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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareA COMPARATIVE STUDY OF CARDIAC FUNCTIONS IN TOBACCO SMOKERS AND NON SMOKERS AMONG ADULT MALES IN AND AROUND SULLIA
English0105AnandkumarEnglish Shilpa PatilEnglish Shobith BangeraEnglish Urban D. SouzaEnglishBackground: Cigarette smoking is one of the common cause of Hypertension. Hence the present study is conducted to evaluate the effect of smoking on cardiac functions among healthy individuals as the previous studies done have conflicting results.
Objectives: To evaluate the cardiac functions among smokers and non smokers in Sullia
Methods: The present study was carried out on 100 apparently healthy male subjects included 50 smokers (study group) and 50 non – smokers (control group) in the age group of 18 to 30 years. Cardiac parameters were compared between smokers and non-smokers. Stastistical analyses was performed using student’s t-test for 2 group comparisons.
Results: In this study the effect of smoking on cardiac parameters like Resting Heart Rate(RHR), Diastolic Blood Pressure(DBP) and on Mean Blood Pressure(MBP) is negligible except on Systolic Blood Pressure (SBP) in which there is statistically significant decrease in blood pressure in smokers compared to non smokers.
Conclusion: There was significant decrease in Systolic Blood Pressure (SBP) among smokers compared to non-smokers.In the present study Blood Pressure(BP) levels in smokers was rarely recorded during or immediately after smoking when acute rises in BP occur due to nicotine induced adrenergic drive, therefore BP levels of smokers tend to be systematically underestimated. The acute rise in BP may be followed by reduction due to body’s homeostatic mechanism to maintain BP which may be attributed to rebound phenomenon and the adaptation process. Futher study has to be conducted between young and old age smokers with large sample size taking into consideration the time of sampling i.e taking the readings immediately after smoking.
EnglishRHR, DBP, SBP, MBPINTRODUCTION
Cigarette smoking constitutes one of the major cause of morbidity and mortality to mankind. According to WHO estimation, 194 million men and 45 million women use tobacco in smoke or smokeless form in India.1 The WHO predicts that tobacco deaths in India may exceed 1.5 million annually by 2020.2 Cessation of smoking reduces risk of diseases caused by it.3 Non optimal levels of blood pressure (BP) and smoking are the first and second most common causes of death in the world, and, together, these two risk factors account for more than 20% of the global burden of premature death.4 Smoking is the most prevalent and most preventable risk factor for cardiovascular diseases. Smoking results in a twofold increase in the risk of coronary artery disease and is responsible for one-fifth of all cardiovascular deaths and increases the risk of heart failure threefold.5 The two most toxic constituents of cigarette smoke are nicotine and carbon monoxide; however, cigarette smoke contains about 2000 additional toxic components. Cigarette smoke exerts the most marked detrimental effects on the endothelial system and especially on the coronary endothelial system.6 Nicotine acts as an adrenergic agonist, mediating local and systemic catecholamine release and possibly the release of vasopressin.7 Thus smoking causes an acute increase in blood pressure (BP) and heart rate and has been found to be associated with malignant hypertension8 Paradoxically, several epidemiological studies have found that BP levels among cigarette smokers were the same as or lower than those of non-smokers.4 Active smokers can display BP values which vary widely according to a great number of individual, racial, lifestyle factors and also the time of sampling after smoking episode. While a smoker is actively smoking, transiently sympathetic responses, which acutely raise BP levels, usually occur due to kick induced by smoking.Reports emphasize that hypertension or hypotension can be associated with cigarette smoking in active smokers .9 In particular, increased BP10 and smoking11 are major risk factors for cardiovascular diseases (CVD), including coronary heart disease (CHD) and stroke. Previous studies have indicated that smoking and increased BP interact to increase markers of cardiovascular risk, including levels of plasma fibrinogen12 and carotid intima-media thickness.13 Hence, a combination of raised BP and smoking may have a synergistic impact on cardiovascular events, especially those caused by atherosclerosis and thrombosis.14 If such an interaction exists, multifactorial interventions aimed at both lowering BP and quitting smoking will contribute more to reducing CVD than expected and hence contribute to less mortality and morbidity.Hence the present study is conducted to emphasise the adverse effects of smoking on cardiac parameters and the need to quit smokig to save mankind.
MATERIALS AND METHODS
The study protocol was approved by the institutional ethical committee in KVG Medical College, Sullia. The present study was carried out on 100 apparently healthy male subjects which included 50 smokers(study group) and 50 non–smokers(control group) in the age group of 18 to 30 years after obtaining informed and written consent. Smokers having minimum history of smoking tobacco for more than two year duration and still smoking at least five or more cigarettes per day was included in the present study. Age below 18 years and above 30 years,History of cardiovascular diseases, History of chronic drug intake, History of infection, Alcoholics were excluded from study. Examination proforma used for recording the clinical examination findings was designed and validated. Resting pulse rate of the subjects was recorded in sitting posture.Blood pressure of the subjects was recorded in sitting posture by using Mercury sphygmomanometer and littman stethoscope by auscultatory method. The equipment was checked and calibrated for its accuracy as per the recommendations by British hypertension society. Systolic blood pressure and Diastolic blood pressure was recorded. Mean blood pressure was calculated as 1/3 Systolic blood pressure + 2/3 Diastolic blood pressure. Average of three recordings was taken. The results were given as Mean ± Standard Deviation and range values. Comparisons were performed using students t-test for 2 group comparisons using SPSS software 19 version. The p value of less than 0.05 was considered as statistical significant.
RESULTS AND ANALYSIS
For this cross sectional study 50 healthy smokers and 50 healthy controls in the age group of 18-30 years were selected. Fifty male smoking subjects and also fifty male non-smoking subjects were analyzed for the results. The results obtained were expressed as Mean ± SD, statistical technique like student t-test for two group comparisons and ANOVA (F test) for multiple group comparisons were used for analyzing data. On analyzing the physical characteristics of the 50 nonsmoking subjects the mean age (in yrs) is 20.08 ± 3.2; the mean height (in m) is 1.71 ± 0.06; the mean weight (kg) is 67.34 ± 10.7 and mean BMI is 22.78 ± 2.83 (Table 1). On analyzing the physical characteristics of the 50 smoking subjects, the mean age (in yrs) is 24.40 ± 2.1; the mean height (in m) is 1.73 ± 0.05; the mean weight (kg) is 66.50 ± 11.2 and the mean BMI IS 22.17 ± 3.37.
Resting heart rate In
Non-smokers mean resting heart rate was 80.96±4.41 and 81.84±3.04 in smokers. There was slight increase in resting heart rate in Smokers compared to Non-smokers but not statistically significant.
Systolic Blood Pressure
In Non-smokers mean Systolic Blood Pressure was 117.36±4.34 and 115.60±3.65 in smokers. There was statistically significant decrease in Systolic Blood Pressure in Smokers compared to Non-smokers.
Diastolic Blood Pressure
In Non-smokers mean Diastolic Blood Pressure were 77.56 ±3.66 and 76.96 ±3.38 in smokers. There was slight decrease in Diastolic Blood Pressure in Smokers compared to Non-smokers but not statistically significant.
Mean Blood Pressure
In Non-smokers Mean Blood Pressure was 90.82 ± 3.27 and 89.83 ± 2.86 in smokers. There was slight decrease in Mean Blood Pressure in Smokers compared to Nonsmokers but not statistically significant.
DISCUSSION
Tobacco smoking is the major preventable cause of death in many parts of the world. Tobacco related lung diseases and cardiovascular diseases cause a significant proportion of total deaths and chronic disability. In this study, a group of youngsters in the age group of 18 – 30 years with 2 and more years of smoking were selected basically to highlight the cardiac risks during the transient phase of smoking. Transient or middle phase of smoking where in an individual is exposed to smoking bout for a period of 2 to 5 years. In young age, any abnormalities may be corrected or if he quits smoking, the rest of his life, quality of health may be better and can be prevented from the long term adverse health effects. Resting heart rate: In smokers resting heart rate was slightly increased but not significant and similar findings were also found by Roberto et al 15 and Minami et al.16Heart rate measured by ambulatory monitoring is higher throughout the day when smokers are smoking compared with when not smoking.17 The extent of elevation of heart rate is independent of the blood level of nicotine absorbed from the cigarettes. The elevated heart rate is presumed to reflect persistent sympathetic nervous stimulation, which may be an important mechanism by which nicotine can contribute to cardiovascular disease and nicotine may also play a role in producing endothelial dysfunction, lipid abnormalities, and insulin resistance in smokers. Cigarette smoking acutely increases plasma levels of nor epinephrine and epinephrine and enhances 24-hour urinary excretion of these catecholamines.18 Cigarette smoking increases heart rate both acutely (up to 20 beats per minute) as well as throughout the day with regular dosing (average increase 7 beats per minute as measured during ambulatory monitoring). There is slight decrease in systolic, Diastolic and mean blood pressure among smokers in this present study. Similar findings were also found by Manfred et al, 19 Koichi et al, 20 Okubo et al, 21 Yasushi et al22 and Hongmei et al.23 The rebound phenomenon and the adaptation process were suggested as reasons smokers showed lower blood pressure than non-smokers.24 we cannot disregard the possibility that our results were affected by these factors. However, it has been suggested that after the first few puffs of smoke, blood pressure increases abruptly and only returns to presmoking levels after 1–2 hours.25 Thus it was pointed out that unless smokers had refrained from smoking on the day of examination, it was unlikely that lower blood pressure in smokers was due to withdrawal.26 Therefore, the rebound phenomenon and the adaptation process cannot explain the mechanism of the effect of smoking on blood pressure completely. Among cardiovascular parameters, blood pressure (BP) is adversely influenced by tobacco smoke with a high rate by a mechanism yet under discussion. In addition, it is not clear if smoking exposure causes a rise or reduction of blood pressure and, otherwise, also if the occurrence of hypertension in smokers is a consequence of the greatest number of hypertensive people independently from smoking, or smoking actively contributes to changes in BP.27 Initially, a vasoconstriction mechanism mediated by nicotine causes acute but transient increase in systolic BP. This phase is followed by a decrease in BP as a consequence of depressant effects played chronically by nicotine. Simultaneously, carbon monoxide is acting directly on the arterial wall causing, in the long run, structurally irreversible alterations. At this time, there is a change in BP that increases again, and often constantly, its levels.28 Such a hypothesis explains BP changes following chronic exposure. On the contrary, acute exposure to passive smoking determines a transient increase in systolic BP due to a combined effect of nicotine that acts by endothelial dysfunction and sympathetic stimulation, and carbon monoxide which exerts its toxic effects directly. Active smokers can display BP values which vary widely according to a great number of individual, racial, and lifestyle factors. Moreover, changes in BP have been documented in the same smoker while he is smoking a cigarette or not.
CONCLUSION
In this study the effect of smoking on cardiac parameters like RHR, DBP and MBP is negligible except on SBP in which there is statistically significant decrease in smokers. In this study the age group selected was 18-30 years, may be in younger people there is no much effect on cardiac parameters by smoking due to short duration of exposure and better disease combating activity. The rebound phenomenon and the adaptation process were suggested as reasons smokers showed lower blood pressure than non-smokers. Further study has to be conducted between young and old age smokers with large sample size.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the authors whose articles are cited and included in the references of this manuscript. Authors are grateful to the authors, editors, publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=585http://ijcrr.com/article_html.php?did=5851. Sinha DN, Gupta PC, Pednekar MS. Tobacco use in a rural area of Bihar. Indian J Community Med 2003;28(4): 10–12
2. Murray CJ, Lopez AD.eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected to 2020. Cambridge, Massachussets: Harvard School of Public Health, 1996.)
3. Burns DM. Nicotine Addiction. In: Kasper, Fauci B, Longo, Houser, Jameson, eds. Harrison’s Principles of Internal Medicine. (vol.2). 16th edn. New York: McGraw-Hill; 2005.p.2574.
4. Berglund G, Wilhelmsen L. Factors related to blood pressure in a general population sample of Swedish men. Acta Med Scand. 1975;198:291–8.
5. Lakier JB. Smoking and cardiovascular disease. Am J Med 1992;93:8–12S.
6. Czernin J, Waldherr C. Cigarette smoking and coronary blood flow. Prog Cardiovasc Dis 2003;45:395–404.
7. Cryer PE, Haymond MW, Santiago JV, Shah SD. Norepinephrine and epinephrine release and adrenergic mediation of smoking-associated hemodynamic and metabolic events. N Engl J Med. 1976;295:573–7.
8. Tuomilehto J, Elo J, Nissmen A. Smoking among patients with malignant hypertension. BMJ. 1982;1:1086.
9. Hughes k, Leong WP, Sothy SP, Lun KC, Yeo PPB. “Relationships between cigarette smoking, blood pressure and serum lipids in the Singapore general population,” International Journal of Epidemiology. 1993;22( 4) 637–43.
10. MacMahon S, Peto R, Cutler J, Collins R, Sorlie P, Neaton J et al. Blood pressure, stroke, and coronary heart disease. Part 1, Prolonged differences in blood pressure: prospective observational studies corrected for the regression dilution bias. Lancet. 1990;335:765–74.
11. Ariesen MJ, Claus SP, Rinkel GJ, Algra A. Risk factors for intracerebral hemorrhage in the general population: a systematic review. Stroke. 2003; 34:2060–5.
12. Tuut M, Hense HW. Smoking, other risk factors and fibrinogen levels: evidence of effect modification. Ann Epidemiol. 2001;11:232–8.
13. Howard G, Wagenknecht LE, Burke GL, Diez-Roux A, Evans GW, McGovern P et al. Cigarette smoking and progression of atherosclerosis: The Atherosclerosis Risk in Communities (ARIC) Study. JAMA. 1998;279:119–24.
14. Labarthe DR. Epidemiology and Prevention of Cardiovascular Diseases: A Global Challenge. Gaithersburg, MD: Aspen Publication Inc; 1998.
15. Roberto F, Annalisa Z, Paola L, Gianluigi M, Gianmarco V, Alessandro V. Cigarette Smoking and Blood Pressure in a Worker Population: A Cross-Sectional Study. European Journal of Cardiovascular Prevention and Rehabilitation. February 1996; 3(1): 55–9.
16. Junichi M, Toshihiko I, Hiroaki M. Effects of Smoking Cessation on Blood Pressure and Heart Rate Variability in Habitual Smokers. Hypertension 1999;33:586–90.
17. Benowitz NL, Kuyt F, Jacob P. Influence of nicotine on cardiovascular and hormonal effects of cigarette smoking. Clin Pharmacol Ther. 1984;36:74–81.
18. Benowitz NL, Gourlay SG. Cardiovascular toxicity of nicotine: implications for nicotine replacement therapy. J Am Coll Card 1997; 29:1422–31.
19. Manfred S, Eliezer J, Yair L. Blood pressure in smokers and nonsmokers: Epidemiologic findings American Heart Journal. 1986 May; 111( 5): 932–40.
20. Koichi H, Hiroaki T, Munehiro S, Suminori K, Jun S, Kikuo A. Relationship of cigarette smoking to blood pressure and serum lipids. Atherosclerosis. 1990 October; 84( 2-3): 189–93.
21. Okubo Y , Miyamoto T, Suwazono Y , Kobayashi E and Nogawa K. An association between smoking habits and blood pressure in normotensive Japanese men. Journal of Human Hypertension .2002; 16: 91–6.
22. Yasushi O, Yasushi S, Etsuko K, Koji Nogawa . An association between smoking habits and blood pressure in normotensive Japanese men: a 5-year follow-up study. Drug and Alcohol Dependence. 2004 February 7; 73(2):167–74.
23. Hongmei L, Weijun T, Aili W, Zhe L, Yonghong Z. Effects of cigarette smoking on blood pressure stratified by BMI in Mongolian population, China. Blood Pressure. April 2010;19(2):92–7.
24. Higgins MW, Kjelsberg M. Characteristics of smokers and nonsmokers in Tecumseh, Michigan. II. The distribution of selected physical measurements and physiologic variables and the prevalence of certain diseases in smokers and nonsmokers. Am J Epidemiol 1967; 86: 60–77.
25. Hansen KW, Pedersen MM, Christiansen JS, Mogensen CE. Night blood pressure and cigarette smoking: disparate association in healthy subjects and diabetic patients. Blood Press 1994;3: 381–8.
26. Omvik P. How smoking affects blood pressure. Blood Press 1996;5:71–7. 27. Trap-Jensen J. “Effects of smoking on the heart and peripheral circulation.” American Heart Journal.1988; 115(1):263–7.
28. Leone A. “Biochemical markers of cardiovascular damage from tobacco smoke.” Current Pharmaceutical Design. 2005; 11(17): 2199–208.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareEVALUATION OF STUDENT SEMINAR IN MEDICAL EDUCATION: STUDENTS' PERSPECTIVE
English0609Jitendra R. PatelEnglish Dharmik S. PatelEnglish Rajesh DesaiEnglish Jasmin ParmarEnglish Ravi ThakerEnglish Nikita D. PatelEnglishBackground: Teaching methods in India is dictated by the ancient teaching method. With modern times, teaching method should be improvised. Nowadays a deluge of techniques is encouraged to increase the interest of students in learning.
Aim and Objective: The purpose of the study was to examine the approach of 1st year medical students of one private medical college in Gujarat towards seminar presentation.
Method: Study was undertaken on 110 students of 1st year MBBS. A questionnaire was prepared regarding effectiveness of seminar in learning process and feedback was taken from all 110 students.
Result: More than 76% students responded positively to all questionnaire asked regarding seminar than teacher-centric method.
Conclusion: Students’ attitude was very decisive for an active learning method like seminar and it should be promoted in routine practice.
EnglishSeminar, Medical education, Teaching methodsINTRODUCTION
In medical education, break out of new medical colleges; devaluation of merit in admissions, particularly in private institutions; increasing capitation fees; admission of suboptimal quality of students with poor motivation; gross shortage of patients in many institutions; a less than desirable evaluation system; — all contribute to this cloudy picture of teaching methods. The out-dated curriculum and insensitivity to modern concepts of teaching–learning contribute to this problem1 . Teaching in India is still controlled by teacher centered classrooms3 . Students passively receive information from the teacher and internalize it through memorization3 . Concepts such as independent learning, flexibility in learning, critical thinking and problem solving are least recognized2 . Reports have shown that students’ inactivity in traditional teacher-centred classes would make them bored and exhausted that consequently would decrease their concentration and learning and finally would result in their absence from the classroom3 . Nowadays a deluge of techniques is encouraged to increase the interest of students in learning. Because of increasing competitive demands in the academic community, educators now strive to provide the most productive classroom experience for their students4 . Facilitating small-group discussions within the larger class, giving short writing exercises, incorporating quizzes taking field trips, using debates, seminar presentation by the students and project based learning have been promoted nowadays5 . The aim of active learning methods is to engage students in higher-order thinking tasks as analysis, synthesis, and evaluation.4 The purpose of the study was to examine the approach of 1st year medical students of Medical College in Gujarat towards seminar presentation. In medical education, preparation of individual presentations will give students confidence, help them to overcome their nervousness and motivate them to speak before other people without hesitation4 . This study was in the context of exploring “effective seminar” from a student’s perspective which will help the medical professionals in managing this type of teaching technique more efficiently.
DESIGN AND METHOD
The study was carried out at the department of physiology in private medical college in Kutch district of Gujarat. Study was undertaken on 110 students of 1st year MBBS. A questionnaire was prepared regarding effectiveness of seminar in learning process and feedback was taken from all 110 students. Total nine questions were included in the questionnaire. Nine questions were distributed in three different tables (Table 1, 2, 3). Than these tables were given to all 110 students and asked to feel the details after explaining the procedure. The participants were informed what the investigation was about and were told that the responses would be anonymous and must be unbiased. Grading and Likert scale was used for taking feedback6 . Consent was obtained from all the students and propose of the study was explained. A Questionnaire was prepared with the help of many faculty members. It was assessed and summarised with the MS excel and IBM SPSS statistical software version 20.0. Permission and ethical clearance from Institutional research committee was taken.
RESULT
This was an observational study. We took the feedback from the students regarding seminar and summarised the feedback in tables. (Table 1, 2, 3)
DISCUSSION
Several new methods of assessment have been developed and implemented over this time and they have focused on clinical skills, communication skills, procedural skills, and professionalism. Assessment creates excellence and it leads to the process of precise learning7 . In our study, maximum students believed that interactive and student centric education methods were more interesting and non-boring which also aids in good learning. More than 76% students were agreed out of total participants. Study showed that education methods must be modified and improved. Lecture, probably the oldest teaching method, is still the most common form of medical education. Although engaging, but this method encourages passivity with more of teacher talk and lack of interaction with students8 , 9 . In the seminar, Students actively research a topic and prepare the PowerPoint presentation to teach the class. By this, a student learns his own topic even better. Apart from learning, the students acquire other skills like searching the internet-based materials and preparing presentations which can help them learn in an easier and better way. Problem-solving exercises, analysis of case reports, student presentations and students working cooperatively in groups are recommended active learning activities for teaching in medical colleges10. The majority of college students are active learners requiring learning experiences that engage their senses11. The seminar method appeared to have a positive effect on the trainees’ assessment of their learning12. Although, it is well-established that active learning provides significant practical and theoretical advantages over passive learning, teachers are often seen reluctant to employ these active learning strategies in routing teaching practice13. Proper selection of seminar topics, involvement of students in interaction and involvement of teachers can make the more definitive outcome. Limitations of this study were relatively smaller size of subject, inclusion of single medical college and non-inclusion of other advance teaching methods. By including many medical colleges and advance methods, this study could be made more appealing.
CONCLUSION
Our study demonstrated that the majority of students consider seminar presentation as an active learning technique. Students’ attitude was very decisive for an active learning method like seminar and it should be promoted in routine practice. Further studies on a larger scale are required to develop more understanding on this aspect.
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 liter
Englishhttp://ijcrr.com/abstract.php?article_id=586http://ijcrr.com/article_html.php?did=5861. Ananthakrishnan N. Medical education in India: Is it still possible to reverse the downhill trend?; Natl Med J India. 2010; 23(3):156-60.
2. Adib-Hajbaghery M, Aghajani M. Traditional Lectures, Socratic Method and Student Lectures: Which One do the Students Prefer?. Webmed Central Medical Education. 2011;2:WMC001746.
3. Schreiber EB, Fukuta J, Gordon F. Live lecture versus video podcast in undergraduate medical education: A randomised controlled trial. BMC Medical Education. 2010;10:68.
4. Aditya Jain, Ramta Bansal, KD Singh, Avnish Kumar. Attitude of medical and dental first year students towards teaching methods in a medical college of northern India. Journal of Clinical and Diagnostic Research; 2014; 8(12):XC05-XC08.
5. Bonwell C, Eison J. (1991). Active Learning: Creating Excitement in the Classroom AEHE-ERIC Higher Education Report No. 1. Washington DC: Jossey-Bass.
6. Likert, Rensis. “A Technique for the Measurement of Attitudes”. Archives of Psychology. 1932; 140: 1–55.
7. S. Gopalakrishnan, P. Ganesh kumar. Community medicine teaching and evaluation: scope of betterment. Journal of Clinical and Diagnostic Research. 2015; 9(1):XE01-XE05.
8. Doucet MD, Purdy RA, Kaufman DM, Langille DB. Comparison of problem based learning and lecture format in continuing medical education on headache and management. Med Educ. 1998; 32:590-96.
9. Hrepic Z, Zollman DA, Rebello SN. Comparing students and experts’ understanding of the content of a lecture. J Sci Edu Tech. 2007;16:213-24.
10. Vella F. Medical education: Capitalizing on the lecture method. FASEB J. 1992;6:811–12.
11. Twigg CA. The need for a national learning infrastructure. Educom Rev. 1994;29:4–6.
12. Skeff KM, Stratos GA, Campbell M, Cooke M, Jones HW., III Evaluation of the seminar method to improve clinical teaching. J Gen Intern Med. 1986;1:315–22.
13. Benek-Rivera J, Matthews VE. Active learning with jeopardy: Students ask the questions. Journal of Management Education. 2004;28:104-18.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareEXTERNAL AND INTERNAL EGG QUALITY CHARACTERISTICS OF THREE VARIETIES OF HELMETED GUINEA FOWL (NUMIDAMELEAGRIS) IN NIGERIA
English1017Onunkwo D. N.English Okoro I. C.EnglishAn investigation of the egg quality characteristics 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 quality traits. Parameters collected for egg quality traits include: Egg Weight (EW), Egg Length (EL), Egg Width (EWD), Egg Index (EI), Shell Thickness (ST), Shell Weight (SW), Albumen Height (AH), Albumen Weight (AW), Albumen Diameter (AD), Yolk Length (YL), Yolk Height (YH), Yolk Weight (YW), Yolk Diameter (YD), Yolk Index (YI), and Haugh Unit (HU). The egg quality data were treated statistically. The Pearl, Lavender and Black varieties showed great
similarities in two important indices for assessing egg quality traits, namely: Haugh unit (88.95, 89.04, and 88.56) and yolk index values (0.40, 0.41, and 0.42) respectively. Based on the mean internal egg quality values, Differences were observed in albumen weight (18.23, 19.79 and 17.36) and yolk diameter (32.31, 31.91 and 31.50) of the Pearl, Lavender and Black varieties respectively. The Lavender and Pearl varieties recorded higher values in both traits than the Black. The result of the mean external egg quality traits showed that the Pearl and Lavender varieties are similarly longer and wider than the Black variety. The Black
variety however outperformed the Pearl variety in shell thickness. The Pearl and Lavender varieties showed more similarity in performance than the Black. However, since, the Lavender variety performed better than the Pearl variety in albumen weight and shell thickness, it is thus recommended.
EnglishEgg quality, Egg characteristics, Guinea fowl, VarietiesINTRODUCTION
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. 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). The Pearl is the most common and probably the first developed from the Wild West African birds (Ikani and Dafwang, 2004). 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(Ayorinde, 1990). Laying may continue for 7 or more years. The eggs and to a lesser extent the meat of guinea fowl are widely eaten by Nigerians because of the distinctive flavor they produce (Dudusola, 2010). According to Ayorinde (1990), guinea fowl meat has higher protein content (about 28%), an eviscerated yield of over 80% and a yield of edible carcass of between 50% and 80%. The good keeping quality of guinea fowl eggs and the hardy disease resistant nature of the stock contribute to the prominent position of this species in Nigeria. Egg quality is composed of those characteristics of an egg that affects its acceptability to consumers such as cleanliness, freshness, egg weight, shell quality, yolk index, albumen index, Haugh unit and chemical composition (Song et al., 2000). In other countries like India, it is the more important price contributing factor in table and hatching eggs and as such the economic success of a laying flock solely depends on the total number of quality eggs produced (Parma et al., 2006). Chicken eggs has been very well studied for its external and internal qualities as well as for its composition; however such information are not so abundantly documented in other poultry species (Dudusola, 2010). Certain traits of economic importance in egg production include the egg number, egg quality traits, and other egg indices (Oluyemi and Robert, 2000).
MATERIALS AND METHOD
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 apart yielded 350 F1 keets. 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
Data was collected for egg quality traits fortnightly. With the aid of a scalpel, the eggs were broken and the content emptied into a Petri-dish. The following parameters were determined:
• Egg Weight (EW): This was measured using an electronic sensitive scale.
• Egg Length (EL): This was determined using Vernier Caliper.
• Egg Width (EWD): This was determined using Vernier Caliper
. • Egg Index (EI): This was computed from the ratio: EI = Mean Egg Width Mean Egg Length
• Shell Thickness (ST): This was determined using a micrometer screw gauge. The average of the three readings at the broad, narrow and mid sections was taken as the shell thickness for each bird in the group.
• Shell Weight (SW): This was measured using electronic scale
• Albumen Height (AH): This was measured with a Spherometer.
• Albumen Weight (AW): The albumen was placed in a Petri-dish on an electronic scale and the weight of the albumen was determined by difference
. • Albumen Diameter (AD): This was computed as follows: AD = Long diameter + short diameter 2
• Yolk Length (YL): This was determined using Vernier Caliper
• Yolk Height (YH): This was measured with a Spherometer
. • Yolk Weight (YW): The yolk was separated from the albumen and then placed in a weighed Petridish on an electronic scale and the weight of the yolk was determined by difference.
• Yolk Diameter (YD): This was measured using a Vernier Caliper as the width of the yolk.
• Yolk Index (YI): This was computed from the ratio YI = Yolk height Yolk diameter
• Haugh Unit (HU): This was estimated using the equation according to Haugh (1937): HU = 100Log {H+7.57-1.7 W0.37} Where, H = Observed Albumen Height (mm) W = Observed Weight of Egg (g).
Statistical Analysis
Data collected for the egg quality traits were subjected to Analysis of Variance (ANOVA) in Completely Randomized Design (CRD) using the general linear model described by Steel and Torrie (1980) and significant means were separated using Duncan’s Multiple Range Test (Duncan, 1955).The statistical model used is as shown below:
RESULTS
External Egg Quality Traits in Three Varieties of Helmeted Guinea Fowl from 28 to 46 Weeks of Age The external egg quality traits in three varieties of helmeted guinea fowls from week 28 to 46 weeks of age is presented in Table 2. Non-significant differences (P> 0.05) were found in the shell weight values of Black and Lavender whereas a significant difference (P< 0.05) was found in Pearl. The shell thickness values were observed to vary (P< 0.05) in Black whereas no significant differences (P> 0.05) were observed in Pearl and Lavender. Black and Lavender showed fluctuating trends whereas the Pearl variety showed a decreasing trend with slight fluctuations. Chineke (2001) reported similar trends in the shell thickness of the Olympia Black laying variety. Oke et al. (2004) reported values which portrayed a decreasing trend in Pearl which agrees with our present report in Pearl variety. The egg weight values varied (P< 0.05) for Black and Pearl whereas no significant difference (P>0.05) was observed in Lavender as shown in Table 2. The three varieties showed very slight increases in egg weight. However, some decreases were noticed in the Black and Lavender towards the end of lay. The egg length values of each of the three varieties varied (P< 0.05) as shown in Table 2.Significant difference (P< 0.05) was observed in the egg width values in Black whereas no significant differences (P> 0.05) were observed in Pearl and Lavender as shown in Table 2. The Black and Lavender variety showed a fluctuating trend whereas the Pearl variety showed an increasing trend up to the 36th week and fluctuated thereafter. Chineke (2001) reported an increasing trend for the first three weeks which fluctuated thereafter in Olympia Black laying variety; this agrees with the present report for Pearl variety. The following Researchers have also reported increases in egg width: Gerstmayr and Horsi (1990); Olori and Sonaiya (1992; Austic and Neslieim (1990); and Asuquo (1994). The three varieties recorded significant differences (P0.05) was observed in Black va riety. The three varieties showed a decreasing trend up to the 38th week and the Pearl and Lavender varieties thereafter maintained a slightly increasing trend with slight fluctuations whereas the Black increased with a big trough in week 44. The decreasing trend suggests some level of similarities which could have resulted by genetic or non-genetic reasons (Chineke, 2001). The albumen height (AH) values were observed to vary significantly (P0.05) were observed for Pearl and Lavender. Significant difference may be due to non-genetic factors and due to variations in physiological status of the animal. The three varieties showed a somewhat increasing trend from at least the 36th week. Oke et al. (2004) reported values that showed somewhat increasing trend which agreed mostly with the present report for Pearl variety. It is noteworthy that the Black and Lavender showed initial decreases whereas the Pearl variety maintained its increasing trend. Yolk diameter (YD) varied (P< 0.05) in each of the three varieties. The three varieties maintained a decreasing trend. Normally, a higher yolk height associated with a lower yolk diameter, results in better quality of the egg. Yolk index (YI) varied (P< 0.05) in each of the three varieties. The three varieties showed a fairly increasing trend with slight fluctuations. This increasing trend implies that the yolk height increased as the yolk diameter decreased over time. This is to say that yolk quality increases with age in the wet season. The similarity in trend may again be due to genetic reasons (Chineke, 2001). None significant difference (p> 0.05) was found in the mean yolk index values of the three varieties. Obike et al. (2011) obtained a mean yolk index value of 38.90 and 38.65 in Pearl and Black varieties of guinea fowl which were slightly lower than the 40.00 and 42.00 obtained in this study for Pearl and Black varieties respectively. Significant differences (P0.05) was observed in the mean Haugh unit values of the three varieties which again suggest similarities. The Haugh unit values obtained in this study is higher than the 70% benchmark noted for quality eggs (Adeogun and Amole 2004). They also reported that the higher the yolk index and Haugh unit, the higher the quality of the egg.
DISCUSSION
In shell weight values, Black and Lavender varieties showed similar trends with slight fluctuations which might be due to fluctuations in calcium metabolism. Onyeanusi (2007) noted that calcium has significant effect during egg production in guinea fowls. The Pearl variety portrayed an increasing trend up to the 40th week. The mean shell weight of the three varieties did not vary significantly (P> 0.05). Obike et al. (2011) obtained a mean shell weight values of 7.27 g and 7.12 g in Pearl and Black varieties of guinea fowl which compares with the values obtained in this study. Significant differences (P< 0.05) were observed in the mean shell thickness of the three varieties. The higher values obtained in this study may be because the shell thickness was obtained from the shells with their membranes intact. The slight increases in egg weight values of the three varieties agrees with the report of Chineke (2001) in Olympia Black laying variety, and Oke et al. (2004) who reported values that showed increases as production advanced. Obike et al. (2011) and Oke et al. (2004) obtained a mean egg weight of 37.67 g and 36.24 g respectively in Pearl variety of Guinea fowls which is slightly lower than the value (39.99 g) obtained in this study. These investigators also obtained a value of 37.91 g in Black variety which agrees with the present report for Black variety (37.67 g) The three varieties showed increasing trend which again may be due to genetic reasons (Chineke, 2001). Chineke (2001) and Oke et al.,(2004) reported an increasing trend in egg length. The following Researchers have also reported increases in egg length: Gerstmayr and Horsi (1990); Olori and Sonaiya (1992); Austic and Neslieim (1990); Asuquo (1994). Non-significant difference (P>0.05) was observed in the mean egg length values of the three varieties. Obike et al. (2011) obtained a mean egg length of 46.84 mm and 47.40 mm in Pearl and Black variety of Guinea fowls respectively which almost agrees with the present report of 45.20 mm in Pearl and 45.74 mm in Black variety Significant differences (P< 0.05) were observed in the mean egg width of the three varieties. The Pearl and Lavender varieties were the most significant while the Black variety was the least. Obike et al. (2011) obtained a mean egg width of 36.60 mm and 36.83 mm in Pearl and Black guinea fowls respectively which almost agrees with the present report for Pearl (35.69 mm) but slightly higher than the value 34.97 mm reported for Black. Significant differences (p< 0.05) were observed in the mean egg index value of the three varieties. Significant differences (P< 0.05) were observed in the mean albumen weight of the three varieties. The Lavender variety had the highest albumen weight (19.790 g) followed by the Pearl (18.236 g), and lastly the Black variety (17.355 g). Obike et al. (2011) obtained a mean albumen weight values of 17.38 g and 17.48 g respectively in Pearl and Black varieties of Guinea fowls which compares with the values obtained in this present study. Non-significant difference (P>0.05) was observed in mean albumen diameter in the three varieties of guinea fowl studied which suggests similarity. Obike et al. (2011) obtained a mean albumen diameter values of 61.27 mm and 66.97 mm in Pearl and Black varieties of guinea fowls which are lower than the values 79.26 mm and 76.69 mm obtained for Pearl and Black varieties respectively in this study. The three varieties showed an increasing trend in the Albumen Height up to the 40th week and thereafter showed a decreasing trend. The decrease may be associated with non-genetic factors (Chineke, 2001) such as the increasing humidity and higher rainfall which probably affected intake and metabolism thus resulting in increased fluidity of the albumen. Genetic or non-genetic factors (Chineke, 2001) like nutrition, and changing environmental conditions (Bernacki, 2003) could be responsible for the significant differences in the Yolk Weight. Oke et al. (2004) however, reported values that show an increasing trend in Pearl variety of Guinea fowl which concurs mostly with the present report for Pearl variety and to some extent, the Lavender variety but contrasts with the Black variety. Non-significant difference (P>0.05) was found in the mean yolk height values of the three varieties. The mean yolk height values obtained for the three varieties are lower than the value (15.89 mm) obtained by Oke et al. (2004) but compared with the values 13.09 mm in Pearl variety and 13.70 mm in Black variety of Guinea fowl reported by Obike et al. (2011). Significant differences (P0.05) was observed in the mean Haugh unit values of the three varieties which again suggest similarities. The Haugh unit values obtained in this study is higher than the 70% benchmark noted for quality eggs (Adeogun and Amole 2004). They also reported that the higher the yolk index and Haugh unit, the higher the quality of the egg.
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.
CONCLUSION
The three varieties of guinea fowl showed similarities in their external traits but differed in egg width and egg index. The Pearl and Lavender recorded higher values than the Black guinea fowl. The three varieties performed similarly well in Haugh unit (88.95, 89.04, and 88.56) and yolk index values (0.40, 0.41, and 0.42) in Pearl, Lavender, and Black respectively, which are very important indices for assessing egg quality. Considering the mean values, the three varieties showed similarities in most of the parameters except in albumen weight and yolk diameter. The result of the mean external egg quality traits showed that the Pearl and Lavender varieties are similarly longer and wider than the Black variety. The Black variety however outperformed the Pearl variety in shell thickness. The Pearl and Lavender varieties showed more similarity in performance than the Black. From the foregoing, the Pearl and Lavender varieties showed more similarity in performance than the Black variety and thus may be more genetically related than the Black. However, since, the Lavender variety performed better than the Pearl variety in albumen weight and shell thickness, it is thus recommended.
Englishhttp://ijcrr.com/abstract.php?article_id=587http://ijcrr.com/article_html.php?did=5871. Adeogun, I. U. and Amole, F. O. (2004). Some quality parameters of exotic chicken eggs under different storage condition. Bulletin for Animal Health andProduction in Africa (Kenya). Vol.52 (1): 43-47.
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. Bernacki Z. and Heller, K. (2003). Ocean jakosci jaj perlic szarych w roznych okresach niesnosci. Pr. Kom. Nauk. Roln. Boil. BTN 51: 27-32.
6. Chineke, C.A. (2001). Interrelationships existing between bodyweight and egg production traits in Olympia BlackLayers. Nigeria Journal of Animal Production. 28 (1): 1-8.
7. Dudusola, I.O. (2010). Comparative evaluation of internal and external qualities of eggs from quail and guinea fowl. International Research Journal of Plant Science. Vol.1 (5). Pp.112-115.
8. Duncan, D.B. (1955). Multiple Range Test. Biometrics. 11: 1-42
. 9. FDLPS/RIM (1991). Nigerian National Livestock Survey Report. Federal Department of Livestock and Pest Control Services, Abuja Nigeria.
10. 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.
11. 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.
12. Nowaczewski, S., Katarzyna, W., Maciej, F., Helena, K., Andrzej, R., Stanislawa, K. and Andrzej, R. (2008). Egg quality from domestic and French guinea fowl. Nauka Przyr. Tachnol. 2.2. 8.
13. 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.
14. 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.
15. 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.
16. Oke, U.K., Herbert, U. and Nwachukwu, E.N. (2004). Association between bodyweight and egg production traits in the guinea fowl (Numida meleagris galleata pallas). Livestock Research for Rural Development 16 (9).
17. Oluyemi, J. A. and Roberts, F. A. (2000). Poultry production in warm wet climates. Spectrum Books Limited; 2nd ed., Nigeria. Pp 202-233.
18. Onyeanusi, B.I. (2007). Calcium and phosphorus levels in Nigerian guinea fowls. International Journal of Poultry Science, 6(8): 610-611.
19. Parmar, S. N. S., Thakur, M. S. Tomar, S. S. and Pillai, P. V. A. (2006). Evaluation of egg quality traits in indigenous Kadaknath breed of poultry. Livestock Research for Rural Development. 18 (9).
20. Song, K.T., Choi, S.H. and Oh, H.R. (2000). A comparision of egg quality ofpheasant, chukar, quail and guinea fowl. Asian-Australian Journal of AnimalScience, 13: 986-990.
21. 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 Review2231-21960975-524177EnglishN-0001November30HealthcareINFLUENCE OF BREAST CANCER ON SERUM TESTOSTERONE AND SEX HORMONE BINDING
GLOBULIN LEVELS AMONG SUDANESE LADIES
English1821Kamal Eldin Ahmed AbdelsalamEnglishBackground: Breast cancer is the most frequent cancer and the second leading cause of cancer deaths among women worldwide and an increasing incidence rate has been observed in Sudan.
Objective: this study was aimed to determine the effect of breast cancer on testosterone and sex hormone binding globulin inSudanese female patients.
Materials: This study included 120 untreated breast cancer patients with clinical and histopathological evidence and 100 healthy volunteers as a control. Venous blood was drawn from the cases and controls.
Methods: Testosterone and sex hormone binding globulin were estimated in blood samples by using radio-immune assay. Paired t-test was used to compare the mean serum levels of testosterone and sex hormone binding globulin between patients and controls.
Results: In the present study there were significant high levels of serum testosterone in premenopausal lady patients with breast cancer as compared to control group (p value EnglishTestosterone, Sex hormone binding globulin, Breast cancerINTRODUCTION
Breast cancer is a malignant tumor starts from the breast tissues and cells. Breast cancer affects 13% of women during their lives. Cancers originating from ducts are known as ductal carcinomas; those originating from lobules are known as lobular carcinomas [1]. In 2008 breast cancer caused 458,503 deaths worldwide, it is compromises 13.7% of the total cancer deaths among women. Breast cancer is more than 100 times more common in women than breast cancer in men, although males tend to have poorer outcomes due to delays in diagnosis [2]. The primary risk factors for breast cancer are sex, age, lack of childbearing or breastfeeding, higher estrogen levels, race, socioeconomic status and dietary iodine deficiency [3]. Testosterone is a steroid hormone and is found in mammals, and other vertebrates. In human, testosterone is originally secreted in male testes and female ovaries. It is the major male sex hormone and an stimulating steroid [4]. In men, testosterone plays a major role in the developing of the male reproductive system particularly testis and prostate as well as progressing the secondary sexual characteristics like increased muscle, bone mass and the growth of body-hair. In addition, testosterone has important role in human health and well-being addition to the prevention of osteoporosis [5]. On average, an adult human male produces about ten times more testosterone than an adult human female, but females are more sensitive to the hormone [6]. About sixty to seventy percent of secreted testosterone is bound to special type of protein so named sex hormone binding globulin (SHBG). Sex hormone binding globulin (SHBG) is a glycoprotein which possesses high affinity for 17 beta-hydroxysteriod hormones such as testoster one and oestradiol. It is synthesized in the liver, plasma concentrations being regulated by, mainly androgen/oestrogen balance along with other factors such as thyroid hormones, insulin and dietary factors. The main function of this protein is transporting of sex steroids in plasma. The concentration of sex hormone binding globulin is a major factor regulating their distribution between the protein-bound and free states. The exact role of the protein in the submission of hormones to target tissues is not yet clear. Measurement of sex hormone binding globulin is used to evaluate androgen metabolism disorders and in identification of women with hirsutism who are more likely to respond to estrogen therapy [7]. Testosterone/ sex hormone binding globulin ratios correlate well with both measured and calculated values of free testosterone and help to differentiate subjects with excessive androgen activity from normal individuals [4]. Sex hormone binding globulin levels is controlled by feedback mechanism factors. The negative feedback factors include insulin, insulin-like growth factor 1, transcortin and hyperandrogenism. Whereas, the positive feedback factors of sex hormone binding globulin levels include high levels of growth hormone, estrogen and thyroxin hormone [7]. Increased sex hormone binding globulin level results in increasing of total testosterone level. Reference ranges for serum sex hormone binding globulin is ranged between 40 to 120 n.mol/L for premenopausal females, and 28 to 112 n.mol/L for postmenopausal females [8]. True androgen status can be determined by measuring the free testosterone or by calculating total testosterone / sex hormone binding globulin ratio, which known as the free androgen index (FAI) [9]. The expected testosterone levels for women are lower than the normal levels for men. The testosterone levels in women are set according to the stages of life [3]. Girls before puberty comprise the minimum levels of testosterone due to their body’s stage of development. Then, during puberty, testosterone is started to be produced from adrenal glands with other sex hormones and making pre-menopausal women have the second-highest levels of testosterone [10]. As a woman begins being aged, she produces more testosterone, less estrogen and other female sex hormones. Therefore, menopausal and postmenopausal women have the highest levels of testosterone [11]. High testosterone levels in women can cause many problems including growth of facial and body hair, deep voice, and aggressiveness [12]. The aim of this study is to examine the role of alterations in testosterone and SHBG in woman developing breast cancer.
MATERIALS AND METHODS
This was a cross sectional case-control study conducted period between 2011and 2014 in Khartoum State, Sudan. The study included 100 normal healthy persons (control) and 120 untreated breast cancer patients with clinical and histopathological evidence, from the out patients and hospital admissions of the Radiation and Isotopes Center Khartoum (RICK). All selected participants were premenopausal women, and the ages of them were 28-50 years, and all of them with no history of smoking or biochemical evidence of diabetes, hormonal disorders, hypertension, hyperlipidaemia, renal or liver disease or family history of the breast cancer. This study was approved by the ethical committee of Omdurman Islamic University. Informed consent was obtained from each participant. Fasting 10ml venous blood was drawn between 6-10 a.m. and serum was separated and analyzed within 3 hours after collection. Then testosterone and sex hormone binding globulin tests were estimated by radioimmunoassay (RIA) an automated techniques as described by Choudhury et al [13]. Statistical analyses were performed using SPSS (Statistical Package for Social Sciences). Differences in mean values between groups were evaluated by a one-way analysis of variance (ANOVA) and Student’s t-test. Statistical analysis where the value of pEnglishhttp://ijcrr.com/abstract.php?article_id=588http://ijcrr.com/article_html.php?did=5881. Veljkovic M, Veljkovic S. The risk of breast cervical, endometrial and ovarian cancer in oral contraceptive users. Med Pregl 2010,63:657-661.
2. Goncalves V, Sehovic I, Quinn G. Childbearing attitudes and decisions of young breast cancer survivors: a systematic review. Hum Reprod Update 2014,20:279-292.
3. Maggio M, Cattabiani C, Lauretani F, Mantovani M, Butto V, De Vita F, et al. SHBG and endothelial function in older subjects. Int J Cardiol 2013,168:2825-2830.
4. Saad F. The role of testosterone in type 2 diabetes and metabolic syndrome in men. Arq Bras Endocrinol Metabol 2009,53:901-907.
5. Smith LB, Walker WH. The regulation of spermatogenesis by androgens. Semin Cell Dev Biol 2014,30:2-13.
6. Yasui T, Uemura H, Irahara M, Arai M, Kojimahara N, Okabe R, et al. Associations of endogenous sex hormones and sex hormone-binding globulin with lipid profiles in aged Japanese men and women. Clin Chim Acta 2008,398:43- 47.
7. Sun L, Jin Z, Teng W, Chi X, Zhang Y, Ai W, et al. SHBG in GDM maternal serum, placental tissues and umbilical cord serum expression changes and its significance. Diabetes Res Clin Pract 2013,99:168-173.
8. Perry JR, Weedon MN, Langenberg C, Jackson AU, Lyssenko V, Sparso T, et al. Genetic evidence that raised sex hormone binding globulin (SHBG) levels reduce the risk of type 2 diabetes. Hum Mol Genet 2010,19:535-544.
9. Wei S, Schmidt MD, Dwyer T, Norman RJ, Venn AJ. Obesity and menstrual irregularity: associations with SHBG, testosterone, and insulin. Obesity (Silver Spring) 2009,17:1070- 1076.
10. Kumsar S, Kumsar NA, Saglam HS, Kose O, Budak S, Adsan O. Testosterone levels and sexual function disorders in depressive female patients: effects of antidepressant treatment. J Sex Med 2014,11:529-535.
11. El Khoudary SR, McClure CK, VoPham T, Karvonen-Gutierrez CA, Sternfeld B, Cauley JA, et al. Longitudinal assessment of the menopausal transition, endogenous sex hormones, and perception of physical functioning: the Study of Women’s Health Across the Nation. J Gerontol A Biol Sci Med Sci 2014,69:1011-1017.
12. Jukic AM, Weinberg CR, Wilcox AJ, McConnaughey DR, Hornsby P, Baird DD. Accuracy of reporting of menstrual cycle length. Am J Epidemiol 2008,167:25-33
. 13. Choudhury BK, Choudhury SD, Saikia UK, Sarma D. Gonadal function in young adult males with metabolic syndrome. Diabetes Metab Syndr 2013,7:129-132.
14. Abdelsalam KE, Hassan IK, Sadig IA. The role of developing breast cancer in alteration of serum lipid profile. J Res Med Sci 2012,17:562-565.
15. Halava H, Korhonen MJ, Huupponen R, Setoguchi S, Pentti J, Kivimaki M, et al. Lifestyle factors as predictors of nonadherence to statin therapy among patients with and without cardiovascular comorbidities. CMAJ 2014,186:E449-456.
16. Bhaskaran K, Douglas I, Forbes H, dos-Santos-Silva I, Leon DA, Smeeth L. Body-mass index and risk of 22 specific cancers: a population-based cohort study of 5.24 million UK adults. Lancet 2014,384:755-765.
17. Biro FM, Pinney SM, Huang B, Baker ER, Walt Chandler D, Dorn LD. Hormone changes in peripubertal girls. J Clin Endocrinol Metab 2014,99:3829-3835.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareAUDITORY BRAINSTEM PROCESSING OF COMPLEX SPEECH SOUNDS IN HIGH RISK INFANTS-A PRELIMINARY STUDY
English2227Muhammed AyasEnglish Hakam YaseenEnglish Rajashekhar B.EnglishBackground: The ability of the auditory brainstem process for complex speech sound is precursor for the normal language development. Infants who are born prematurely are at high risk for hearing loss and should be evaluated for their hearing at the earliest to identify the hearing related disorders.
Objectives: The aim of the study was to explore how an immature auditory brainstem responds for the complex acoustic stimuli such as speech sounds. Method: Twelve high risk infants were recruited in the prospective, observational study. Speech Evoked Auditory Brainstem Response (SEABR) was recorded in all the high risk infants using stop consonant/da/.
Results: The results of the study were promising in such a way that the onset and sustained responses were encoded in the premature auditory brainstem with greater fidelity.
Conclusion: The scalp-recorded SEABR offers a unique window in understanding how the human auditory brainstem represents key elements of the speech signal. From the current study, we draw the inference that all the high risk infants should undergo a SEABR recording and such findings would enable the clinicians and researchers to dwell in to the possible onset of APD in these high risk populations.
EnglishSpeech evoked auditory brainstem response (SEABR), High risk infants (HR infants), Frequency following response (FFR), Auditory processing disorders (APD), Language developmentINTRODUCTION
The ability of the auditory system to precisely encode the speech sound is vital for the development of speech and language in infants and children. Such an auditory stimulation plays a major role in the maturation of the auditory cortex and makes the auditory areas capable for the intake of acoustic stimulation (Kral et al, 2005, Ponton et al 2002). In newborns and infants, though the central auditory structures are not developed completely yet, continuous acoustic stimulation is important for the synaptic pruning and proliferation, which results in the better development of auditory areas in the brain (Kuhl, 2004, Keuroghlian, and Knudsen ,2007). Due to the widespread application of Universal Newborn hearing screening program (UNHS) program (Shulman et al,2010, Patel and Feldman,2011 , Haves,1999, Wiechbold, Hues and Muller,2006,Gorga et al 2001,Kerchner et al ,2004), today, almost all hospitals are equipped to screen newborns for their hearing. These screening processes have paved a path for the early identification of hearing loss and its intervention (Ching et al 2013,Ptok and Med, 2011, Paludetti et al 2012, Spiyak and Sokol, 2005, Buttros, Vohr et al 2008, Kenna,2004,Kasal et al 2012, Christensen, Thomson, Letson, 2008).However, certain sections of researchers have also pitched their criticism on the growing number of false positive and false negative responses obtained in UNHS (Davis et al 1997,Colgen et al 2012,Nelsen et al 2008, Clemens and Davis 2001). This could be due to the technical failures or procedural flaws during the hearing screening program (Ciorba et al 2007,Gorga et al 2001,Mencher et al 2001). By keeping in mind that the auditory stimulation is vital for the speech and language development in children (Sharp and Hellenbrand, 2008, Tomblin et al 2014, Laws and Hall 2014), it is important to study, how such an auditory processing is categorically processed in these infants. There is a dearth of literature on how speech sounds are processed in the central auditory system of very young infants. Such a research question is imminent as there is a growing population of children who are categorized into poor readers or performers at school level due to apparent breakdown in the central auditory processing of speech signals, though these children has absolutely normal hearing when assessed with pure tones (Ahmmed et al 2014, Allen and Allan, 2014).The possible causes for these APD have paved a ground breaking research in Paediatric audiology, which insists on thorough auditory processing evaluation in children or may be a continuous monitoring at the infant stage itself. The lack of scientific evidence in literature has also been a key reason not to authenticate when and how to proceed for this type of hearing assessment. The basic question arises in the wakening of growing APD is that, can the auditory processing abilities be probed in the infant stage itself, especially in high risk infants. It is clearly understood that the premature babies are at high risk for developing hearing loss or may develop ANSD due to their increased medical complications (Cristobal and Okhalai,2008, Borrdori et al 1997,Marlow and Hunt,2000).These hearing difficulties will have detrimental effect on normal language development. Till date to our knowledge, there are very few reports on how the speech sounds are processed through auditory brainstem in infants, especially high risk infants. A chunk of studies has been done using non speech sounds like pure tones or tone bursts (Ptok et al 2005, Ahmmed et al 2014).This information is limited to comment on the brainstem processing for speech sounds. Thus it is important to probe into how the brainstem process speech sounds in high risk infants. One of the popular methods to objectively assess the brainstem processing of speech is using speech sounds integrated with ABR (Skoe and Kraus, 2010) Speech evoked Auditory Brainstem Response BR (SEABR) has gained its popularity by using it in various populations such as children, musicians and adults for various aims(Tierney and Kraus,2013,song et al,2011,Anderson et al 2010).SEABR can be defined as the evoked potential recorded in response to a speech sounds from the auditory brainstem in time locked manner.SEBAR has been in the research ground more than a decade by probing the auditory processing abilities in various populations especially using the stimuli stop consonant /da/ (Ruso et al 2004).It is widely believed that such a complex speech sounds can offer an enormous wealth of information on auditory processing in humans (Johnson et al 2005, 2007). Hence, in the current study, the basic aim was to study how the premature auditory brainstem processes the speech sounds and its features such as onset responses, formant transition and frequency following response, which will shed light into the complex auditory processing mechanism in infants.
MATERIALS AND METHODS
a. Participants
The prospective, observational study were carried out in a tertiary care hospital in India, within a specially created sound treated room in the Neonatal intensive care unit (NICU).Twelve high risk infants were included in the study. All the high risk infants were recruited based on the inclusion criteria such as, all the infants should be born before 36 weeks of gestational age during the study period, low birth weight (less than 1500g), hyperbilirubinemia requiring phototherapy. Infants with Congenital malformations and perinatal asphyxia were excluded from the study infants The current study was approved by the institutional research and ethics committee (IREC).Parents were informed about the potential importance and scientific benefit of reporting the data and consensus obtained before proceeding for the study. A duly signed consent form from all the parents was obtained before the SEABR recording.
b. Stimulus and recording parameters
SEABR were elicited by using a stop consonant /da/(Russo et al 2004).The speech stimulus is 40-ms synthesized /da/ which has an initial noise burst and formant transition between the consonant and a steady-state vowel, and was synthesized with a fundamental frequency (F0) that linearly rises from 103 to 125 Hz with voicing beginning at 5 ms and an onset noise burst during the first 10 ms. The first formant (F1) rose from 220 to 720 Hz while the second and third formants (F2 and F3) decreased from 1700 to 1240 Hz and 2580 to 2500 Hz, respectively, over the duration of the stimulus (Russo et al, 2004). The fourth and fifth formants (F4 and F5) were constant at 3600 and 4500 Hz, respectively. The stimuli was presented at repetition rate of 7.1/s. Electrophysiological responses were collected with Ag – Ag Cl electrodes, and recorded from Cz (active)-to right earlobe (reference), with the left earlobe as ground by using Intelligent Hearing System (IHS) version 4.0.3. Electrode impedance were less than 5 kOhms for each electrode and the difference between the electrodes was less than 3KOhms.The stimuli were presented to the right ear through insert earphones (ER-3A) at an intensity of 60 dB SPL while the left ear was unoccluded. 2000 alternating sweeps were collected to extract the final waveform. The analysis time window was kept 60 ms while recording the data.
d. Data Analysis
The brainstem response to a complex speech sound includes transient peaks that reflect the encoding of rapid temporal changes which were compared by means of latencies and amplitudes, as well as sustained elements that comprise the frequency following response (FFR), that encodes the harmonic and periodic sound structure of vowels, The characteristic response to the speech stimulus /da/ includes a positive peak (wave V), likely analogous to the wave V elicited by click stimuli, followed immediately by a negative trough (wave A). Following the onset response, peaks C to F are present in the FFR period and the offset (wave O) indicates the cessation of the stimulus. The latencies of the waveform were identified by two trained audiologists.
e) Statistical Analysis
All the data were entered in a SPSS-version 14 system. The mean and standard deviation of all the 7 peak latencies were obtained.
RESULTS
The result of the study has been categorized into onset and sustained responses (FFR).
A) Onset response: The onset responses were highly replicable both within and across subjects (figure 1). Peaks V, A, and C were detectable in all the infants. However,3 infants, peak c were not been recorded. The onset response waves V and A were largest in magnitude and followed by peak C. The mean and standard deviation obtained for wave V is 7.73ms (SD-.40) and for wave A is 9.15ms (SD-.54). For Wave C the mean values were 12.69ms (SD-1.11). There was a slight variation seen in the wave C across the infants. The reason for this will be discussed later. In the offset measures, Wave O were obtained with a mean value of 48.58ms (SD-1.51). General variance is noted in offset responses as well. (table-1)
B) Sustained Response (FFR): The FFR was evident in all infants (figure-1). The FFR is the phase locked Reponses obtained between in 14ms to 40ms. The wave D-E-F were prominently recorded with a mean value of 22ms-31ms-40ms respectively with a standard deviation of 1.49-1.89- 2.12.The slight variation in the peak responses could be due to the infant related factors during the recording time.(table-2).
DISCUSSION
The auditory brainstems ability to respond for complex speech sound is precursor for the normal language development. The SEABR faithfully reflects many acoustic properties of the speech signal. These responses provides a mechanism for understanding the neural bases of normal auditory brainstem function, by providing a quantifiable tool to asses an infant’s attention-independent neural encoding of speech sounds. The aim of the current study was to explore the auditory brainstem encoding of speech sounds in premature infants. The results of the current study are promising in such a way that the complex speech sounds are able to record in such versatile population. The onset and sustained responses-FFR were recorded with good precision with good amplitude and it was replicated in all infants with good fidelity. The current study will explore on how the onset and sustained responses were encoded in High Risk (HR) infants. The onset response (transient) measures included latency and amplitudes of peaks V, A, C, and O, slope, area and amplitude of the VA complex as a unit. The onset responses of the stop consonant /da/ were recorded in all HR infants. The wave V to A slope were seen as similar that of the responses recorded in children in other studies (Anderson et al 2010, Johnson at all 2007 Russo et al 2004).However in few recordings, wave V-A were prolonged, which could be attributed to the neural conduction delay. In contrast, evidence from the literature states that due to the maturational process, the latency of wave v can be negligibly prolonged in infants (Thaivan et al 2007, Ponton, Moore and Eggermont 1996). It is important to note that these responses could well give an important information on how well a developmental auditory system respond to a burst portion of a complex speech sounds such as stop consonants. It is to be noted that in 3 infants the peak C was not prominent compare to others. Peak C depicts the formant transition feature of the complex stimuli /da/. The acoustic features of this information would give an insight into how the complex signals are routed through the auditory brainstem to the auditory cortex. Studies have reported that the disruption in formant transition of the signals is evidently seen in children who are diagnosed with APD (Moore 2011, Allen and b Allen 2014, Banai and Kraus, 2006). The offset responses peak O is also an important component of SEABR as it marks the cessation of voicing of the stimulus during the recording. The FFR is synchronous to the sound, with each cycle faithfully representing the temporal structure of the sound. Thus the FFR reflects the neural phase-locking response with an upper limit of about 1000 Hz (Russo et al 2004) In the current study, FFR were recorded in all the infants. The periodicities of the stimulus were faithfully encoded in the immature brainstem revealing a possible inherent mechanism in infants to extract the speech sounds especially fundamental frequency. The fidelity of these responses opens up a debate on an old school of thought on how an infant identifies mother’s voice from that of others. The fundamental frequency, which is defined as the lowest lowest frequency in the signal is important for the speaker identification and differentiation of high and low pitch sounds. Results from the current study strengthen the notion that the ability of the auditory brainstem to identify the speech sounds could have been inherently developed in infants in early days of life. This offers a path breaking evidence for a further investigation on how the FFR responses changes during the developmental stages in life. Evidence from the literatures suggests that during the developmental course the auditory system undergoes vigorous synaptic pruning and myelination (Moore and Linthicum 2001, Moreno et al 2009). The FFR finding from the study points out atypical mechanism that process the complex speech sounds with great fidelity. However it is premature to comment such a mechanism functions in the immature auditory system. Also the scalp-recorded FFR probably reflect multiple sources in the immature brainstem (LL, CN, IC) (Chandrashekaran et al 2012). SEABR being a non invasive method to examine the subcortical encoding of speech features helps one to probe more closely the representation of speech features. The findings of the study also suggest that the close proximity of FFR responses in infants indicate that the Fo and harmonic structure of vowels are well developed and encoded with precision. There are reports stating that disruption in FFR could be seen in children with APD ( Banai et al 2007, Russo et al 2009,Hornicket et al 2012). By taking all these evidence into account, from the current study we can state that the infants who are at risk for hearing loss showed a satisfactory evidence of brainstem processing for complex acoustic stimuli such as speech stimuli. However, such inference cannot be drawn from the non speech stimulus recording using clicks or tone bursts. This underlies the importance of using speech stimuli for electrophysiological research and a paradigm shift from non speech stimuli to speech stimuli research in young children coming years.
CONCLUSION
The scalp-recorded SEABR offers a unique window in understanding how the human brainstem represents key elements of the speech signal. From the current study we draw the inference that all the high risk infants should undergo a SEABR recording in order to rule out APD in the early stage itself. Such recordings would enable the clinicians and researchers to dwell in to the possible onset of APD in these populations. Though the findings from the current study cannot be generalized in to the whole population owing to the limited data, by widening the potential importance of the study with more data these findings can be replicated in to clinical settings for hearing evaluation in infants and children.
Acknowledgements
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. The authors also would like to thank all the babies and parents for taking part in the study.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareImprint Cytology: A Reliable Alternative to Frozen Section
English2831Prashant SharmaEnglish Arshi Syed J.EnglishBackground: There are instances when either we do not perform pre-operative biopsy due to the fear of spread of malignancy, or needle aspiration cytology is inconclusive. During surgical exploration for a benign pathology if surgeons find suspicious lesions, per-operative cytological diagnosis becomes important to rule out malignancy. The frozen section facility is available only at few large volume centres. So there is always a need for an easy and cheap alternative to frozen section that can help surgeons at low volume centres as well.
Aim: Aim of the study was to assess the reliability of imprint cytology in per-operative (immediate) diagnosis of malignancy.
Material and methods: The present study was a prospective analysis of 69 specimens from suspected or diagnosed cancer patients that were sent for per-operative (or urgent) imprint cytology (IC) from July 2012 to Feb. 2014, at surgical oncology unit of our institute. All the specimens were then subjected to paraffin section (PS) and final reports were compared.
Results: Out of 69 specimens 61 were found to be malignant, and five were found to be benign by both IC and PS. In all such situations IC helped us a lot in decision making regarding change in treatment plan further. The sensitivity and specificity of imprint
cytology were 96.8 % and 83.3% respectively. The positive predictive value (PPV) of IC was 98.3 %.
Conclusions: The imprint cytology is a cheap and reliable method for per-operative diagnosis of malignancy. It can be used for per-operative confirmation of parathyroid glands before auto-implantation.
EnglishFrozen section, Imprint cytology, Per-operative cytology, Touch cytologyINTRODUCTION
For past many years it has become a trend to have definitive diagnosis before surgery, as it helps in surgical planning, planning of neo-adjuvant therapy and in patient counselling. This practice has decreased the numbers of surgical explorations. Surgeons feel difficulty in planning out the extent of resection of lesion whenever initial tissue diagnosis is not available. Still there are instances when we do not perform pre-operative biopsy or cytology due to the fear of capsular rupture, needle tract seedling or spread of malignancy. Sometimes fine needle aspiration cytology (FNAC) or needle biopsy is inconclusive and we have to take surgical (excision) biopsy, and then plan the definitive procedure after biopsy report, thus making it a 2 stage procedure. Many times during surgical exploration for a benign pathology if surgeons find suspicious lesions, per-operative cytological diagnosis becomes important to rule out malignancy, as this may change the intra-operative surgical plan further. Since a long time frozen section (FS) and imprint cytology (IC) are considered as two methods of per-operative cytological diagnosis. After popularity of frozen section in practice, pathologists have given up interest towards imprint cytology. The frozen section facility is available only at few centres in India as compared to large number of hospitals and patients. So there is always a need for an easy and cheap alternative to frozen section that can help surgeons at low volume centres as well. The aim of this study was to assess the reliability of imprint cytology in per-operative (immediate) diagnosis of malignancy.
Material and methods
The present study was a prospective analysis of 69 specimens from suspected or diagnosed cancer patients that were sent for per-operative (or urgent) imprint cytology from July 2012 to Feb. 2014, at surgical oncology unit of our institute. In all these situations it was important to confirm (or to rule out) malignancy, as this would make a major difference in treatment plan or extent of resection or in initiating a specific treatment. At our hospital we did not have facility for frozen section. Many times we felt difficulty in decision making where per-operative cytological diagnosis was needed. So we started doing imprint cytology as an alternative to frozen section based on previous literature, along with systematic recording of data. Slides were either made in operation theatre or fresh adequate tissue samples were taken and wrapped in saline soaked cotton gauss pieces and, sent to pathology laboratory for urgent imprint cytology. The imprint cytology slides were then prepared in pathology lab by standard technique, fixed and stained. The reporting was done by a senior pathologist who was expert in cytological diagnosis of malignancy. All the specimens were then subjected to paraffin section (PS) and final reports were compared.
Results
The results are shown in table 1. From various surgical explorations (or excision biopsies) suspicious 12 metastatic nodules, six breast lumps, two encapsulated ovarian masses and 14 lymph nodes (including celiac, pelvic or para-aortic lymph nodes) were examined and all found to be positive by IC and PS as well. In all such situations IC helped us a lot in per-operative decision making. The sensitivity and specificity of imprint cytology were 96.8 % and 83.3% respectively. The positive predictive value (PPV) of IC was 98.3 %. The average time taken in reporting was 23 minutes. The only false positive result of IC was a specimen of lower uterine fibroid protruding out of cervix with surface erosions. It was giving appearance of defined cervical cancerous mass clinically (including imaging), but showing only dysplasia in cervical biopsy. We did radical hysterectomy and send specimen for imprint cytology to rule out malignancy in cervical mass before pelvic lymph node dissection (PLND). The IC reported it as malignant and we did bilateral PLND. Later on in final PS report it was found to be a uterine fibroid with surface dysplasia, all nodes negative. Now let me discuss with you the two false negative cases. There was a confirmed case of carcinoma cervix, confined to cervix only in imaging, opened for radical hysterectomy. On exploration there was a significantly large, hard, round right pelvic lymph node (LN), which was sent for imprint cytology. The IC reported it as granulomatous disease and we proceeded to radical hysterectomy. The LN was finally found to harbour metastatic cancer. The second false negative report was from a per-operative biopsy of stomach suspicious of linitus plastica. Multiple endoscopic biopsies were negative for malignancy, but clinically patient was not improving and CT (computed tomography) scan was constantly showing a diffuse wall thickening. Surgery with per-operative cytology was planned. The tumour was inoperable on exploration, as it was infiltrating into porta and transverse mesocolon. A small full thickness stomach wall biopsy was taken and sent for IC, which was negative for malignancy. We took a large full thickness biopsy and based on clinical judgement closed the abdomen. Finally both showed carcinoma stomach. In a known case of laryngeal malignancy, ‘wide field laryngectomy’ surgery was planned. During surgery all four parathyroid glands were isolated and cut. One fourth part of each was sent for confirmation by IC. In the report three were normal parathyroids (auto-implanted) and one was found to be metastatic LN (discarded), which were confirmed by final PS. The sub typing of malignancy (although it was not a predecided criterion to report) was given in 22 IC reports, but it was changed finally in nine patients. This makes IC unreliable for diagnosis of specific subtype (PPV 59 % only).
Discussion
Imprint cytology (IC) and frozen section (FS) are renowned techniques of per-operative cytology and the diagnostic accuracy of both is comparable. Liu et al have investigated the utility of intraoperative touch preparation with comparison of frozen section in 122 cases. The rate of correct diagnosis for touch preparation was 88.5% as compared to 86.1% for frozen section. The rate of incorrect diagnosis for touch preparation was 4.1% as compared to 2.5% for frozen.[1] Scucchi et al compared 2,250 intraoperative cytology with frozen section with the final diagnosis achieved on paraffin sections. The diagnostic accuracy of each technique alone was 94.9%. For frozen section the sensitivity was 89.9% and specificity 97.9% as compared to the touch cytology, which had a sensitivity of 94.9%, and specificity of 96.8%.[2] Guarda et al carried out a comparative study of the two techniques and found the accuracy of cytology and frozen section 98.4% and 99.2% respectively.[3]
The greatest advantage of IC examination is of not having artifacts, resulting in superb nuclear and cytological details.[1] IC provides better and crisp cellular morphological details and even some tissue architecture.[4] Very small fragments of tissue provide sufficient cells for IC, but difficult to process and report on FS. The diagnosis of very small lesions is therefore facilitated and tissue is saved for permanent section.[5] Certain tissues that cannot be studied by frozen section i.e. bone, necrotic tissue and fat etc. give accurate results on touch preparations.[1] IC was found to be more valuable in the field of neuro-pathology, lymph node and most of the epithelial tumours.[3] Parathyroid glands are correctly identified by IC, slightly more sensitive than FS.[5] Used intraoperatively, the imprint method can provide valuable information when frozen-section interpretation is equivocal. IC is particularly valuable in the diagnosis of certain neoplastic lesions which can simulate inflammatory lesions on FS eg. Well differentiated Pancreatic cancer, metastatic signet ring cell carcinoma in LN (can be mistaken for reactive sinus histiocytosis on FS). Certain benign inflammatory lesions can simulate malignancy on FS e.g. Organizing pneumonia (anaplastic carcinoma), intense sinus histiocytosis (can simulate metastatic carcinoma) that can be diagnosed with IC.[5] Well-differentiated tumours and tumours with a dense fibrous stroma cannot be diagnosed by imprint cytology method.[5] On the other hand Frozen Sections provided more tissue architectural details. It is well recognized, however, that the freezing and sectioning techniques of frozen section results in unavoidable distortions and artifacts, rendering diagnosis difficult in many instances.[1] The diagnostic accuracy in distinguishing benign from malignant lesions by combined procedures was 100%. There were no false positive or false negative cases.[4] To increase diagnostic accuracy many people recommend the combined use of imprints and frozen sections.[5] For diagnosing specific subtypes of malignancy, the diagnostic accuracy of each method alone was 96.6% with a sensitivity of 86% and specificity of 100% and the combined sensitivity 90%. The benefit of frozen section is that the tissue architecture closely approximates permanent histology sections.[4] By virtue of our experience from this study, we would like to emphasize upon these few points:-
1. Imprint cytology is a reliable method to rule out malignancy in a short time. It may help surgeons to make changes in the previously made treatment plan. The confirmation of malignancy can help an oncologist to start therapy earlier without waiting for the results of final biopsy
. 2. This method can be used to find out adequacy of biopsy specimen. Many times we are not sure while taking core biopsies (may be sonography or CT guided) that correct specimen is retrieved or not. Immediate imprint cytology from biopsy specimen will tell us that the tissue contains viable tumour, necrosed tissue or normal tissue. If the biopsy is not representative of disease we can take more samples immediately, hence to save time, patients’ comfort and cost.
3. The imprint cytology can differentiate between a normal parathyroid gland and a lymph node with or without metastasis. This may help head and neck surgeons in per-operative confirmation of normal parathyroid glands before using them for auto-implantation. Now days, it is highly emphasised not to implant parathyroid glands without histological confirmation.
4. The imprint cytology is not a reliable investigation for sub-typing of cancer. It cannot differentiate between the grades of differentiation from well to poorly differentiated cancers. Its reliability on differentiating lung cancer into various subtypes like small cell, squamous cell or adenocarcinoma is not acceptable. Also it can’t differentiate among various grades of dysplasia and early invasive cancer. This limitation should always be kept in mind. 5. Frozen section needs a good cryostat and other specialized materials along with experienced pathologist and technician. The cost of the setup ranges from Rupees 4 lac to 20 lac. There are problems regarding maintaining low temperature in the range of minus 15 to 20 0 centigrade (sometimes even lower) with the cheaper cryostats along with issues regarding wastage of precious sample and poor quality of slides with cheaper devices. To make frozen section cost effective a centre should have at least 5 specimens for frozen section per day. This is the basic reason why frozen section is not available in majority of the hospitals even in big cities.
Conclusion
Imprint cytology is a cheap and reliable method for peroperative diagnosis of malignancy, and can be used in place of frozen section, where such facility is not available. It can be used for per-operative confirmation of parathyroid glands before auto-implantation. Acknowledgement Authors acknowledge the support of head of the departments of general surgery, pathology and anaesthesia. Authors also acknowledge the support of nursing staff and technical staff who were involved in the process of sampling, preparation, transportation, staining and other works. Authors also acknowledge all the patients who gave consent and supported for this 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 and journals from where the literature for this article has been reviewed and discussed.
Englishhttp://ijcrr.com/abstract.php?article_id=590http://ijcrr.com/article_html.php?did=5901. Ahmareen Khalid and Anwar Ul. Touch Impression Cytology Versus Frozen Section as Intraoperative Consultation Diagnosis. International Journal of Pathology; 2004; 2(2):63-70.
2. Liu Y, Silverman JF, Sturgis CD, Brown HG, Dabbs DJ, Raab SS.: Utility of intraoperative consultation touch preparations. Diagn Cytopathol 2002 May;26(5):329-33.
3. Scucchi LF, Stefano DD, Cosentino L and Vecchione A: Value of cytology as an adjunctive intra operative diagnostic method. An audit of 2250 consecutive cases. Actacytological, September –October 1997;Volume 41.No.5:p1489-96.
4. Guarda LA: Intraoperative cytologic diagnosis: Evaluation of 370 consecutive intraoperative cytologies.Diagn Cytopathol.1990;Volume 6 (no.5):p304-7.
5. KC Suen, WS Wood, A A Syed, NF Quenville, and PB Clement. Role of imprint cytology in intraoperative diagnosis: value and limitations. J Clin Pathol. 1978 April; 31(4): 328-337.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareISCHEMIC STROKE IN AN ATRIAL SEPTAL ANEURYSM INDIVIDUAL- A CASE REPORT
English3234Sahid Imam MallickEnglish Sauvik DasguptaEnglish Auriom KarEnglish Soumava MukherjeeEnglish Sneha Jatan BothraEnglish Mansi DasEnglish N. B. DebnathEnglishAn atrial septal aneurysm (ASA) is a well recognized but rare cardiac defect where there is localized saccular deformity of atrial septum that bulges in to either right or left atrium. It may be present isolated or in presence of other defects. ASA can be diagnosed by tranthoracic (TTE) or transesophageal (TEE) echocardiography. In most situations it is diagnosed incidentally and often consider as benign entity. However, atrial arrhythmias and arterial embolisms are the complications ASA may present with. Here we present a 40 years male patient presents with right middle cerebral artery ischemic stroke with left sided hemi paresis,
seizures and altered sensorium. All blood parameters and Doppler imaging showed normal study. Echocardiography revealed a moderate atrial septal aneurysm. Patient was treated with anti coagulation and discharged in stable condition.
EnglishAtrial septal aneurysm (ASA), Ischemic stroke, EchocardiographyINTRODUCTION
Atrial septal aneurysm (ASA) is a congenital malformation of the septum primum layer of the interatrial septum but differences between interatrial pressure forces have also been reported as a cause of its development.1 Atrial septal aneurysm may be isolated or associated to another anomaly and their commonest association is patent foramen ovale (PFO). Other associations are atrial septal defect, mitral valve prolapsed, tricuspid valve prolapse, marfans syndrome, sinus of valsalva aneurysm and aortic dissection. The widespread availability of TTE and TEEhas identified ASA with increasing frequency.2 Although these abnormalities are considered clinically benign entities, they have been independently associated with ischemic stroke.3 According to Hanley’s diagnostic criteria, atrial septum is considered to be aneurysmal, when a dilated segment protrudes at least 15 mm beyond the level surface of the atrial septum.1
CASE REPORT
A 40 years male patient with no previous significant medical history presented with sudden onset history of seizures and left-sided hemi paresis followed by altered sensorium. On admission patient’s physical examination revealed right facial palsy, grade III-IV mid systolic mummur better heard at apex, left upper and lower limb grade II power with extensor planter response on left side, pulse was 78/minutes, regular and blood pressure was 116/70 mmHg. All peripheral pulses were palpable. Patient was drowsy at the time of admission, but arousable. Per abdomen and respiratory system examination did not reveal any abnormality. Electrocardiogram showed normal sinus rhythm. Chest X-ray showed normal cardiac size and clear lung field. Laboratory findings including complete blood count, liver function test, kidney function test, lipid profile and coagulopathy screening were all normal. CT scan of brain showed acute ischemic infarction on right middle cerebral artery territory. Carotid Doppler study was normal and lower limbs Doppler study excluded presence of any deep venous thrombosis. Tranthoracic echocardiography (TTE) showed an atrial septal aneurysm. An echo contrast study with agitated saline was performed to exclude presence of any patent foramen ovale (PFO). A transesophageal echocardiography (TEE) was adviced, but patient’s bystanders denied further investigation after explaining details of examination procedure. Patient was put on anti epileptic drugs and subsequently anti coagulated with warfarin. Patient was improved and discharged 8 days after admission with minimal residual neurological deficit.
DISCUSSION ASA is a congenital malformation of the septum primum layer of the interatrial septum and it is an infrequent finding in adult patients. ASA formation may be secondary to raised interatrial pressure gradients, producing a bulging septal shift toward the low-pressure side1 , however, it has been also found in patients with normal atrial pressures, 4 suggesting a primary (congenital?) malformation. According to autopsy study by Silver and Dorsey,1 patient having a protrusion of the aneurysm >10 mm beyond the plane of the atrial septum into either the right or left atrium considered to be having atrial septal aneurysm. However, according to diagnostic criteria of ASA proposed by Hanley and coworkers2 considered the atrial septum to be aneurysmal when a dilated portion protruded at least 15 mm beyond the plane of the atrial septum or when the atrial septum showed phasic excursions during the cardio respiratory cycle ≥15 mm with the base of the aneurysm ≥15 mm. In the largest series of cases of ASA diagnosed by TEE, Pearson and coworkers5 considered a septum aneurysmal when it had an excursion >10 mm into either the left or right atrium or a sum of the total excursion into the left or right atrium >10 mm, with a base width ≥15 mm. In our patient aneurismal protrusion was about 16 mm. The frequency of ASA in adult population is quite low (2.2%) 1 . Many authors suggested that ASA either alone or with combination of other defects may cause ischemic stroke due arterial embolism which is based on clinical studies demonstrating a statistical association between ASA and previous ischemic cerebral and/or peripheral embolic events. It has been speculated that ASA is a direct source of thrombus formation6 . This is supported by anecdotal findings demonstrating thrombotic material within the aneurysmal sac in patients at autopsy1 or cardiac surgery7 .Several studies suggested a possible relationship between ASA and ischemic stroke1, 5. The mechanism of stroke in patients with ASA remains poorly understood8 . Cerebral embolism might result from paradoxical embolism of venous thrombi across a right to left shunt, passage of a thrombus created on the left atrial side of the aneurysm 9 . Schneider et al6 reported a thrombus in 2 of 23 consecutive patients with ASA; in 1, thrombotic material appeared to override a PFO, suggesting paradoxical embolism; in the second, a thrombus was attached to the left atrial side of the aneurysm. In this patient CT brain demonstrated infarction possibly reflected cryptogenic stroke in a atrial septal aneurysm as no other possible causes of ischemic stroke was found.
CONCLUSION
Though there are no definitive mechanism documented for ischemic stroke in ASA patients, but isolated ASA may be a possible risk factor for ischemic stroke. Large scale prospective studies are required to understand the mechanism between atrial septal aneurysm and ischemic stroke.
ACKNOWLEDGEMENTS
The authors are grateful to the participants who voluntarily took part in the study. Authors wish to acknowledge the support provided by the Department of General Medicine, Nil Ratan Sircar Medical College, Kolkata for encouraging research and its publication. 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=591http://ijcrr.com/article_html.php?did=5911. Silver MD, Dorsey JS. Aneurysms of the septum primum in adults. Arch Pathol Lab Med. 1978; 102:62–5.
2. Hanley PC, Tajik AJ, Hynes JK, Edwards WD, Reeder GS, Hagler DJ, et al. Diagnosis and classification of atrial septal aneurysm by two dimensional echocardiography: Report of 80 consecutive cases. J Am Coll Cardiol.1985; 6:1370–82.
3. Gallet B, Malergue MC, Adams C, Saudemont JP, Collot AM, Druon MC, et al. Atrial septal aneurysm a potential cause of systemic embolism. Br Heart J. 1985; 53:292–7.
4. Hauser AM, Timmis GC, Stewart JR, Ramos RG, Gangadharan V, Westveer DC, Gordon S. Aneurysm of the atrial septum as diagnosed by echocardiography: analysis of 11 patients. Am J Cardiol. 1984; 53:1401-1402.
5. Pearson AC, Nagelhout D, Castello R, Gomez CR, Labovitz AJ. Atrial septal aneurysm and stroke: a transesophageal echocardiographic study. J Am Coll Cardiol. 1991; 18:1223-1229.
6. Schneider B, Hanrath P, Vogel P, Meinertz T. Improved morphologic characterization of atrial septal aneurysm by transesophageal echocardiography: relation to cerebrovascular events. J Am Coll Cardiol.1990; 16:1000-1009.
7. Grosgogeat Y, Lhermitte F, Carpentier A, Facquet J, Alhomme P, Tran TX. Aneurysme de la cloison interauriculaire révélé par une embolie cérébrale. Arch Mal Coeur. 1973; 66:169-177.
8. Mugge A, Daniel WG, Angermann C, Spes C, Khandheria BK, Kronzon L, et al. Atrial septal aneurysm in adult patients.A multicenter study using transthoracic and tarnsoesophageal echocardiography. Circulation.1965; 91:2785–92.
9. El-Chami MF, Hanna IR, Helmy T, Block PC. Atrial septal abnormalities and cryptogenic stroke: A paradoxical science. Am Heart Hosp J. 2005; 3:99–104.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareFUNCTIONAL AND RADIOLOGICAL OUTCOME OF UNCEMENTED BIPOLAR ARTHROPLASTY
IN UNSTABLE INTERTROCHANTERIC FRACTURES OF THE ELDERLY
English3539Jalaluddeen Mahin VaidyarEnglish Sandeep ShibliEnglish U. Hashir SafwanEnglish Shabir KassimEnglishBackground: Bipolar hemiarthroplasty is an effective option for unstable intertrochanteric fractures in the elderly. This study evaluated the functional and radiological outcome following uncemented hemiarthroplasty in elderly unstable intertrochanteric fractures
Methods: 25 hips were followed for a period of 1 year after hemiarthroplasty with a blast coated revision stem (Orthovasive). The mean age was 77 and mean follow up 16 months. The modified Merle D’Aubigne score was assessed for function and radiological results were assesses using a range of indices.
Results: At the last follow up the mean Merle D’Aubigne score was 14.5. Twenty cases (80%) regained their preoperative walking ability postoperatively. Radiologically, there were 15 cases (60%) of bone in growth and 10 cases (40%) with stable fibrous fixation. Endosteal new bone formation was found in 10 (40%) patients. There were no cases with progressive subsidence or significant changes in alignment.
Conclusions: The functional and radiological outcome after 1 year followup in unstable intertrochanteric fractures in elderly patients with uncemented bipolar arthroplasty was satisfactory.
EnglishElderly, Unstable intertrochanteric fracture, Uncemented bipolar arthoplastyINTRODUCTION
Severely displaced and comminuted intertrochanteric fractures are common in elderly patients with osteoporosis. Traditionally, they have been treated by internal fixation which have often had complications of nonunion, implant failure and screw cutout.1,2 Bipolar arthroplasty being an alternative to internal fixation , allows for rapid rehabilitation of the elderly patient.3 Controversy regarding use of cement in arthroplasty is there. Cemented fixation has the advantage of giving immediate stability in aged patients.4 Cementless fixation has the distinct advantage of avoiding cardiovascular toxicity of cement which may be disastrous in the elderly.5 The present study aims to evaluate the functional and radiological outcome of uncemented bipolar hemiarthroplasty in patients over the age of 70 years with unstable intertrochanteric fractures.All patients were implanted with cylindrical corundum blasted proximal and isthmic fixing stems
METHODS
Uncemented bipolar arthroplasty using the corundum blasted revision stem (orthovasive, biorad medisys) and 22.2/28 mm femoral head with corresponding femoral cup ( INDUS) was performed on 25 patients with unstable intertrochanteric fractures in patients over the age of 70 who were walking with or without a walking aid at our institution between January 2010 and December 2014. All the above patients could be followed up for 1 year and were included in our study. All patients had AO type A2 or A3 fractures which are associated with high rates of internal fixation failure. The mean age of the patients was 77 (range, 70 to 90 years). There were 17 females (68% ) and 8 males (32%). The mean follow-up period was 16 months (range, 12 to 20 months). The mean time from fracture to surgery was 2 days. 18 patients (72%) had multiple morbidities. (Table 1)
Operative technique
Surgery was performed by the same team in all cases under spinal anaesthesia in all cases. An uncemented corundum blasted revision femoral stem (Orthovasive, Biorad medisys) was inserted through the posterolateral approach. A bipolar femoral cup(indus) and a corresponding 22.2 or 28 mm femoral head was used.Depending on whether the abductor mechanism was in continuity, trochanteric fragment was fixed by tension band wiring. Patient was made to sit up with legs dangling on the side and quadriceps muscle strengthening begun on day 1. All patients were started on partial weight bearing with quadrangular walker and full weight bearing within 4 days and 1 month respectively.
Functional outcome assessment
The modified Merle Dáubigne scores 6) at the last followup were classified into four categories; excellent, good, fair and poor.Preoperative and postoperative walking abilities were compared.
Radiological assessment
On the postoperative radiographs, proximal canal fit was deemed good if the stem filled the proximal canal more than 75% and distal fit was good if there was a gap less than 1 mm between the stem and inner cortex.7,8) The femoral stem stability was classified into fixation by bone ingrowth, stable fibrous fixation, and unstable prosthesis according to the criteria of Engh et al.9,10)The changes in the alignment and subsidence of the femoral components were measured from after surgery to the last follow-up; ≥ 3° of valgus or varus and ≥ 5 mm longitudinal change were considered significant.3 The radiolucent line, bone resorption, endosteal new bone formation and osteolysis were examined in the seven zones described by Gruen et al.11) A radiolucent line denoted the radiolucent area around the stem surrounded by radiodense lines, and was considered present if it occupied ≥ 50% of any zone.12)Loosening of the femoral stem was defined as the appearance of a radiolucent line progressive or > 1 mm in all zones, or the presence of continuous subsidence or migration of the femoral stem.
RESULTS
The mean Modified Merle D ‘aubigne score at the last follow up was 14.5. Six (24%)patients had an excellent score, 11(44%)patients had a good score, 6(24%) patients had a fair score and 2(8%)patients had a poor score. Of the 25 patients, 8 (32%) and 17 (68%)patients could walk with and without aid before surgery respectively. Of the 17 patients , 14 could still walk without support after surgery , but of these 3 needed a walking aid . Of the 8 patients who needed a walking aid before surgery, 6 patients used the same aid after surgery and 2 patients needed to use a quadrangular walker. None of the patients were unable to walk. Overall, 20 out of 25 patients regained their preoperative walking ability.(Table 2) All patients achieved either a proximal or isthmic fit or both. The proximal fit, the isthmic level press fit and both were seen in 7(28%), 11(44%) and 7 (28%) respectively. The stability of the femoral stem at the final follow up were classified according to the criteria of Engh et al. There was fixation by bone ingrowth in 15 patients(60%) and stable fibrous fixation in 10 patients(40%). There were no unstable prostheses. A radiolucent line was observed in 3 patients and mainly in Gruen zones 2 and 7; in zone 2 in 1 patient and in zone 7 in 2 patients. Endosteal new bone formation was observed in 10 patients, mainly in Gruen zones 4, 5 and 6 . Bone resorption was noted in 12 patients(48%) and mostly in Gruen zones 1 and 7. None of the cases showed a change in alignment of the implant more than 3 degrees, valgus or varus. The amount of femoral stem subsidence was 1 and 2 mm in 5 and 7 patients respectively. Deep infection occured as a postoperative complication in one patient which healed uneventfully by debridement and lavage . No heterotopic ossification was seen in any case. No intraoperative femoral fracture or death occured during surgery. There were no dislocations or embolic episodes . There was one death due to myocardial infarction at 8 months followup in a patient with previous cardiac illness.
DISCUSSION
Elderly patients with unstable intertrochanteric fractures have severe comminution and displacement. These fractures are less amenable to open reduction and fixation often leading to fixation failure or nonunion.2)The inability to mobilize early in the postoperative period often leads to postoperative complications and high mortality. Hemiarthroplasty is invariably the most effective primary treatment method for unstable intertrochanteric fractures with respect to early postoperative mobilization.3,4,13,14) In patients with poor bone quality , cemented implants have the distinct advantage of offering initial implant stability.13,15,16) The high death rate in arthroplasty patients undergoing cemented fixation 5) can be prevented by use of cementless implants.But implant migration due to lack of osteointegration, thigh pain and bone resorption as a result of increased stiffness can be a problem 17,18). But recent reports are encouraging in that , by promoting osteointegration of cementless implants , there has been no increase of implant failure rates , even in elderly patients with osteoporosis. 17)In our study, initial press fit fixation was achieved in all patients either at the proximal canal or isthmus, and fixation by osteointegration or fibrous fixation after a 1 year follow up was observed, even though minimal subsidence was observed in few patients. This indicates the high Osteointegration rates in the diaphysis of osteoporotic elderly patients with blast coated implants. There were no incidents of stem loosening,progression of subsidence or alignment changes. Bone resorption was mainly noted in gruen zones 1, 2 and 7, which did not produce any fracture or loosening.In elderly patients with multiple co morbidities , early ambulation within one week is essential for preventing complications . Early mobilisation is feasible only with initial press fit fixation. In a study comparing hemiarthroplasty and internal fixation, better results were seen in the hemirthroplasty group with respect to limping and use of walking aids in patients with limited walking ability before surgery. 14)The use of a cylindrical implant as in our study for isthmic or diaphyseal fixation is necessary in elderly patients with intertrochanteric fractures where proximal femorl fit is difficult to achieve. The orthovasive stem , owing to the cylindrical shape makes isthmic or diaphyseal fixation regardless of the Dorr type. 19). In our study , initial press fit at the isthmus was achieved in 60 % of patients in whom proximal fixation was not possible. The prevention of complications associated with bed rest such as Deep vein thrombosis and subsequent embolism , bed sores were achieved by the initial press fit fixation, the subsequent mobilisation and intensive quadriceps femoris muscle rehabilitation. The overall functional recovery was deemed satisfactory in view of all patients walking with or without aid at final followup excepting one patient who was bedridden with a cerebrovascular accident. Cemented fixation is associated with the highest mortality rate in arthroplasty patients 20) , which is a concern in elderly patients.In our study, uncemented fixation in unstable intertrochanteric fractures using a cylindrical implant resulted in satisfactory results due to avidance of cement related complications and early mobilisation due to achievement of initial on table press fit stability. CONCLUSION The short term results of uncemented bipolar hemiarthroplasty with a cylindrical stem in elderly patients with unstable intertrochanteric fractures yielded satisfactory results. Further studies with long term follow up should be done to determine long term functional outcome.
ACKNOWLEDGEMENTS
Authors acknowledge the immense help received from the scholars whose articles are cited and included in the 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.
SOURCE OF FUNDING
Self –funded. Funded at the faculty level using the faculties’ own source of funds.
CONFLICTS OF INTEREST
The authors declare that there are no conflicts of interest
ETHICAL CLEARANCE
Ethical clearance for this study has been obtained from the Highland Hospital Institutional and Ethics committee
Englishhttp://ijcrr.com/abstract.php?article_id=592http://ijcrr.com/article_html.php?did=5921. Haidukewych GJ, Israel TA, Berry DJ. Reverse obliquity fractures of the intertrochanteric region of the femur. J Bone Joint Surg Am. 2001;83(5):643–650.
2. Kang SY, Lee EW, Kang KS, et al. Mode of fixation failures of dynamic hip screw with TSP in the treatment of unstable proximal femur fracture: biomechanical analysis and a report of 3 cases. J Korean Orthop Assoc. 2006;41(1):176– 180.
3. Hwang DS, Kwak SK, Woo SM. Results of cementless hemiarthroplasty for elderly patients with unstable intertrochanteric fractures. J Korean Hip Soc. 2004;16(3):386–391.
4. Rothman RH, Cohn JC. Cemented versus cementless total hip arthroplasty: a critical review. Clin Orthop Relat Res. 1990;(254):153–169.
5. Christie J, Burnett R, Potts HR, Pell AC. Echocardiography of transatrial embolism during cemented and uncemented hemiarthroplasty of the hip. J Bone Joint Surg Br. 1994;76(3):409–412.
6. Merle d’aubinge R, Postel M. Functional results of hip arthroplasty with acrylic prosthesis. J Bone Joint Surg [Am] 1954;36-A:451–75.
7. Kang JS, Moon KH, Park SR, Sun SH. Long-term results of total hip arthroplasty with an AML hip prosthesis. J Korean Hip Soc. 2004;16(1):17–23.
8. Kim YH, Kim VE. Cementless porous-coated anatomic medullary locking total hip prostheses. J Arthroplasty. 1994;9(3):243–252. [PubMed]
9. Engh CA, Bobyn JD, Glassman AH. Porous-coated hip replacement: the factors governing bone ingrowth, stress shielding, and clinical results. J Bone Joint Surg Br. 1987;69(1):45–55. [PubMed]
10. Engh CA, Massin P, Suthers KE. Roentgenographic assessment of the biologic fixation of porous-surfaced femoral components. Clin Orthop Relat Res. 1990;(257):107–128. [PubMed]
11. Gruen TA, McNeice GM, Amstutz HC. “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res. 1979;(141):17–27. [PubMed]
12. Kim YM, Kim HJ, Ahn JH, Kim KH, Kang SB. Early postoperative periprosthetic radiological findings in cementless THRA: comparison between porous-coated implant and hydroxyapatite-coated implant. J Korean Orthop Assoc. 1997;32(4):1005–1014.
13. Stern MB, Angerman A. Comminuted intertrochanteric fractures treated with a Leinbach prosthesis. Clin Orthop Relat Res. 1987;(218):75–80. [PubMed]
14. Moon CY, Ji JH, Park SE, Kim YY, Lee SW, Kim WY. Comparison of the clinical outcomes between internal fixation and primary hemiarthroplasty for treating unstable intertrochanteric fracture in the elderly. J Korean Hip Soc. 2008;20(4):273–277.
15. Green S, Moore T, Proano F. Bipolar prosthetic replacement for the management of unstable intertrochanteric hip fractures in the elderly. Clin Orthop Relat Res. 1987;(224):169– 177.
16. Haentjens P, Casteleyn PP, De Boeck H, Handelberg F, Opdecam P. Treatment of unstable intertrochanteric and subtrochanteric fractures in elderly patients: primary bipolar arthroplasty compared with internal fixation. J Bone Joint Surg Am. 1989;71(8):1214–1225.
17. Andress HJ, Kahl S, Kranz C, Gierer P, Schurmann M, Lob G. Clinical and finite element analysis of a modular femoral prosthesis consisting of a head and stem component in the treatment of pertrochanteric fractures. J Orthop Trauma. 2000;14(8):546–553. [PubMed]
18. Maloney WJ. Femoral fixation in older patients: uncemented is reasonable in many patients. 74th Annual Meeting of the American Academy of Orthopaedic Surgeons; 2007 Feb 14-18; San diego, CA, USA.
19. Dorr LD, Faugere MC, Mackel AM, Gruen TA, Bognar B, Malluche HH. Structural and cellular assessment of bone quality of proximal femur. Bone. 1993;14(3):231–242.
20. Parvizi J, Holiday AD, Ereth MH, Lewallen DG. The Frank Stinchfield Award: sudden death during primary hip arthroplasty. Clin Orthop Relat Res. 1999;(369):39–48.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareFUNCTIONAL OUTCOME OF SHOULDER FOLLOWING MINI OPEN REPAIR FOR ROTATOR CUFF INJURIES
English4044Jalaluddeen Mahin VaidyarEnglish Shabir KassimEnglish Sandeep ShibliEnglish U. Hashir SafwanEnglishBackground: Rotator cuff injuries are a common cause of shoulder pain in the adult population. The present study aims to assess the outcome following rotator cuff repair by mini open approach
Materials and methods: This is a prospective study done on thirty patients with rotator cuff injuries. 13 full thickness and 17 partial thickness were followed up for 2 years following repair by mini open approach and functional scoring was done, preoperatively and postoperatively with the Constant and Murley scoring system.Statistical analysis of scores were done with ANOVA and pairwise comparisons between mean scores at different time intervals done with Bonferroni correction test.
Results: The mean preoperative score was 59.5 while the mean score at 2 year follow up was 91.8 which is highly significant. There was no significant difference between mean scores of the full thickness tear mini open repair versus the partial thickness tear miniopen repair.
Conclusion: Miniopen repair of rotator cuff injuries offers excellent functional outcome at 2 year followup.There is no difference in functional outcome between partial and full thickness tear treated by miniopen repair.
EnglishRotator cuff tear, Mini open approach, Functional outcomeINTRODUCTION
Shoulder pain is the third most common musculoskeletal symptom encountered in medical practice after back and neck pain. The point prevalence of shoulder pain has been estimated to be 7–25% and the incidence as 10 per 1,000 per year, peaking at 25 per 1,000 per year among individuals with ages 42–46 years.1,2 Rotator cuff disease encompasses a wide range of pathology from minimal bursal articular side irritation and tendonitis to severe degenerative rotator cuff arthropathy. Rotator cuff pathology affects adults of all ages and other shoulder afflictions must be ruled out by careful history and physical examination 3. Epidemiological studies strongly support a relationship between age and cuff tear prevalence. In a recent study the frequency of such tears increased 13% in youngest group ( aged 50-59yrs) to 20 % ( aged 60- 69yrs), 31% ( aged 70-79yrs) and 51% in oldest group ( 80-89yrs)4 Already in the beginning of the 20th century, the rotator cuff was recognized as an important contributor to normal shoulder function, and tears of the rotator cuff as a possible cause of shoulder pain and dysfunction Rotator cuff tears can lead to a variety of clinical manifestations, including debilitating shoulder dysfunction and impairment. The goal of rotator cuff repair is to eliminate pain and improve function with increased shoulder strength and range of motion. Optimal repair of the rotator cuff includes achievement of high fixation strength, minimal gap formation and maintenance of mechanical stability under cyclic loading, and proper healing of tendon to bone.5 Mini-open repairs were developed because they had the potential advantage of less deltoid morbidity, and they have demonstrated results that have been similar to those of open repairs. The use of the complete arthroscopic repair is technically demanding and requires a large volume practice in order for a surgeon to obtain proficiency. Because of the technical demands of this procedure, many orthopaedic surgeons still consider the mini-open repair to be the gold standard for rotator cuff repair.6 The standard treatment for full-thickness rotator cuff repair is with an open acromioplasty procedure. An alternative procedure for a full-thickness rotator cuff tear is with a combined procedure of arthroscopic subacromial decompression and mini-open repair, which has the potential advantages of a preserved deltoid origin, lower perioperative morbidity, shorter hospital stays and less soft tissue dissection. In addition to adequate activity level, chronicity of tear with rapidly advancing surgical techniques and modes of fixation, optimal rehabilitation following rotator cuff surgical repair has become increasingly important and challenging for the orthopedic surgeon and physical therapist. This study will address the role of miniopen repair in treatment of rotator cuff tear and assess the functional outcome in the form of range of motion using Constant and Murley Scale (Table 1 ) In constant and murley system following parameters were determined
? Pain
? Activities of daily living
? Range of motion
? Power
METHODS
Materials
This is a prospective study conducted on 30 patients at our institute who underwent miniopen rotator cuff repair between January 2010 and December 2012. 30 patients were included in the study who had clinical or radiological(MRI) evidence of rotator cuff tear and have underwent atleast 6 weeks of conservative management from onset of symptoms. Patients with associated fractures of the shoulder were excluded.The patients were evaluated clinically with a standard range of tests for individual rotator muscles. Shoulder function was recorded preoperatively using the constant and murley score. There were 20 males (66.7%) and 10 (33.3%) female patients in the study.The mean age was 53.6 (range 35- 70 years) (Table 2).There were 13 (43.2%) full thickness tears and 17 (56.6%) partial thickness tears. Of the tears, 8 (26.6%)were degenerative tears and 22 (73.2%) were traumatic tears. 24 (79.9%) patients presented with inability to lift the shoulder and only 6 (19.9%) patients presented with pain in the shoulder. Jobes empty can test was positive in all cases. External rotation stress test was positive in 25 cases and negative in 5 cases. The arm lift off test was positive in only 3 cases and negative in 27. The belly press test was positive in 11 and negative in 19. The speed test was negative in all cases. The mean preoperative constant and murley score was 59.50 ( range 45- 68). The mean score for a full thickness tear was 58.79 (range 48-65) and the mean score for a partial thickness tear was 60.13 (range 45 -68).
Surgical technique and Postoperative treatmen
t Under general anaesthesia, an initial arthroscopic subacromial decompression was done. Then a direct repair of the rotator cuff was done via an anterolateral portal extension approach (mini –open) with a deltoid split without detachment. By manouvering the arm, the entire extent of the tear can be seen. The edges of the tear are debrided, insertion site for suture anchors on greater tuberosity prepared , tear is mobilized, sutures placed through the edge of the tear and tied down to the anterolateral aspect of the greater tuberosity with suture anchors. For large tears , under some tension, special intratendinous sutures are placed through the cuff and these are repaired using the suture anchors placed in the superolateral greater tuberosity7 Following the procedure, the operated arm is placed at the side in a sling with a small pillow. The sling is worn continuously for 6 weeks, except during bathing and exercises. The standard postoperative rehabilitation program is summarized below (Table 2). However, if a subscapularis repair is performed, passive external rotation is limited to 90 degrees (i.e., straight ahead) for the first 6 weeks. In addition, terminal extension of the elbow is restricted if a biceps tenodesis was performed.
Follow up
Patients treated post operatively was immobilized for 6 weeks in shoulder immobilizer with 30 degree abduction and pendulum exercises started from first post operative day and patients continues in shoulder immobilizer for rest of the day for 6 weeks were followed up at 3weeks,6weeks,12weeks, 6months, 1 year and 2 year . Patient functional assessment was done based on pain relief, ability to carry on activities of daily living, strength and patient satisfaction post operatively . A proforma was designed which would be filled by the patient himself and shoulder scoring system was calculated accordingly. Ultrasound examinations of the operated shoulder were done and cuff integrity was checked. Strength and range of motion were documented by operating surgeon. Results were finally evaluated using Constant and Murley shoulder scoring system.
Statistical method
Data was analysed using ANOVA and further post hoc analysis was performed by Bonferroni correction test.
RESULTS
The mean constant and murley score at the final follow up was 91.8 ± 1.5 (excellent as per score). The mean score for full thickness tear at final followup after repair was 91.3 ± 1.3 and that for partial thickness tear was 92.1 ±1.5 . The constant and murley scores at different time intervals are tabulated (Table 4) Pairwise comparison was made between the mean constant and murley score of each followup interval using the Bonferroni correction test to determine significant change of score. ( Table 5) The maximum change ( Mean difference 32.3 ± 0.9) in the score was noted between preoperative mean score and the mean score at final followup which was highly significant(pα o.ooo) Comparison of constant murley score according to type of tear was done (Table 6) by t-test. The t-value at 2 year followup between mean scores for full thickness and partial thickness tears was 1.53 which was not significant (p 0.137).
DISCUSSION
Rotator cuff pathology affects adults of all ages and other shoulder afflictions must be ruled out by careful history and physical examination3 . Epidemiologica*l studies strongly support a relationship between age and cuff tear prevalence. In a recent study the frequency of such tears increased 13% in youngest group ( aged 50-59yrs) to 20 % ( aged 60-69yrs), 31% ( aged 70-79yrs) and 51% in oldest group ( 80-89yrs) 4 Rotator cuff tears can lead to a variety of clinical manifestations, including debilitating shoulder dysfunction and impairment. The goal of rotator cuff repair is to eliminate pain and improve function with increased shoulder strength and range of motion. Optimal repair of the rotator cuff includes achievement of high fixation strength, minimal gap formation and maintenance of mechanical stability under cyclic loading, and proper healing of tendon to bone.1 Mini-open repair has the potential advantage of less deltoid morbidity, and they have demonstrated results that have been similar to those of open repairs. Because of the technical demands of this procedure, many orthopaedic surgeons still consider the mini-open repair to be the gold standard for rotator cuff repair.6 The standard treatment for full-thickness rotator cuff repair is with an open acromioplasty procedure. An alternative procedure for a full-thickness rotator cuff tear is with a combined procedure of arthroscopic subacromial decompression and mini-open repair, which has the potential advantages of a preserved deltoid origin, lower perioperative morbidity, shorter hospital stays and less soft tissue dissection. The study was taken up to evaluate the functional outcome of patients treated with miniopen repair for rotator cuff tears. The functional outcome was assessed by using Constant and Murley scoring system. In 1990, Levy et al.8 reported a preliminary one-year follow-up study of twenty-five patients who had been treated with an arthroscopic subacromial decompression and then a lateral deltoid-splitting open repair. Twenty of the patients had a good or excellent result .In our study total number of 30 patients with a follow up of 2years, preop Constant Murley score had a mean of 59.80 and by the end of 2years it was 91.80 with a p value Englishhttp://ijcrr.com/abstract.php?article_id=593http://ijcrr.com/article_html.php?did=5931. Carl A Bretzke MD, et al, Ultrasonography of the Rotator Cuff Normal and Pathologic Anatomy, Invst Radiology. 1985; 20:311-315.
2. Campbell’s Operative Orthopaedics, 11th edition. Pg 2601- 2602.
3. Arthroscopic evaluation and management of rotator cuff tears Eric S. Millstein, MD, Stephen J Snyder ,MD orthop Clin N Am 34 (2003) 507-520.
4. Rotator cuff tear, http ://en.wikipedia.org/wiki/Rotator_ cuff_tear.
5. Neil S. Ghodadra et al Of Orthopaedic and Sports Physical Therapy | Volume 39 | Number 2 | February 2009 | 81.
6. Shane J. Nho, Michael K. Shindle et al ,J Bone Joint Surg Am. 2007;89:127-136.
7. Yamagughi, K: Mini-open rotator cuff repair. JBJS, 83-A, 764-772, May, 2001. 8. Levy HJ, Uribe JW. Delaney LG. arthroscopic assisted rotator cuff repair : preliminary results. arthroscopy 1990;6:55- 60.
9. Baysal D, Balyk R, Otto D, Luciak-Corea C, Beaupre L (2005) functional outcome and health-related quality of life after surgical repair of full thickness rotator cuff tear using a mini-open technique.Am J sports Med 33:1346- 1355.
10. Chun JM, Kim SY, Kim JH (2008), arthroscopically assisted mini-deltopectoral rotator cuff repair. orthopedics 31:74.
11. Duralde XA, Greene RT(2008) Mini-open rotator cuff repair via an anterosuperior approach. J Shoulder Elbow Surg 17:715-721.
12. Hanusch BC, Goodchild L, Finn P, Rangan A (2009) Large and massive tears of the rotator cuff: Functional outcome and integrity of the repair after mini-open procedure. J bone Joint Surg Br 91:201-205.
13. J Bone Joint Surg Br February 2009 vol. 91-B no. 2 201- 205.
14. DeLorme D: Die Hemmungsba?nder des Schultergelenks und ihre Bedeutung fu?r die Schulterluxationen. Arch Klin Chirurg 1910; 92:79-101.
15. Mary.S Hollister, Laurence. A. Mack, Association of Sonographically Detected Subacromial / Subdeltoid Bursal Effusion and Intraarticular Fluid with Rotator Cuff Tear, American Journal Of Radiology 1995; 165:605-606.
16. Mathieu J C M Rutten MD, Gerrit J. Jager et al, US of the rotator cuff: pitfalls, limitations and artifacts, Radiographics , RSNA . 2006; 26: 589-604.
17. Constant CR, Murley AH : A clinical method of functional assessment of the shoulder . Clin Orthop Relat Res, 1987 Jan;(214) 160-4.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-524177EnglishN-0001November30HealthcareIMAGING IN TRAUMATIC DIAPHRAGMATIC RUPTURE - A DIAGNOSTIC DILEMMA
English4547Skandesh B. M.English Arjun PrakashEnglish Shama ShettyEnglish Vinay Kumar D. P.EnglishCase report: We report a rare case of traumatic diaphragmatic rupture with chest radiology and Computed tomography(CT) findings in whom emergency laparotomy was performed resulting in successful repair of diaphragmatic injury.
Discussion: Traumatic diaphragmatic rupture occurs in patients who sustain blunt and penetrating thoracoabdominal injuries. The most common herniated viscera are the stomach and colon on the left side and the liver on the right side. Specific signs in X-ray and Compute tomography (CT) will help in early diagnosis.
Conclusion: Traumatic diaphragmatic rupture remains a diagnostic challenge for both radiologists and surgeons. Early diagnosis
and repair of diaphragmatic tears is desirable. Clinical examination coupled with meticulous radiological examinations like
X-ray and Computed tomography(CT) will help in early diagnosis.
EnglishTrauma, Diaphragm, Rupture, Blunt injuryINTRODUCTION
Blunt diaphragmatic ruptures are difficult to diagnose at initial presentation because of non-specific clinical features. However, these injuries do not resolve spontaneously; therefore, it warrants timely management. If the diagnosis is missed, patients may develop intrathoracic visceral herniation and strangulation, with a morbidity and mortality rate of up to 50%.1 Although chest radiographs are recommended for all patients after major trauma, chest radiography is insensitive in depicting diaphragmatic rupture, with sensitivity of 46% for left-sided ruptures and 17% for right-sided ruptures.2 CT is the imaging modality of choice in the evaluation of severe blunt abdominal trauma. CT has a sensitivity of 61-71% and a specificity of 87-100% as an aid in the diagnosis of acute traumatic diaphragmatic rupture.3
CASE REPORT
A 40-year-old man was brought to the emergency department after sustaining blunt thoracoabdominal trauma after a motor vehicle injury. The patient complained of acute shortness of breath. On examination, there was mild tachypnea and tachycardia. General examination of the patient was unremarkable and respiratory examination of the patient revealed reduced air entry with decreased chest expansion in the left hemithorax and auscultation of bowel sounds in the left lower chest. Preliminary routine investigations were normal and the patient’s chest x-ray (postero-anterior view in erect position) revealed tracheal and mediastinal shift to the right and fundal gas shadow in left hemithorax. Left hemidiphragm could not be well outlined. Definite defect of diaphragm could not be appreciated well on x-ray. The x-ray showed no evidence of rib fractures or pneumothorax. Plain CT scan of thorax was advised to the patient which revealed focal defect of left diaphragm measuring 6.1x5.4cm (Anteroposterior x Transverse) with herniation of stomach and proximal half of body of the stomach into the left hemithorax with waist-like constriction of the herniating stomach at the site of the diaphragmatic tear (collar sign) causing mass effect in the form of tracheal and mediastinal shift to the right side associated with minimal pneumothorax. The herniated stomach was lying in a dependent position against the posterior ribs (Dependent viscera sign) as the patient was scanned in supine position. Patchy ground glass opacities were noted involving the apicoposterior segment of left upper lobe suggesting contusion. The patient underwent emergency laparotomy for repair of his injury. Successful repair of the diaphragmatic injury was achieved.
DISCUSSION
Traumatic diaphragmatic rupture can be due to blunt, penetrating injuries or iatrogenic causes. It occurs in up to 6% of patients after major blunt trauma.4 The most common cause is motor vehicle collisions. Most cases occur in young men after motor vehicle accidents.5 The most common herniated viscera are the stomach and colon on the left side and the liver on the right side. Injuries to the left hemidiaphragm occur three times more frequently than injuries to the right side following blunt trauma, possibly due to a buffering effect of the liver on the right hemidiaphragm. Most ruptures are longer than 10 cm and occur at the posterolateral aspect of the hemidiaphragm between the lumbar and intercostal attachments, spreading radially.6 Specific diagnostic findings of diaphragmatic tears on chest radiographs include intrathoracic herniation of a hollow viscus with or without focal constriction of the viscus at the site of the tear (collar sign) and visualization of a nasogastric tube above the hemidiaphragm on the left side. Other findings include elevation of the hemidiaphragm, distortion or obliteration of the outline of the hemidiaphragm, and contralateral shift of the mediastinum. CT findings suggestive of hemidiaphragmatic tears are direct discontinuity of the hemidiaphragm which is the most sensitive sign of rupture (sensitivity of 73% and a specificity of 90%), 7 intrathoracic herniation of abdominal contents( has a sensitivity of 55% and a specificity of 100%). Another frequently diagnosed sign is the collar sign, a waist like constriction of the herniating hollow viscus at the site of the diaphragmatic tear (sensitivity of 36% ). The dependent viscera sign is an additional sign.8 When a patient with a ruptured diaphragm lies supine at CT examination, the herniated viscera (bowel or solid organs) are no longer supported posteriorly by the injured diaphragm and fall to a dependent position against the posterior ribs and consequently, the dependent viscera sign is present if the upper one-third of the liver abuts the posterior ribs on the right side or if the stomach, spleen, or bowel abuts the posterior ribs on the left side. Indirect signs are hemothorax and hemoperitoneum. Complications include gastrointestinal strangulation and gastric volvulus.
DIFFERENTIAL DIAGNOSIS
• Congenital hernias (Bochdalek and Morgagni),
• Diaphragmatic eventration
• Motion artifacts due to respiratory movement decrease the quality of multiplanar reformation images and can mimic a diaphragmatic rupture, especially on the right side with pseudoherniation of the liver
CONCLUSION
Diaphragmatic injuries are rarely encountered in clinical practice and can be fatal if early diagnosis and treatment is delayed. Imaging studies are pivotal in making an accurate and timely diagnosis. A comprehensive knowledge of imaging features coupled with keen observation is required for rapid diagnosis and management.
ACKNOWLEDGEMENTS
Authors acknowledge Superintendent, Dr Manohar and Principal Dr Shivaramu for granting us permission to publish the case report. 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=594http://ijcrr.com/article_html.php?did=5941. Drews JA, Mercer EC, Benfield JR. Acute diaphragmatic injuries. Ann Thorac Surg 1973; 16:67-78.
2. Gelman R, Mirvis SE, Gens D. Diaphragmatic rupture due to blunt trauma: sensitivity of plain chest radiographs. AJR 1991; 156:51-57.
3. Killeen KL, Mirvis SE, Shanmuganathan K. Helical CT of diaphragmatic rupture caused by blunt trauma. AJR 1993; 173:1611-1616.
4. Ward RE, Flynn TC, Clark WP. Diaphragmatic disruption secondary to blunt abdominal trauma. J Trauma 1981; 21:35-38.
5. Weincek RG Jr, Wilson RF, Steiger Z. Acute injuries of the diaphragm. J Thorac Cardiovasc Surg 1986; 92:989-993.
6. Kuhlman JE, Pozniak MA, Collins J, Knisely BL. Radiographic and CT findings of blunt chest trauma: aortic injuries and looking beyond them. RadioGraphics 1998; 18:1085-1106.
7. Murray JG, Caoili E, Gruden JF, et al. Acute rupture of the diaphragm due to blunt trauma: diagnostic sensitivity and specificity of CT. AJR Am J Roentgenol 1996; 166:1035- 1039.
8. Bergin D, Ennis R, Keogh C, et al. The “dependent viscera” sign in CT diagnosis of blunt traumatic diaphragmatic rupture. AJR Am J Roentgenol 2001; 177:1137-1140.