by their knowledge levels and told that B.Pharm is extensive degree than D. pharm. While majority of respondents told that MR with B. Pharm degree is far superior in knowledge than other degrees mentioned in questionnaire. So the study reveals that majority of doctors wants a medical representative who is good at product knowledge and can provide scientific information. That is why they think that MRs should have B.Pharm as their Minimum qualification.
Question 5: In your opinion what should be the qualities of a good MR?
The survey indicated that regularity has been considered as the most essential quality of a medical representative followed by sincere in claims, brief detailing, good education, product knowledge, courtesy, personality and salesmanship in that order of preference. When asked that why majority of doctors considered regularity as most essential quality that medical representative must possess, majority of doctors told regularity reflects the efforts of a MR. They told regular MR develop a relation with doctors which is not possible in case of irregular MR , regular MR can brings answers to the questions raised by doctors quickly than irregular MR. Few doctors also told that regular MR from many companies bring useful literature and samples for them regularly. So it was concluded from the above question that a MR should be regular with sincerity in claims, should be quick with detailing and have good product knowledge.
Question 6: Do you find medical literature distributed by representatives of any use to you? The most frequent answer (34.34%) was somewhat. The second most frequent answer was very little (32.32%), next comes very much (21.71%) and the last was none (11.11%). It was noted that MBBS are more likely to use medical literature than MD and MS. Majority of MD (47.36%) and MS (57.89%) have opinion that medical literature is of very little use to them and a significant percentage of both (21.06%) think that medical literature is of no use to them. It is derived from the study that majority of MD and MS owing to higher education are less receptive to information provided by medical literature. Experienced doctors also pay less attention to medical literature provided by MR, actually when asked why few of them told they cannot depend on information provided by medical literature because the information in literature may be biased.
Question 6(a): If little and not at all what are the short comings?
Total 87 respondents told that literature provided by medical representatives are little and not at all useful to them. Majority of them (80.45%) told that medical literature is too detailed and time consuming. 13.79% told that it is misleading, 3.44% of respondents think it is not informative only 2.29% of respondents think it is not interesting.
Question 7: Are the drug samples distributed by MRs are useful to you?
Most frequent answer was to some extent (50%). The next most frequent (23.23%) answer was very little. A small percentage (16.66%) told very much and 10.10% respondents told none. Study shows that drug samples distributed by medical representatives are useful to majority of doctors. Samples are more useful to doctors in village area to treat the patients.
Question 8: In your opinion, how do drug samples distributed by MR serve you?
Most of the respondents (63.13%) told that they use samples for poor people, 17.17% respondents told samples serves them to remind of brand. 16.66% respondents told that they use samples to try and ensure potency of drug. Very few respondents (3.03%) told that they use samples to try and ensure potency of brands.
Question 9: Do you prefer MR who distributes samples to you?
54.54% of respondents told they prefer medical representatives who distribute samples. 45.45% of respondents told they do not prefer medical representatives who distribute samples to them. Few doctors told that they will prefer MR if the start to provides samples for poor people for full course of therapy not only for few initial days. They told MRs are giving the samples in very less quantity so that if doctor wants to give the free medicines to poor people they have to give samples for few initial days and after giving samples of one company they cannot switch to another brand. Then poor patients have to purchase the drugs by their own.
Question 10: Would you like to give suggestions as to how the services of representatives can be made more useful to you?
Not many respondents respond to this question because of time constraint. Some good answers were – Medical representatives must at all times maintain a high standard of ethical conduct in profession. They must ensure that the frequency, timing and duration of calls on health professionals. Further representatives must observe the wishes of an individual health professional like representatives must be sensitive to a doctor’s workload and tailor visits accordingly; also they should ensurethat an appropriate interval is maintained between visits and promptly follow up on all requests and queries of health professionals.
CONCLUSION
To conclude, doctors find the services rendered by medical representative useful. Today, providing information on price and discounts and availability of drugs are most important services rendered by medical representatives. So it was concluded from the study that many doctors are price sensitive today and want drugs at less price for their patients.Study revealed that young doctors and students are more likely to entertain medical representatives than experienced doctors. Further regularity is considered as most important quality of medical representatives. So it was concluded from the study that a MR should be regular with sincerity in claims, should be quick with detailing and have good product knowledge. Also doctors want medical representatives having sound product knowledge that’s why most of them considered bachelor in pharmacy as minimum qualification. Majority of medical representatives working in the field do not meet quality criteria by doctors. Overall this study may help to increase the effectiveness of personal selling by pointing medical representatives towards right direction.
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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