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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareUNILATERAL QUADRIFURCATION OF RENAL ARTERY: A RARE VARIATION AND ITS CLINICAL IMPLICATIONS
English0109Bharambe V. K.English Shinde A. A.EnglishIntroduction: Renal transplantation has become the treatment of choice for most patients with end-stage renal disease. This involves recovering the kidney along with adequate vessel length from the donor and implanting it into the recipient anastomosing all vessels diligently. Usually “single renal artery kidneys” are preferred. However with the ever increasing waiting list of patients needing kidney transplants, kidneys with multiple arteries supplying it, are also used for transplant purposes. Case study: During routine dissection of an adult male cadaver by medical students, the aorta and right renal artery showed variations. Result: The right renal artery was observed to be quadrifurcating into inferior phrenic, inferior suprarenal and two duplicate renal arteries. There was no middle suprarenal artery and the branches of renal artery or their branches were the sole arterial supply to the suprarenal gland. No variations were observed in the branching pattern of the left renal artery. Discussion: Precise knowledge of renal arterial supply and associated variations is critical for success of renal surgeries as well as to avoid complications. Present article discusses the details of the rare hitherto unreported variation of “quadrifurcation of renal artery”, its possible embryological explanation and its clinical implications from point of view of renal surgeries.
EnglishRenal Artery, inferior phrenic artery, inferior suprarenal artery, quadrifurcation of renal artery, duplication of renal arteryINTRODUCTION
With advent of science, kidney transplantation is almost considered a common surgery today. It involves removal of kidney from the donor and implanting it into the recipient anastomosing every vessel with the recipient’s vessels. The knowledge of vessels supplying the kidney, its surrounding structures and possible variations in these vessels therefore is of paramount importance for the operating surgeon. Many researchers have reported various variations in origin, number and branching pattern of the renal arteries (1,2). There have also been reports of variations in origins and branching patterns of both suprarenal and inferior phrenic arteries.(3,4) However there are no reports of variations of all the above mentioned arteries being observed in the same individual as in the present case where we report finding of “quadrifurcation” of right renal artery into inferior phrenic artery , inferior suprarenal artery and 2 duplicate renal arteries.
CASE STUDY
During routine dissection of a 40 year old male cadaver preserved in 10% formalin, by medical students, it was found to be showing a variation in the branching pattern of aorta and of the right renal artery. The right renal artery was observed to be taking origin from aorta slightly below the origin of superior mesenteric artery. (Fig 1,2a,2b) This was referred to as the main right renal artery. The trunk of the main right renal artery was resting posteriorly on the right crus of diaphragm, covered anteriorly by Inferior vena cava. It was about 6 mm long and quadrifurcated into four branches namely inferior phrenic artery, inferior suprarenal artery and two duplicate renal arteries of the right side. On further dissection the inferior phrenic artery was seen giving rise to a small superior suprarenal artery which along with the inferior suprarenal artery, supplied the right suprarenal gland. The right middle suprarenal artery was absent. The two duplicate renal arteries gave rise to multiple branches that supplied the kidney. The duplicate renal arteries were situated such that one was anteriorly placed and the other posterior to it. The left renal artery took origin from aorta at a slightly lower level compared to right renal artery and immediately gave rise to a branch which supplied the region of upper pole of left kidney as well as the left suprarenal gland. The rest of left renal artery divided into branches at the hilum of left kidney to supply it. It also gave origin to the left inferior suprarenal artery. The left inferior phrenic artery and middle suprarenal artery were observed to be direct branches of aorta.
DISCUSSION
The abdominal aorta gives rise to inferior phrenic arteries at the level of T12.(Fig 2a,b) These are a pair of parietal branches that supply the diaphragm. It also gives rise to middle suprarenal arteries and renal arteries at a lower level, which are pairs of visceral arteries supplying suprarenal glands and kidneys respectively. The inferior phrenic arteries and renal arteries give origin to superior and inferior suprarenal arteries respectively, which supply the suprarenal gland along with the middle suprarenal artery(5). Renal arteries are two large vessels, branching laterally from the aorta, just below superior mesenteric artery. These are end arteries with no anastomoses. The right renal artery is longer than left, passes behind the inferior vena cava and right renal vein. Near the hilum each renal artery divides into three to four branches which lie mostly between the renal vein anteriorly and the ureter posteriorly but some branches may lie posterior to the hilum of kidney. One or two accessory renal arteries are frequently seen especially on the left side(6). There have been many reports of accessory renal arteries. Rao and Rachana in 2011 have described a unilateral right sided accessory renal artery that arose separately from the aorta to supply the upper pole of right kidney(7). Shinde et al reported finding of an unilateral accessory inferior hilar artery in a case of tortuous abdominal aorta(8). Shinde and Bharambe give a 4% incidence of lower polar supernumerary renal artery(9). Kanaskar et al have described two accessory renal arteries on the right side, one of which arose from aorta while the other was a branch of renal artery (2). Mehta and Arole have described finding of 11 cases of accessory renal arteries out of 50 kidneys studied (10). However finding of duplicate renal arteries is rare. Patel et al described a case of unilateral left sided double renal artery, one of which arose from aorta at L1 level while the other arose 5 cm below it(11). Budhiraja et al have reported 8.33% incidence of finding of duplication of renal arteries with a higher incidence on the right side compared to left (1). These duplicate renal arteries were situated anteriorly and posteriorly emerging at the same level from aorta. The present article reports duplicate renal arteries with a similar disposition (Fig 2b). Such duplicate hilar arteries have also been referred to as double hilar arteries. Triple hilar arteries have also been described, but were not observed in present case (12). Bergman reported that the middle suprarenal artery can be found to be replaced by the superior suprarenal artery (3). More often it can be replaced by the inferior suprarenal artery. In present case the superior suprarenal artery was found to be a branch of inferior phrenic artery which was a branch of renal artery, the middle suprarenal artery was absent and the inferior suprarenal artery arose from the renal artery (fig 2b). Thus the middle suprarenal artery was replaced by the inferior suprarenal artery. Topaz et al have described finding of a common trunk of inferior phrenic arteries taking origin from right renal artery and then diving into the right and left inferior phrenic arteries (4). In the present study it was observed that while the right inferior phrenic artery arose from the right renal artery, the left inferior phrenic artery was a direct branch of abdominal aorta (Fig 2b). Both the inferior phrenic arteries in turn gave origin to the superior suprarenal artery which supplied the right and left suprarenal glands respectively. Associated with variations in renal arteries, there are also reports of variations in origin of testicular arteries. Panagouli et al have described a case where there was bilateral origin of testicular arteries from accessory renal arteries (13). In present case however the testicular arteries were both taking origin directly from abdominal aorta (Fig 2b). Thus parts of various observations found in the present study have been reported earlier, however finding many of the variations together in one cadaver, in the form of quadrifurcation of the main right renal artery branching into inferior suprarenal artery, inferior phrenic artery and two duplicate renal arteries is hitherto unreported. Embryological explanation for the present variation has been discussed by Keibel (14). He stated that the developing mesonephros, metanephros, suprarenal gland and the gonads are all supplied by nine pairs of lateral mesonephric arteries arising from aorta. He divided these arteries into three groups as cranial, middle and caudal arteries. The middle group gives rise to renal arteries and if one extra artery persists partly, it results in formation of duplication of renal artery. A possible fusion of point of origin of cranial and middle lateral mesonephric arteries of right side could explain the quadrifurcation seen in present case report. The anatomical knowledge of existence of multiple arteries or arterial variations is essential before performing any transplantation surgeries where microvascular techniques are employed to reconstruct the renal arteries (15). Transplanting a kidney with renal arterial variation has the disadvantage of higher chances of acute tubular necrosis and graft rejection, as well as decreased graft function and hence transplantation of kidney with single renal artery is preferred (16). But because of increasing demand for kidney transplantation, transplanting kidneys with multiple arteries has become necessary. Also recent advances in technology of microvascular surgery have enabled dependable reconstruction of multiple renal vessels in donor kidneys (15). In these circumstances in order to know the vascular pattern and to plan the surgery, computer tomography and renal angiography should be performed prior to every urological procedure (16). The knowledge of renal vascular pattern is also important in treatment for renal trauma, renal artery embolization, vascular reconstruction surgeries in treatment of congenital lesions and in surgery for abdominal aortic aneurysm. In the present case since the main right renal artery is also giving origin to inferior phrenic artery (which in turn gave origin to superior suprarenal artery) and inferior suprarenal artery with the absence of middle suprarenal artery, special care must be taken during renal surgeries as ligation of this renal artery will cut off blood supply not only to right kidney but also to the right suprarenal gland and part of right diaphragm. Hence such arterial variations must be detected by arteriography prior to surgery. In conclusion the authors believe that today renal transplants, interventional radiological procedures and urologic operations are done routinely. Awareness of the possible variations in the branching pattern of abdominal aorta in relation to arterial supply to the kidney is necessary for correct surgical management in such maneuvers.
CONCLUSION
The present article reports quadrifurcation of the main right renal artery into inferior phrenic artery, inferior suprarenal artery and 2 duplicate renal arteries. Though individual variations of each of these arteries have been reported, occurrence of variation in all these arteries in one single individual is a rare hitherto unreported observation. Transplanting a kidney with renal arterial variation involves higher morbidity but because of increasing demand for kidney transplantation, transplanting kidneys with multiple arteries by microvascular surgery has become necessary. In these circumstances in order to know the vascular pattern and to plan the surgery, it is essential to investigate patients by computerized tomography and arteriography prior to surgery.
ACKNOWLEDGEMENT
The Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to the 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: As this study was carried out in the dissection hall of our Department, there was no separate financial aid provided for it. Conflict of interest: There is no conflict of interest Contribution details: • Concept, Design, Definition of intellectual content: Dr V K Bharambe, Dr Amol Shinde • Literature search: Dr V K Bharambe, Dr Amol Shinde • Clinical studies, Data acquisition, Data analysis: Dr VK Bharambe, Dr Amol Shinde • Manuscript preparation, Manuscript editing, Manuscript review: Dr VK Bharambe, Dr Amol Shinde
Englishhttp://ijcrr.com/abstract.php?article_id=690http://ijcrr.com/article_html.php?did=6901. Budhiraja Virendra, Rastogi Rakhi,Asthana Ak. Renal artery variations: embryological basis and surgical correlation.Rromanian Journal of Morphology and Embryology 2010; 51(3):533–536.
2. Kanaskar N, Paranjape V, Kulkarni J, Shevade S. Double Accessory Right Renal Arteries. IOSR Journal of Dental and Medical Sciences 2012;1(5):17-20.
3. Bergman RA, Cassell MD, Sahinoglu K, Heidger PM. Human doubled renal and testicular arteries. Ann Anat 1992;174(4):313-315.
4. Topaz O, Topaz A, Polkampally PR, Damiano T, King CA. Origin of a common trunk for the inferior phrenic arteries from the right renal artery: a new anatomic vascular variant with Clinical implications. Cardiovascular Revascularization Medicine 2010;57–62.
5. Moore KL, Dallay AF,Agur AM(Eds). Clinically oriented Anatomy, Wolters Cluwer, Lippincott Williams and Wilkins Publishers, New Delhi,2006;294-301.
6. Standring Susan, Ellis H, Healey JC (Eds), Gray’s anatomy: the anatomical basis of clinical practice, Elsevier–Churchill Livingstone Publishers, London, 2005 1274–1275.
7. Rao RT, Rachana. Aberrant renal arteries and its clinical significance:a case report.IJAV 2011;4:37-39.
8. Shinde A, Rao MP, Mishra PP, Paranjape V. Tortuous abdominal aorta with right testicular vein terminating into right renal vein. A report from cadaveric dissection. Med J D Y Patil Univ 2013;6:334-37.
9. Shinde A, Bharambe V. A Cadaveric study of lower polar supernumerary renal arteries-Embryological and clinical consideration. IOSR Journal of Dental and Medical Sciences 2014;13(7):06-09.
10. Mehta G, Arole V. Accessory renal arteries: A cadaveric study. International Journal of Biomedical and advanced Research 2014;05(04).
11. Patel S, Wanjari A, Naik A, Deshpande J. A case Report:double renal arteries. IJAV 2012;5:22-24.
12. Budhiraja V, Rastogi R, Bankwar V, Sathpati DK. Hilar renal arteries: A morphological study from central India with clinical correlation. Eur J Anat 2012;16(3):167-171.
13. Panagouli E, Lolis E, Venieratos D. Bilateral origin of the testicular arteries from the lower polar accessory renal arteries. Int J. Morphol 2012;30(4):1316-1320.
14. Felix W. Mesonephric arteries (aa. mesonephricae). In: Kiebel F, Mall FP eds. Manual of human embryology Vol 2. Philadelphia, Lippincott. 1912; 820–825.
15. Brannen GE, Bush WH, Correa RJ Jr, Gibbons RP, Cumes DM. Microvascular management of multiple renal arteries in transplantation. J Urol. 1982 Jul;128(1):112-5.
16. Kadotani Y, Okamoto M, Akioka K, Ushigome H, Ogino S, Nobori S, Higuchi A, Wakabayashi Y, Kaihara S, Yoshimura N. Management and outcome of living kidney grafts with multiple arteries. Surg Today 2005; 35: 459–466.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareEVALUATION OF CLINICALLY SIGNIFICANT HYPOCALCEMIA AFTER TOTAL THYROIDECTOMY: A PROSPECTIVE STUDY
English1013Ashim SarkarEnglish Subhasis JanaEnglish Bijan BasakEnglish Ganesh Chandra GayenEnglish Santanu SitEnglish Apurba SarkarEnglishPurpose: Many factors are responsible for the occurrence of hypocalcemia after total thyroidectomy (TT). This study was conducted to look at the factors usually concerned in post TT clinically significant hypocalcemia (CSH). A scoring system is being developed in combination with these factors for early diagnosis of CSH. Study Design: Institution based Prospective study. Materials and Methods: Total 50 patients with benign goiter and early carcinoma thyroid were included in this study and all were go through total thyroidectomy. Age of the patients, pre-operative thyroid hormone status, serum Ca2+ level and 25 (OH) vitamin D were studied. Post-operative iPTH level at 8 hours and calcium level at 12 hours were measured. Condition of parathyroid gland and size of the nodule were studied and preserved during operation. CSH prediction score (0 to 8) was designed based on these 8 factors. Statistical Analysis: SPSS 16 software was used. Independent samples T-test and Chi-square test was used for comparison between two groups. P value 3) can be taken account to predict it to discharge patients within one day after surgery.
EnglishTotal thyroidectomy, 25 OH vitamin D3, Clinically significant hypocalcemia, intact PTH.INTRODUCTION
Temporary symptomatic hypocalcemia occurs in some patients after total thyroidectomy (TT). This is a limiting factor in an early discharge of the patients from hospital1 . The incidence has been reported to vary from 0.5% to 75%2 . Early treatment can be started in these patients who were likely to develop clinically significant hypocalcemia (CSH), and the others, in those the incidence of hypocalcemia is unlikely and can be discharged as a day care surgery. Post-operative serum calcium, post-operative intact PTH (iPTH), serum 25 OH vitamin D levels, pre-operative serum calcium, presence of hyperthyroidism, advanced age of the patient, parathyroid preservation, and size of goiter at surgery have all been implicated in the development of post TT hypocalcemia 2-17. It has been realized from various studies published in literature that no single factor can predict its occurrence 2-17. The study was carried out to consider all these factors and to create a multi-factorial scoring system. We hope that this will facilitate us to predict incidence of post TT clinically significant hypocalcemia and enable us to discharge the patients within one day after surgery
MATERIALS AND METHODS
This prospective study was conducted at Burdwan Medcal College and Hospital a rural based medical college and hospital from February 2013 to January 2014. All patients undergo total thyroidectomy for benign thyroid swelling and stage one carcinoma thyroid (< T2/N0/ M0). All surgeries were performed by a surgeon, who is well trained in thyroid surgery. Patients who developed clinically significant hypocalcemia (CSH) within 12 hours of surgery were excluded from the final analysis. Demographics of the study population, status of hyperthyroidism, pre-operative levels of free serum Ca+2 and 25 (OH) vitamin D, post-operative serum parathyroid hormone (iPTH) at 6 hours and serum calcium at 10 hours, nodules size and parathyroid preservation status during operation were recorded. Hypocalcemia prediction score (0 to 8) was designed based on these factors [Table 1]. Post-operative Hypocalcemia was defined as serum calcium < 7.5 mg% occurring anytime after total thyroidectomy. Patients who have low serum calcium (< 7.5 mg %) and develope carpopedal spasm [induced within 2 minutes on eliciting the Trousseau sign (Figure 1)] after total thyroidectomy, said to have clinically significant hypocalcemia (CSH). A minimum of 0 points and maximum of 8 points were chosen to each case. Statistical Analysis: SPSS 16 software was used. Independent samples T-test and Chi-square test was used for comparison between two groups. P value 60 years are susceptible to hypocalcemia. We also found that the age was insignificant parameter in predicting clinically significant hypocalcemia . Preservation of parathyroid gland is inversely proportional for the development of post total thyroidectomy (TT) hypocalcemia. Some authors have suggested that at least 3 parathyroids are to be saved while others opined that 2 functional glands are enough to prevent post TT hypocalcemia17. In our study, in patients with 2 or Englishhttp://ijcrr.com/abstract.php?article_id=691http://ijcrr.com/article_html.php?did=6911. Pradeep PV, Ramalingam K, Jayashree B. Post total thyroidectomy hypocalcemia: A novel multif-factorial scoring system to enable its prediction to facilitate an early discharge. J Postgrad Med 2013;59:4-8.
2. Pfleiderer AG, Ahamd N, Draper MR, Vrotsou K, Smith WK. The timing of calcium measurements in helping to predict temporary and permanent hypocalcemia in patients having completion and total thyroidectomies. Ann R Coll Surg Engl 2009;91:140-6.
3. Noordzij JP, Lee SL, Bernet VJ, Payne RJ, Cohen SM, McLeod IK, et al. Early prediction of Hypocalcemia after Thyroidectomy using Parathyroid hormone: An analysis of pooled individual data from nine observational studies. J Am Coll Surg 2007;205:748-54.
4. Husein M, Hier MP, Al Abdulhadi K, Black M. Predicting calcium status post thyroidectomy with early calcium levels. Otolaryngol Head Neck Surg 2002;127:289-93.
5. Lo CY, Luk JM, Tam SC. Applicability of intra operative parathyroid hormone assay during thyroidectomy. Ann Surg 2002;236:564-9.
6. Payne RJ, Hier MP, Tamilia M. Post operative parathyroid hormone level as a predictor of post thyroidectomy hypocalcemia. J Otolaryngol 2003;32:362-7.
7. Soon PS, Magarey CJ, Campbell P, Jalaludin B. Serum intact PTH as a predictor of hypocalcemia after total thyroidectomy. ANZ J Surg 2005;132:584-6.
8. Lombardi CP, Raffaelli M, Prince P. Early prediction of post thyroidectomy hypocalcemia by a single iPTH measurement. Surgery 2004;136:1236-40.
9. Babu US, Calvo MS. Modern India and Vit D dilemma: Evidence for the need of a national food fortification program. Mol Nutr Food Res 2010;54:1134-47.
10. Khadgawat R, Brar KS, Gahlo M, Yadav CS, Malhotra R, Guptat N, et al. High prevalence of Vitamin D deficiency in Asian Indian patients with fragility hip fracture: A pilot study. J Assoc Physicians India 2010;58:539-42.
11. Erbil Y, BozborsA, Ozbey N. Predictive value of age and serum parathormone and vitamin D3 levels for post operative hypocalcemia after total thyroidectomy for non toxic multinodular goiter Arch Surg 2007;142:1182-7.
12. Erbil Y, Barbaros U, Temel B, Turkoglu U, Issever H, Bozbora A. The impact of age, vitamin D(3) level, and incidental parathyroidectomy on postoperative hypocalcemia after total or near total thyroidectomy. Am J Surg 2009;197:439- 46.
13. Biet A, Zaatar R, Strunski V. Post operative complications in total thyroidectomy for Graves’s disease: Comparison with multinodular benign goiter surgery. Ann Otolaryngol Chir Cervicofac 2009;126:190-5.
14. Erbil Y, Ozbey NC, Sari S, Unalap AR, Agcaoglu O, Ersoz F, et al. Determinants of post operative hypocalcemia in vitamin D deficient Graves’ patients after total thyroidectomy. Am J Surg 2011;201:678-84.
15. Yamashita H, Murakami T, Noguchi S. Post operative tetany in Graves, disease. Important role of vitamin D metabolites. Ann Surg 1998;229:237-45.
16. Dedivitis RA, Pfuetzenreiter EG Jr, Nardi CE, Barbara EC. Prospective study of clinical and laboratorial hypocalcemia after thyroid surgery. Braz J Otorhinolaryngol 2010;76:71- 7.
17. Thomusch O, Machens A, Sekulla C, Ukkat J, Brauckhoff M, Dralle H. The impact of surgical technique on postoperative hypoparathyroidism in bilateral thyroid surgery: A multivariate analysis of 5846 consecutive patients. Surgery 2003;133:180-5.
18. Kotan C, Kosem M, Alquan E, Ayakta H, Sonmez R, Soylemez O. Influence of the refinements of surgical technique and surgeons experience on the rate of complications after total thyroidectomy for benign thyroid disease. Acta Chir Belg 2003;103:278-81.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareSTUDY OF INCIDENCE OF INGUINAL HERNIAS AND THE RISK FACTORS ASSOCIATED WITH THE INGUINAL HERNIAS IN THE REGIONAL POPULATION OF A SOUTH INDIAN CITY
English1418Ayesha FatimaEnglish Mohammed Riyaz MohiuddinEnglishBackground: Hernias constitute an important public health problem and often pose a surgical dilemma even for the most skilled surgeons. They are a leading cause of work loss and disability and are sometimes lethal. An early diagnosis and referral to the surgeon should mean short waiting time, elective surgery and a better prognosis. Objectives: 1) To know the incidence of inguinal encountered in both male and female sexes 2) To analyze the common risk factors associated with these hernias. Material and Methods: 433 patients (457 Inguinal hernias), of different ages and sexes, attending the out patient department and admitted in the general ward and post operative ward of different hospitals were considered for study. Study period: The study was carried out for a period of 12 months from September 2009 to September 2010. Results: Inguinal hernia was seen in 365(84.3%) males and 68(15.7%) females. The number of right sided inguinal hernias was 266(58.21%) and the number of left sided inguinal hernias was 143(31.29%).They were 24(5.25%) bilateral hernias. In the present study out of the total 457 inguinal hernias, 379(82.93%) were of indirect variety and 78(17.07%) were direct variety. Out of 433 patients of Inguinal hernia it was found that 312 patients (72%) were physically active. Chronic cough was found to be not associated with incidence of inguinal hernia. In the present study 66% of inguinal hernia patients were found to have constipation. 26% were having family history significant. Conclusion: Incidence of inguinal hernias showed a clear male preponderance. Incidence was highest in children less than 10 years. of age. Strenuous physical activity and constipation were found to be risk factors for Inguinal Hernia.
EnglishRisk factors, Incidence, Inguinal HerniaINTRODUCTION
Hernia has traditionally generated a lot of debate over the decades. There is almost no limit to how BIG a hernia could get if left untreated! As defined by Astley Cooper in 1804, a “Hernia is a protrusion of any viscus from its proper cavity. The protruded parts are generally contained in a sac like structure, formed by the membrane with which the cavity is naturally lined.”The word hernia is derived from the Latin word for “Rupture”.Hippocrates used the Greek word “Hernios” for a bud or bulge to describe abdominal hernias. Statues of this era portray this condition. Hernias constitute an important public health problem and often pose a surgical dilemma even for the most skilled surgeons. They are a leading cause of work loss and disability and are sometimes lethal. An early diagnosis and referral to the surgeon should mean short waiting time, elective surgery and a better prognosis. Thus knowledge of hernias both usual and unusual and protrusions that mimic hernias are essential components of the armamentarium of the general and pediatric surgeon. Hernias can be congenital or acquired, complete or partial, external or internal, reducible or irreducible, direct or indirect. The previous studies indicate that external hernias are more common than internal hernias. Abdominal hernias are by far the commonest type of hernias we come across. Inguinal hernias being more frequent and among the inguinal hernias, the indirect variety is more.
In general the incidence increases with the increase in age. Genetic factors certainly play a role as a positive family history frequent hernias is common. Developmental phenomenon also plays a role. For example, in the evolution of quadruped to a biped the unprotected groin is more vulnerable to changes in the intra abdominal pressure, predisposing to inguinal herniation. So the present study focuses to know the incidence of the Inguinal hernia based on the factors affecting the occcurence of hernias To verify or impugn the accepted figures it was undertaken to investigate Inguinal hernia cases presenting themselves at the Out Patient Department and wards of various hospital of Hyderabad. AIM The aim of the present study is to evaluate the incidence of Inguinal hernias in the regional population of Hyderabad, and to analyze the effects of changing life styles in the occurrence of Inguinal hernias
OBJECTIVES
1)To know the incidence of inguinal encountered in both male and female sexes
2)To analyze the common risk factors associated with these hernias.
MATERIAL AND METHODS:
433 patients (457 Inguinal hernias),of different ages and sexes, attending the out patient department and admitted in the general ward and post operative ward of the following hospitals were considered for study: Osmania General Hospital, Afzalgunj, Durgabai Deshmukh Hospital, Vidyanagar, Nilofer Hospital, Nampally and Princess Esra Hospital, Charminar. Both unilateral and bilateral hernias were included in the study. The study was carried out for a period of 12 months from September 2009 to September 2010.
OBSERVATION AND RESULTS
Sex wise distribution of inguinal hernias:
In the present study inguinal hernia was seen in 365(84.3%) males and 68(15.7%) females. Out of 457 inguinal hernias 387(84.68%) were seen in males and 70(15.68%) were seen in females.M: F= 5.36.Details are shown in Table No: 1
DISTRIBUTION OF INGUINAL HERNIAS ACCORDING TO SIDE:
The number of right sided inguinal hernias was 266(58.21%) and the number of left sided inguinal hernias was 143(31.29%).They were 24(5.25%) bilateral hernias. R: L= 1.86:1.
DISTRIBUTION OF INGUINAL HERNIAS ACCORDING TO TYPE:
Inguinal hernias can be either direct inguinal hernias or indirect variety. In the present study out of the total 457 inguinal hernias, 379(82.93%) were of indirect variety and 78(17.07%) were direct variety.
SEX AND AGE WISE DISTRIBUTION IN DIFFERENT TYPES OF INGUINAL HERNIA:
Out of the 304 indirect hernias in males, peak incidence was seen in the age group 0-10 years. Out of the total 61 direct inguinal hernias in males, peak incidence was seen in the age group 61-70 and was found to be statistically significant.(chi square=92.6 pEnglishhttp://ijcrr.com/abstract.php?article_id=692http://ijcrr.com/article_html.php?did=6921. Bret A Nicks et al , Hernias http://emedicine.medscape.com/article/775630-overview (cited on 03/10/09).
2. Eustace Stevers Golladay et al, Abdominal hernias http://emedicine.medscape.com/article/189563-overview (cited on 24/06/10).
3. D.K. Gupta et al., Inguinal hernia in children: an Indian experience, Pediatr Surg Int 1993;8:466-468. 4. Charles N.R et al., A Two Year Retrospective Study Of Congenital Inguinal Hernia At Western Regional Hospital, Nepal, J. Nep Med Assoc 2000;39:172-175.
5. Shams Nadeem Alam et al., Mesh Hernioplasty :Surgeons’ Training Ground, Pakistan Journal of Surgery 2007;Volume 23, Issue 2.
6. BinBisher Saeed A et al., Inguinal Hernia Repair by Darning, Yemen Journal for Medical Sciences 2009;1(3).
7. Liem MS1 , van der Graaf Y, Zwart RC, Geurts I, van Vroonhoven TJ: Risk factors for inguinal hernia in women: a case-control study. The Coala Trial Group. http://www. ncbi.nlm.nih.gov/pubmed/9366619 (cited on 09/05/10).
8. http://www.mayoclinic.org/diseases-conditions/inguinal-hernia/basics/risk-factors/con-20021456 (cited on 24/06/10).
9. Lau H1 , Fang C, Yuen WK, Patil NG.: Risk factors for inguinal hernia in adult males: a case-control study. http://www.ncbi.nlm.nih.gov/pubmed/17263984 (cited on 08/04/10).
10. Babar Sultan et al., Frequency of External Hernias in Ayub Teaching Hospital Abbotabad, J Ayub Med Coll Abbotabad 2009;21(3).
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareA STUDY ON THE PREVALENCE AND ANTIMICROBIAL SUSCEPTIBILITY PATTERN OF METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS IN A SOUTH INDIAN TERTIARY CARE HOSPITAL
English1922A. Heraman SinghEnglish S. ArunaEnglishContext: Methicillin Resistant Staphylococcus aureus (MRSA) prevalence is increasing worldwide and it remains as a major cause of morbidity and mortality in hospitalised patients due to its versatile behaviour towards antibiotics.
Aims: This study was done to find out the prevalence and antimicrobial susceptibility pattern of MRSA isolates at our hospital setup, in order to guide policy on the appropriate use of antibiotics. Settings and Design: The study was a prospective observational study, carried out in the Department of Microbiology, GSL Medical College, Rajahmundry, Andhra Pradesh. Methods and Material: A total number of 288 strains of Staphylococcus aureus were isolated from various clinical samples received in the laboratory. Staphylococcus aureus was identified by routine standard operative procedures. Antimicrobial susceptibility testing was done by Kirby-Bauer disc diffusion method and the results were interpreted following Clinical Laboratory Standards Institute (CLSI) guidelines. Methicillin resistance was screened by using oxacillin disks [1 mcg]. Statistical analysis used: Data obtained was analysed and presented in counts and percentages. 95 % confidence interval values were also calculated. Results: Methicillin resistance was documented in 120 [41.6%] Staphylococcus aureus isolates. Most of them were isolated from pus, wound swabs, urine and respiratory samples. All MRSA isolates were resistant to penicillin and cefepime. The resistance was high to tetracycline, erythromycin, co-trimoxazole piperacillin / tazobactam, and ciprofloxacin; moderate to aminoglycosides, clindamycin, chloramphenicol and levofloxacin. All MRSA strains were susceptible to vancomycin. Overall, 63.3% [76/120] of MRSA strains were found to be resistant to more than 6 antimicrobials tested. Conclusions: Our study emphasizes the need for regular surveillance and formulation of a strict drug policy on the appropriate use of antibiotics to control MRSA infections. This would also minimise the irrational use of vancomycin and the emergence of vancomycin resistant Staphylococcus aureus [VRSA].
EnglishMRSA, Vancomycin, Antimicrobial susceptibility patternINTRODUCTION
The isolation of methicillin resistant Staphylococcus aureus [MRSA] was reported within one year of introduction of methicillin. Since then, the prevalence of MRSA has increased steadily. In the past 10 years, numerous outbreaks of infections caused by MRSA have been reported 1 . In many hospitals, 40 – 50 % of Staphylococcus aureus isolates are now resistant to methicillin1, 2. MRSA isolates are important for their resistance to many commonly used antibiotics. They exhibit remarkable versatility in their behaviour towards antibiotics which poses a serious therapeutic problem. Thus, MRSA remains as a major cause of morbidity and mortality among hospitalised patients despite the availability of numerous effective anti-staphylococcal antibiotics. This emphasizes the need to study the prevalence and antimicrobial susceptibility pattern of MRSA isolates area-wise in order to guide policy on the appropriate use of antibiotics which would minimise the irrational use of vancomycin and so the emergence of resistance to vancomycin. The present study was carried out to find out the prevalence and antimicrobial susceptibility pattern of MRSA isolates at our hospital set up. The information would also be useful in contributing data to larger more extensive surveillance programs.
SUBJECTS AND METHODS
The present study was conducted in the Department of Microbiology, GSL Medical College and General hospital, Rajahmundry, Andhra Pradesh. A total number of 288 strains of Staphylococcus aureus were isolated from various clinical samples received in the laboratory during the period June 2011 to December 2012. Ethical clearance was obtained from the institute. Standard procedures were followed to isolate the organisms from the clinical samples. Staphylococcus aureus was identified by Gram stain morphology, colony characters on blood agar, biochemical reactions like catalase test, mannitol fermentation, slide coagulase test and tube coagulase test3 . All the Staphylococcus aureus strains were then subjected to antimicrobial susceptibility testing by Kirby-Bauer disc diffusion method and the results were interpreted following CLSI guidelines4 . Methicillin resistance was screened by using oxacillin disks [1 mcg]. Anti-staphylococcal antibiotics like penicillin G [10 units], cefepime [30mcg], ciprofloxacin [5 mcg], levofloxacin [5 mcg], erythromycin [15 mcg], tetracycline [30 mcg], chloramphenicol [30 mcg], co-trimoxazole [1.25/23.75 mcg], piperacillin/tazobactam [100/10 mcg], clindamycin [2 mcg], gentamicin [10 mcg], amikacin [30 mcg], tobramycin [10 mcg] and vancomycin [30 mcg] were tested (Himedia, Mumbai, India ). The data obtained in this study was summarized by counts and percentages. Antimicrobial Susceptibility rates were also presented in 95% confidence interval values.
RESULTS
A total number of 288 strains of Staphylococcus aureus were isolated from different clinical samples obtained from inpatients of the hospital. Methicillin resistance was documented in 120 [41.6%] Staphylococcus aureus isolates (Figure 1). Majority of the MRSA strains were isolated from pus and wound samples [58.3%], followed by urine [22.5%], respiratory specimens [16.6%], blood [1.6%] and body fluids [0.8%] (Table 1). All MRSA isolates were resistant to penicillin and cefepime. Resistance was high to tetracycline, erythromycin, cotrimoxazole, piperacillin/tazobactam, and ciprofloxacin; moderate to aminoglycosides, levofloxacin, clindamycin and chloramphenicol. All MRSA strains isolated in the present study were susceptible to vancomycin (Table 2).
DISCUSSION
MRSA prevalence is increasing worldwide and has become a serious public health issue. The MRSA prevalence rate shows significant regional variance5, 6, 7. In the present study, the prevalence rate of MRSA was found to be 41.66 %. This was higher when compared to various studies reported from India, ranging from 29.1% to 34.78% 8, 9, 10 and abroad, ranging from 9 % to 26.9%5, 11, 12, 13, 14. However, it was comparable to the prevalence rates reported from Varanasi (38.44%), Chennai (45%), Amritsar (46%) and Visakhapatnam (45%) 6, 15, 16, 17. In contrast, studies from Indore (80.89%) and Pakistan (83%) reported much higher prevalence rates of MRSA7, 18. This variation in prevalence rates in different places could be due to differential clonal expansion and drug pressure in the community 6 . MRSA are often multidrug resistant and studies have indicated that there has been progressive increase in the development of resistance to several antibiotics6, 8, 9. In our study, 63.3% [76/120] of MRSA isolates were found to be resistant to more than 6 antimicrobials tested. A study from Varanasi reported that prevalence of multidrug resistant MRSA is high in India and without MRSA surveillance and strict drug policy, the threat would increase 6 . The antimicrobial susceptibility pattern of MRSA isolates varies with place and time5 . Ciprofloxacin has been considered as a potent antibiotic in the therapy of MRSA infections and therefore it is widely used on empirical basis. This resulted in a steady increase of resistance to ciprofloxacin among MRSA isolates 11. Many studies have reported high resistance rates to ciprofloxacin among MRSA isolates ranging from 75.7 % to 88.2 % 6, 8, 13, 16. In the present study it was found to be 70 %. However, this was higher when compared to other studies reported from Eritrea ( 8 % ), Mangalore ( 31.8 % ) and Kano ( 43.7 % ) 5, 9,12 . High resistance was observed in this study among MRSA isolates to antibiotics like co-trimoxazole (86.6%), tetracycline (88.3%), and erythromycin (91.6%). This was indicated in different studies reported from India and abroad 6, 9, 12, 13, 16. In contrast, low resistance was found in Eritrea to erythromycin (27%) and co-trimoxazole (23%) 5. The emergence of high resistance could be due to excessive use and over the counter availability of these antibiotics in the developing world for the treatment of staphylococcal and many other infections both in man and animals6, 11. All MRSA isolates were found to be resistant to penicillin (100%) and cefepime (100%). Interestingly, the resistance to piperacillin and tazobactam combination (75%) was high even though it was not a commonly used antibiotic at our hospital setup. Vancomycin was found to be the most effective antibiotic against MRSA isolates in our study, with a susceptibility rate of 100%. This was in line with the observations made in various studies from India and abroad 9, 12,13,16,17. However, it is quite expensive, toxic and not easily available for regular use and therefore may be reserved for treating life threatening MRSA infections6, 7, 9. In our study MRSA isolates showed moderate resistance rates to gentamicin [51.6%], amikacin [48.3%] tobramycin [41.6%], chloramphenicol [53.3%], clindamycin [53.3%] and levofloxacin [55%] compared to other antibiotics tested. These antibiotics may be tried as an alternative to vancomycin after antimicrobial susceptibility testing is done. This would prevent the emergence of vancomycin resistant Staphylococcus aureus [VRSA] 6, 7, 9 .
CONCLUSION
MRSA is a common pathogen at our hospital setup and vancomycin is still the drug of choice. The presence of high percentage of multidrug resistant MRSA is a serious matter of concern. Therefore, regular surveillance and formulation of a strict drug policy on the appropriate use of antibiotics are very much essential in the control of MRSA infections and to avoid the emergence of VRSA. Regular monitoring on quality, availability and the use of antibiotics also helps in preserving the effectiveness of antibiotics.
ACKNOWLEDGEMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are 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: None Conflict of interest: None Declared
Englishhttp://ijcrr.com/abstract.php?article_id=693http://ijcrr.com/article_html.php?did=6931. Fauci, Brawnwald, Kasper, Hauser, Longo, Jameson et al. Harrison’s Principles of Internal Medicine; 17th edition. 2008; vol 1; 879.
2. Shiv Sekhar Chatterjee, Pallab Ray, Arun Aggarwal, Anindita das and Meera Sharma. Acommunity-based study on nasal carriage of Staphylococcus aureus. Indian J Med Res 130, December 2009, pp 742-748.
3. Collee JG, Fraser AG, Barry P Marmion, Simmons A. Mackie and McCartney Practical Medical Microbiology; 14th edition. Churchill Livingstone, London. 1996; 245- 258.
4. Clinical and Laboratory Standard Institute, 2012. Performance standards for antimicrobial susceptibility testing. Clinical and Laboratory Standards Institute, Wayne. 22nd Informational Supplement, 32 (3).
5. Durgadas Naik, Alem Teclu. A study on antimicrobial susceptibility pattern in clinical isolates of Staphylococcus aureus in Eritrea. Pan African Medical Journal, 2009 3:1.
6. Hare Krishna Tiwari, Darshan Sapkota, Malaya Ranjan Sen. High prevalence of multidrug-resistant MRSA in a tertiary care hospital of Northern India. Infection and Drug Resistance 2008: 1; 57-61.
7. Sheetal Verma, Swati Joshi, V Chitnis, Nanda Hemwani, D Chitnis. Growing problem of methicillin resistant staphylococci – Indian scenario. Indian Journal of Medical Sciences year: 2000 / Volume: 54 / Issue: 12 / page: 535-540.
8. Lahari Saikia, Reema Nath, Basabdatta choudhury, Mili sarkar. Prevalence and antimicrobial susceptibility pattern of methicillin-resistant Staphylococcus aureus in Assam. Indian Journal of critical care Medicine, 2009/ volume:13/ issue: 3/ page: 156-158.
9. Vidya Pai, Venkatakrishna I Rao, Sunil P Rao. Prevalence and Antimicrobial Susceptibility pattern of Methicillin-resistant Staphylococcus aureus [MRSA] isolates at a tertiary care hospital in Mangalore, South India. Journal of Laboratory Physicians / Jul-Dec 2010 / Vol-2 / Issue-2.
10. AA Mehta, CC Rodrigues, RR Kumar, AA Rattan, HH Sridhar, VV Mattoo, VV Ginde. A pilot programme of MRSA surveillance in India. (MRSA Surveillance Study Group). Journal of Postgraduate medicine, year: 1996 / Volume: 42 / Issue: 1 / Page: 1-3.
11. Baral R, B Khanal, A Acharya. Antimicrobial susceptibility patterns of clinical isolates of Staphylococcus aureus Health Renaissance 2011; Vol 9 (No. 2): 78-82.
12. Nwankwo Emmanuel Onwubiko, Nasiru Magaji Sadiq. Antibiotic sensitivity pattern of Staphylococcus aureus from clinical isolates in a tertiary health institution in Kano, Northwestern Nigeria. Pan African Medical Journal. 2011; 8:4.
13. Patrick Eberechi Akpaka, Shivnarine Kissoon, William Henry Swanston and Michele Monteil. Prevalence and antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus isolates from Trinidad and Tobago. Annals of Clinical Microbiology and Antimicrobials 2006, 5: 16.
14. Adebayo O Shittu, Johnson Lin. Antimicrobial susceptibility patterns and characterization of clinical isolates of Staphylococcus aureus in KwaZulu-Natal province, South Africa. BMC Infect Dis 2006; 6:125.
15. M. Shanthi, Uma Sekar. Antimicrobial susceptibility pattern of methicillin resistant Staphylococcus aureus at SriRamachandra medical centre. Sri Ramachandra Journal of Medicine, June 2009, Vol. II, Issue 2.
16. Dr. Bandaru Narasinga Rao, MD, Ph.D., Dr. T. Prabhakar, M.Sc., Ph.D. Prevalence and Antimicrobial Susceptibility pattern of Methicillin Resistant Staphylococcus aureus [MRSA] in and around Visakhapatnam, Andhra Pradesh, India. Journal of Pharmaceutical and Biomedical Sciences [JPBMS].
17. Shilpa Arora, Pushpa Devi, Usha Arora, Bimla Devi. Prevalence of Methicillin-resistant Staphylococcus aureus (MRSA) in a tertiary care Hospital in Northern India. Journal of Laboratory Physicians / Jul-Dec 2010 / Vol-2 / Issue-2.
18. Mehta AP, Rodrigues, C, Sheth K, Jani, S, Hakimiyan A, Fazalbhoy N. Control of methicillin resistant Staphylococcus aureus in a tertiary care centre – A five year study. J Med Microbial 1998; 16: 31-4.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareHEAT SHOCK PROTEIN (HSP60) IN PERIODONTAL DISEASE: A REVIEW
English2326Indumathy P.English K. V. ArunEnglish Sai Prashanth P.EnglishHeat shock proteins are stress proteins that are produced by cells in response to environmental stress. They have various roles in the physiological as well as pathological processes of the body. These proteins have often been implicated in the pathogenesis of various diseases. This review discusses the role of heat shock proteins (Hsp 60) in the pathogenesis as well as treatment of periodontal disease.
EnglishHeat shock protein, Periodontal disease, Immune responseINTRODUCTION
Periodontitis is defined as “an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with pocket formation, recession, or both.1 When exposed to a large array of environmental stresses like temperature, pH, redox potential, prokaryotic and eukaryotic cells respond by inducing the synthesis of specific proteins known as stress proteins, or heat-shock proteins (Hsps) 2 Heat shock proteins have important functions in the cell such as folding, assembly, and translocation of polypeptides across membranes and play a main role in protein repair after cell damage. 3 The human and bacterial cognates of heat shock proteins are similar, sharing more than 50% sequence homology at the amino acid level. 3 During infection, Heat shock proteins from several bacterial species are recognized by the host as immunodominant antigens.4 Heat shock protein production by several periodontopathic micro-organisms has been extensively documented. The presence of these stress proteins has been demonstrated in tissue samples from periodontitis lesions. 5, 6 The sequence homology between the human Heat shock protein 60 (Hsp60) and that of the periodontopathic bacteria like Porphyromonas gingivalis or A actinomycetemcomitans at an amino acid level is 49% and 52%, respectively. 7 Despite being highly homologous between prokaryotic and eukaryotic cells, Hsp60s are considered to be very immunogenic, and immune reactions to microbial Hsp60s may be the cause for the initiation of chronic inflammatory diseases, wherein the autoimmune response to human Hsp60 could be touted as the main factor in pathogenesis of disease.8 This article throws some light on Heat shock proteins (Hsp60), and their role in the etiopathogenesis of periodontitis. A deep understanding of the same has the clinical implications of helping to identify patients who are at risk for developing periodontal disease based on their inability to mount an immune response to specific Hsp or Hsp epitopes. Also, P. gingivalis Hsp60 could potentially be developed as a vaccine to inhibit periodontal disease induced by multiple pathogenic bacteria.
HEAT SHOCK PROTEINS
Heat shock proteins participate in vital physiological processes in the cell such as folding, assembly, and translocation of polypeptides across membranes and play a role in protein repair after cell damage.3 There is a phenomenon termed heat shock response, wherein a cell that experiences increased temperature or any other stress factor, starts producing elevated amounts of heat shock proteins by enhanced transcription. 9
HISTORY
The heat shock response was discovered by Feruccio Ritossa, who observed an enlargement of special sections of Drosophila melanogaster chromosomes (heat shock puffs) after heat treatment of the flies.10 Ritossa subjected these flies to temperature shock induced specific gene activation; the first products of these genes was identified in 1974 and the term “heat shock protein” was adopted. 10 Hsp60 was first described in E.coli by Hendrix in 1979 and has been termed GroEL.11
CLASSIFICATION
Heat Shock Proteins are classified by their molecular weight, size, structure, and function.12
• sHsp - Prevent aggregation of other proteins by collecting protein “ garbage”, act as dustmen of cells
• Hsp60, Hsp70 - Assistance in protein folding and refolding
• Hsp90 - Stabilize substrate proteins and maintain their active, or inactive state, prevent the aggregation of other proteins
• Hsp100 - Desaggregation of proteins
HSPS AND AUTOIMMUNE RESPONSE
Three models have been proposed to link microbial infections to subsequent autoimmune reactions involving Hsps13 . These models are based on a. molecular mimicry between microbial Hsps and Hsps or constitutive proteins from the host b. inflammation-induced exposure of cryptic cell epitopes that could be a target for immune reactions c. antigen persistence in infected sites leading to chronic immunological reactions2 . Immune responses to bacterial Hsps may generate cross reacting immunity to self-Hsp and precipitate damaging inflammatory responses.8,14 Young and Elliott (1989)15 showed that through these cross-reactive epitopes, Tcells with specificity for self-Hsp can be activated during infection. The first report of antibodies against Hsps in a human disease is that of Jarjour et al (1991)16, who suggested that the difference in the levels of anti-Hsps antibodies seen between patients with diseases compared to healthy, could be an indicator of polyclonal B cell activation. 17
HSP60 AND PERIODONTITIS
Periodontitis is a chronic inflammatory disease characterized by mononuclear cell infiltration into the gingival tissues, leading to connective tissue destruction and alveolar bone resorption.8 Although periodontal bacteria like Porphyromonsa Gingivalis, and Aggregatibacter actinomycetem comitans are the causative agents in periodontitis, the progression of the disease and the amount of severity is known to be controlled by host immune responses.18 Pleguezuelos et al (2005)19 have hypothesized that pathogenic bacteria stimulate periodontal cells to increase Hsp60 expression that could in turn initiate macrophages, to start producing proinflammatory cytokines. Due to their high conservation among various microbial pathogens and their ability to induce very strong cellular and humoral immune responses, Hsp60s are thought to play a role as candidate antigens in periodontal disease. 8 A significant temperature elevation up to 2°C is observed in inflamed periodontal pocket.20 It is very well known that pro inflammatory cytokines are produced in periodontitis. These cytokines may cause an elevation of heat shock proteins levels in the inflamed periodontium. Lundqvist et al. (1994)5 found the expression of Hsp60 to be higher in gingival epithelial cells of inflamed tissue samples from periodontitis patients compared with samples from periodontally healthy individuals. Petit et al. (1999)21 suggested that the higher responsiveness to Hsp60 and Hsp70 observed in gingivitis subjects may prevent the conversion from gingivitis to periodontitis. Tabeta et al. (2000)14 reported that gingival tissue extracts from healthy or periodontitis patients contain antibodies to the Porphyromonas Gingivalis GroEL protein (Heat shock protein). Ueki et al (2002)7 demonstrated that Human Hsp60 is expressed abundantly in periodontitis lesions and, also stimulate tumour necrosis factor (TNF) - α production from macrophages Yamazaki et al (2002)8 demonstrated that Hsp60- specific T cells accumulated in the gingival lesions of periodontitis patients but not in gingivitis patients and that the T cell clones with an identical specificity to those in peripheral blood existed in periodontitis lesions. Choi et al (2004)22 showed that Porphyromonas gingivalis Hsp reactive T cell immune response might be involved in immunopathogenesis of periodontal disease. They suggested that T cells in the circulating peripheral blood may home to periodontal lesions where Porphyromonas .gingivalis have infiltrated potentially leading to T cell response cross reactive to mammalian Hsp of gingival fibroblasts. Pleguezuelos et al (2005)19 stated that exogenous HSP60 is capable of initiating an inflammatory response in oral keratinocytes by increasing the expression of proinflammatory cytokines Honda et al (2006)23 proved that Hsp60 expression was up-regulated significantly in periodontitis.
HSP60 VACCINE IN PERIODONTITIS
Heat shock protein (Hsp) can be possibly explored as a candidate for vaccination against periodontitis Choi et al (2005)26 found that P. gingivalis Hsp60 could potentially be developed as a vaccine against multiple periodontopathic bacteria Lee et al (2006)27 found that there was a very strong inverse relationship between post immune anti-P. gingivalis HSP immunoglobulin G (IgG) levels and the amount of alveolar bone loss produced by bacterial infections DISCUSSION Although infectious diseases, by and large have a microbial aetiology, it is now an established fact that the hosts immune response to this microbial assault can itself cause destruction to host tissues. Heat shock proteins are stress proteins, and many studies have demonstrated their increased levels in periodontal disease. They generate a strong pro inflammatory response, and further, there is also the possibility of a cross reactive immune response to mammalian Hsps , due to the strong homology between the bacterial and human Hsps. Since, other infectious diseases have been controlled in the past by administration of vaccines, Heat shock proteins could be considered as a potential candidate antigen to be used as a vaccine to control periodontal disease.
CONCLUSION
Knowledge about Hsp60 and further studies establishing their role in the etiopathogenesis of periodontal disease would aid in diagnosing and also treating periodontal disease. Source of Funding: None Conflict of Interest: None
Englishhttp://ijcrr.com/abstract.php?article_id=694http://ijcrr.com/article_html.php?did=6941. Newman MG, Carranza FA, Takei H, Klokkevold PR. Carranzas clinical Periodontology. 10th ed. Elsevier health sciences; 2006.
2. Goulhen F,Grenier D, Mayrand D Oral microbial heat-shock proteins and their potential contributions to infections. Crit. Rev. Oral Biol. Med. 2003; 14:399–41.
3. Ellis JR, van Eden W, Young D. Stress proteins as molecular chaperones. . Stress Proteins in Medicine 1996:1-26.
4. Kaufmann SH Heat shock proteins and the immune response Immunol Today 1990; 11: 129-136.
5. Lundqvist C, Baranov V, Teglund S, Hammarstrom S, Hammarstrom ML Cytokine profile and ultrastructure of intraepithelial gamma delta T cells in chronically inflamed gingiva suggest a cytotoxic effector function J Immunol 1994; 153: 2302-2312.
6. Ando T,Kato T,Ishihara K,Ogiuchi H, Okuda K Heat shock proteins in the human periodontal disease process Oral Microbiol Immunol 1995 ; 39 :321-327.
7. Ueki K, Tabeta K, Yoshie H, Yamazaki K Self heat shock protein 60 induces tumor necrosis factor –alpha in monocytederived macrophage: possible role in chronic inflammatory periodontal disease Clin Exp Immunol 2002; 127:72-77.
8. Yamazaki K, OhsawaY, Tabeta. K, Ito H, Ueki K, Oda T, Yoshie H, Seymour GJ. Accumulation of Human Heat Shock Protein 60-Reactive T Cells in the Gingival Tissues of Periodontitis Patients. Infect Immun 2002; 70: 2492–2501.
9. Trivedi, V., Gadhvi, P., Chorawala, M., and Shah, G. (2010). Role of heat shock proteins in immune response and immunotherapy for human cancer. Int J Pharm Sci Rev and Res, 2, 57-62.
10. Tissieres A, Mitchell HK, Tracy UM. Protein synthesis in salivary glands of Drosophila melanogaster: Relation to chromosome puffs J Mol Biol 1974; 85: 389-398.
11. Hendrix RW Purification and properties of groE, a host protein involved in bacteriophage assembly J Mol Biol 1979; 129: 404-408.
12. Csermely P, Yahara I. Heat Shock Proteins. In: Keri G, Toth I, editors. Molecular Pathomechanisms and New Trends in Drug ResearchCRC Press, 2003 p. 67-75.
13. Rose NR The role of infection in the pathogenesis of autoimmune disease Semin immunol 1998 ; 10: 5-13.
14. Tabeta K, Yoshie H, Yamazaki K Characterisation of serum antibody to Actinobacillus actinomycetemcomitans GroEL – like protein in periodontitis patients and healthy subjects Oral Microbiol Immunol 2001; 16:290-295.
15. Young RA, Elliott TJ Stress proteins, infection and immune surveillance Cell 1989 ; 59:5-8.
16. Jarjour WN, Jeffries BD, Davis JS, Welch WJ, Mimura T, Winfield JB Autoantibodies to human stress proteins. A survey of various rheumatic and inflammatory diseases Arthritis Rheum 1991; 34:1133-1138.
17. Wu T, Tanguay RM Antibodies against heat shock proteins in environmental stresses and diseases: friend or foe? Cell Stress and chaperones 2006;11:1-12.
18. Seymour GJ, Gemmell E, Reinhardt RA, Eastcott J, Taubman MA Immunopathogenesis of chronic inflammatory periodontal disease: cellular and molecular mechanisms J Periodontal Res 1993;28: 478-486.
19. Pleguezuelos O, Dainty SJ, Kapas S, Taylor JJ A human oral keratinocyte cell line responds to human heat shock protein 60 through activation of ERK1/2 MAP kinases and upregulation of IL-1 β Clin Exp Immunol 2005; 141: 307-314
20. Amano A, Sharma A,Sojar HT, Kuramitsu HK, Genco RJ Effects of temperature stress on expression of fimbriae and superoxide dismutase by porphyromonas gingivalis Infect immun 1994; 62: 4682-4685.
21. Petit MD, Wassenaar A, van der Velden U, van Eden W, Loss BG Depressed responsiveness of peripheral blood mononu-clear cells to heat –shock proteins in periodontitis patients J Dent Res 1999; 78: 1393-1400.
22. Choi JI, Chung SW, Kang HS,Rhim BY, Park YM, Kim US, Kim SJ Epitope mapping of Porphyromonas gingivalis heat shock protein and human heat shock protein in human atherosclerosis J Dent Res 2004; 83:936-940.
23. Honda T, Domon H, Okui T , Kajita K, Amanuma R, Yamazaki K Balance of inflammatory response in stable gingivitis and progressive periodontitis lesions Clin Exp Immunol 2006;144:35-40.
24. Yamazaki K, Ohsawa Y, Itoh H, Ueki K, Tabeta J, Oda T, Nakajima T, Yoshie H, Saito S, Oguma F, Kodama M, Aizawa Y, Seymour GJ T cell clonality to Porphyromonas gingivalis and human heat shock protein 60 s in patients with atherosclerosis and periodontitis Oral microbial Immunol 2004 ;19:160-167.
25. Ford P, Gemmell E, Walker P, West M, Cullinan M, Seymour G Characterisation of heat shock protein specific T cells in atherosclerosis Clin and Diag Lab Immunol 2005; 12:259- 267.
26. Choi JI, Choi KS, Yi NN, Kim US, Choi JS, Kim SJ. Recognition and phagocytosis of multiple periodontopathogenic bacteria by anti-Porphyromonas gingivalis heat-shock protein 60 antisera. Oral Microbiol Immunol. 2005 Feb; 20(1):51-5.
27. Lee JY, Yi NN, Kim US, Choi JS, Kim SJ, Choi JI. Porphyromonas gingivalis heat shock protein vaccine reduces the alveolar bone loss induced by multiple periodontopathogenic bacteria. J Periodontal Res 2006; 41(1):10-14.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareDEMOGRAPHICS AND MANAGEMENT OF FOREIGN BODY PENETRATIONS IN HAND
English2730Pawan Kumar K. M.English Ranganatha B. T.EnglishBackground: The penetration of foreign bodies into the hand is generally accepted as a simple injury with the misconception that treatment will be easy. The aim of this study was to analyze the diagnostic and therapeutic challenges during the removal of foreign bodies in hand. Methods: Prospective analysis of patients who had hand injuries caused by foreign body penetration and had been treated in the Department of Orthopaedics from January 2010 to December 2013. Results: The mean age among the 84 patients was 33.03 with standard deviation of ± 10.98 years, ranging from 14 years to 64 years. Most of them were between the age of 21 and 30 years (43%). About 71.4% (60) of the injured were males. About 69% of foreign body penetrations were occupational injuries. A variety of foreign bodies were isolated from the site of injury; they included metal splinters (33.4%),broken glass (27.4%),broken needles (20%),wood splinters(13%) thorns (5%) and tooth ( 1%). About in 21% (17) of cases the diagnosis of foreign body penetration was missed during the first consultation. Plain radiographs were able to pick up the foreign body in 81% (68) of the cases. In 83.3% of cases local anaesthesia was enough for the extraction of the foreign body. Conclusion: The study gives a clear understanding of the demographics of foreign body penetration and helps to plan in a better
way in managing similar cases.
EnglishForeign body, Hand, Canine tooth, Foreign body penetrationINTRODUCTION
Penetrating injuries to the hand are a common occurrence in the emergency room, and embedment of foreign bodies is suspected in many of these cases. The existing literature offers little information on the characteristics or prevalence of foreign bodies in the hand 1 . Despite significant practical knowledge and experience on foreign body penetration injuries to the hand, deficient management and complications can still be encountered2 . A foreign body, stuck into an extremity, may lead to consequences such as tissue damage, inflammation, infection, delayed wound healing, toxic or allergic reactions, and late injury as a result of migration 3 . In spite of the substantial experience of clinicians on this issue, there are a significant number of articles denoting defective management strategies, such as inadequate tetanus prophylaxis, and uncertainty in basic principles such as selecting the right solution for wound irrigation 4, 5. This study thus aims to reveal the basic features of the affected patients, the properties of the penetrated objects, the events causing this specific type of injury, the management of these injuries, and the outcomes of the patients. It is based on an analysis of a group of patients who had foreign body injuries in a more specific anatomic location, i.e. the hand and wrist .This study aims to cover the clinical and social properties and diagnostic and therapeutic challenges during the removal of foreign bodies in hand.
MATERIAL AND METHODS
This study is based on a prospective analysis of patients who had hand injuries caused by foreign body penetration. After obtaining clearance from institutional ethical committee, eighty four patients, who had been treated by the staff of Department of Orthopaedics from January 2010 to December 2013, were included in the study using proformas filled by us. Age, sex, occupation, mode of injury; domestic accidents, occupational accidents or road traffic accidents, site of injury; region of the hand where the foreign body had breached the skin, nature of foreign body; glass, wood, thorns, metal splinter, needle or tooth etc, time of diagnosis; whether diagnosed or missed initially, diagnostic modality required to diagnose and localise the foreign body and the anaesthesia required for the removal of foreign body were all assessed and are presented henceforth.
RESULTS
The mean age among the 84 patients was 33.03 with standard deviation of ± 10.98 years, ranging from 14 years to 64 ears. Most of them were between the age of 21 and 30 years (43%). About 71.4% (60) of the injured were males. Etiological assessment of foreign body penetration revealed, that the most of them were injured as a result of occupational accidents (69%), second most common mode of injury was road traffic accident (20.3%) and 9% had sustained injuries during domestic chores. A variety of substances were isolated from the site of injury; they included metal splinters(33.4%),broken glass( 27.4%),broken needles(20%),wood splinters(13%) thorns(5%) and tooth( 1%). In all these cases two views roentgenogram was taken. The two view roentgenograms were able to identify 81% (68) of the cases with foreign body. In sixty one (73%) cases the diagnosis was made at the first consultation with the doctor, either at our department or somewhere else and subsequently referred to our hospital for removal of foreign body. About in 21% (17) of cases the diagnosis of foreign body penetration was never made during the first consultation. All of them had presented to our hospital between three weeks to about four months from initial trauma. In all these cases there was history of some medical treatment at the time of initial trauma. Roentgenograms were taken first time at our hospital in all these 17 cases. Eleven (47.8%) cases among these cases had broken glass inside the wound which were visible in radiographs. In rest of the cases foreign bodies ranged from wooden splinters (13%) broken thorn (8.7%) and metal splinters (26%). The rarest foreign body among these was that of a retained canine tooth which was undetected for two months6 .
DISCUSSION
Foreign body penetrations of the hand wrist usually present as emergency cases, but patients with embedded objects presenting to the outpatient department are not uncommon2 . Embedded Foreign bodies can also be removed from patients who are unaware or uncertain of foreign body entry7 .Even our study revealed a similar picture with regard to presentation, 27% (23) of the patients had presented with embedded foreign bodies for duration ranging from three weeks to four months and none of them were aware of the embedded foreign body. Some centres include the fluoroscopy as routine component of foreign body removal surgeries8 . Similarly all cases were subjected to routine two view plain radiograph, including those with visible foreign bodies. The plane radiographs were able to pick up the foreign body in 81% (68) of the cases. Wood splinters and broken thorns were most common foreign bodies missed in radiographs. It has been stated that the two-view radiographs have been shown to be equivalent to the three-view radiographs in detecting glass foreign bodies9 . In another study, when only plain films were utilized, wood and glass FBs were missed in 93% and 25% of the cases10. In majority of cases the foreign bodies were of metallic origin (53.4%), while there were also broken glass (27.4%), wooden splinters (13%), thorns (5%) and one case of canine tooth6 .Metallic origin foreign bodies were usually broken industrial sewing machine needles or metal splinters from fabrication units. Such high incidence of metallic foreign bodies may attributed to the fact that majority of patients attending our hospital are industrial workers. Case reports of embedded organic foreign bodies such as splinters of plants, wood and fish fin fragments demonstrate the typical clinical picture of inflammatory reaction that develops in days or weeks11. In this sense, metal objects are less risky than the organic ones12. The foreign bodies like broken glasses, metal splinters, broken sewing needles etc were all picked up by the radiographs. Additional investigation used for the detection of foreign body alone was ultra sonogram, used in fifteen patients (18%). The ultra sonogram picked up wooden pieces and broken thorns. The literature shows strong support for radiographic detection of glass and metal foreign bodies, albeit with wooden and gravel foreign bodies detected at lower rates10, 13, 14, 15. Additional investigations in the form of a computer tomography were utilised for understanding the location of foreign body penetration and for planning its extraction in about 10% of the cases. The type of anaesthesia is determined by considering the location of the FB, the depth of penetration, the most likely injured structures, the age and the predicted duration of the operation. Similar to other studies16, 17, 18, 19, the vast majority of foreign body removal in our population was performed in the under local anaesthesia. In seventy cases(83.3%) local anaesthesia was enough for the extraction of the foreign body;12.3%(12) and 2.4%(2) required regional blocks or general anaesthesia respectively,dictated mostly due to the depth of penetration by the foreign body and proximity to the vital structures.
CONCLUSION
We in this study have tried to present the demographics, clinical presentation and treatment aspect of the simple entity of foreign body penetration. The study being a prospective analysis has its limitations and being conducted in a single institute may not exactly reflect the demographics of the entire population. Inspite of its limitations, the study helps us to understand about the demographics, nature of foreign bodies routinely encountered, high degree of clinical suspicion and utilization of all available investigative modalities required for diagnosis and management of foreign body penetration in a better way.
ACKNOWLEDGMENTS
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. Source of funding: None Conflict of interest: None Declared
Englishhttp://ijcrr.com/abstract.php?article_id=695http://ijcrr.com/article_html.php?did=6951. Vishnu C Potini, Ramces Francisco, Benhoor Shamian, Virak Tan. Sequelae of foreign bodies in the wrist and hand. Hand 2013; 8:77–81
2. Emre Hocao?lu, Samet Vasfi Kuvat, Burhan Özalp, Anvar Akhmedov, Yunus Do?an, Erol Kozano?lu, Fethi Sarper Mete, Metin Erer. Foreign body penetrations of hand and wrist: a retrospective study. Turkish Journal of Trauma and Emergency Surgery 2013; 19 (1):58-64
3. Han KJ, Lee YS, Kim JH. Progressive median neuropathy caused by the proximal migration of a retained foreign body (a glass splinter). J Hand Surg Eur 2011; 36:608-609.
4. Talan DA, Abrahamian FM, Moran GJ, Mower WR, Alagappan K, Tiffany BR, et al. Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med 2004; 43:305-314.
5. Banwell H. What is the evidence for tissue regeneration impairment when using a formulation of PVP-I antiseptic on open wounds? Dermatology 2006; 212:66-76.
6. Ranganatha BT, Pawan Kumar KM. Canine tooth in hand - A rare entity. Journal of Clinical Orthopaedics and Trauma 2014; 5: 91-93.
7. Ozsarac M, Demircan A, Sener S. Glass foreign body in soft tissue: possibility of high morbidity due to delayed migration. J Emerg Med 2011; 41:125-128.
8. Tuncer S, Ozcelik IB, Mersa B, Kabakas F, Ozkan T. Evaluation of patients undergoing removal of glass fragments from injured hands: a retrospective study. Ann Plast Surg 2011;67: 114-118
9. Steele MT, Tran LV, Watson WA, Muelleman RL. Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration. Am J Emerg Med 1998; 16:627-630
10. Levine MR, Gorman SM, Young CF, Courtney DM. Clinical characteristics and management of wound foreign bodies in the ED. Am J Emerg Med 2008;26:918-922.
11. Hamnett NT, Tehrani H, McArthur P. Perch fin foreign body in a paediatric hand. J Plast Reconstr Aesthet Surg 2013; 63:2198-2199.
12. Halaas GW. Management of foreign bodies in the skin. Am Fam Physician 2007; 76:683-688.
13. Anderson MA, Newmeyer 3rd WL, Kilgore Jr ES. Diagnosis and treatment of retained foreign bodies in the hand. Am J Surg.1982; 144(1):63–67.
14. De Lacey G, Evans R, Sandin B. Penetrating injuries: how easy is it to see glass (and plastic) on radiographs? Br J Radiol. 1985; 58(685):27–30.
15. Russell RC, Williamson DA, Sullivan JW, Suchy H, Suliman O. Detection of foreign bodies in the hand. J Hand SurgAm. 1991;16 (1):2–11.
16. Blankstein A, Cohen I, Heiman Z, Salai M, Heim M, Chechick A. Localization, detection and guided removal of soft tissue in the hands using sonography. Arch Orthop Trauma Surg. 2000; 120 (9):514–517.
17. Salati SA, Rather A. Missed foreign bodies in the hand: an experience from a center in Kashmir. Libyan J Med 2010; 5:5083.
18. Smoot EC, Robson MC. Acute management of foreign body injuries of the hand. Ann Emerg Med. 1983; 12(7):434– 437.
19. Tuncer S, Ozcelik IB, Mersa B, Kabakas F, Ozkan T. Evaluation of patients undergoing removal of glass fragments from injured hands: a retrospective study. Ann Plast Surg. 2011; 67(2):114–118.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareA STUDY ON CRIPPLING IN SKELETAL FLUOROSIS
English3135G. RamkumarEnglish P. ShanmugasundaramEnglishBackground: Ingestion of excess fluoride more than 1 ppm (parts per million) continuously in an endemic area causes fluorosis, a chronic disease due to fluoride intoxication. Fluorosis affects teeth, bone and non skeletal soft tissues in the body. Ingestion of 4 ppm of fluoride in a rural endemic area causes skeletal fluorosis and the clinical findings are analyzed and submitted Materials And Methods: Sengotur an endemic village for fluoride in Salem district of Tamil Nadu, India has been chosen for examination of patients with skeletal fluorosis. Estimation of fluoride in two wells from which the patients drink water was analyzed by iron selective electrode and it was found that the fluoride level of water in one well is 7.5 ppm and another well 5.2ppm. Patients were examined clinically for their appearance, movements of head, rigidity of neck; alterations in the chest, like scoliosis, movements of extremities, walking were examined clinically for a total number of 60 persons with 38 males and 22 females. Results: Rigidity of Neck and Restricted Movements of Skull, Kyphosis of thoracic vertebrae, Scoliosis in the chest, bending downwards to see the floor without seeing the sky, criss cross walking, Joint pains in the upper and lower extremities, Genuvarum with bowing of leg, Crippling state of patient without movement, Paraesthesia and Paraplegia are the findings recorded Conclusion: The study has revealed characteristic of skeletal changes which could be used as clinical diagnostic markers of skeletal fluorosis differentiating from all other osteodystrophies
EnglishDrinking fluoride water 7 ppm, Rigidity of neck, skeletal deformity, Scoliosis, Kyphosis, Genuvarum, Bamboo spine, Scissors gaitINTRODUCTION
Environmental pollution of toxic substances causes human health hazards if they are exposed to excessive level of toxic substances.2 Fluoride is one of the toxic substances. The optimum level of fluoride is 1 ppm for the metabolic activities. Some authors suggest that they play a role in calcification process. More than 1ppm of fluoride in drinking water and food appears to be toxic. Fluoride exist in endemic places particularly in rural areas of rocky soils, well water,1 vegetables grown in fluoride soil, tea and fish and in air due to industrial pollution of fluoride. Excess fluoride causes the disease Fluorosis. Fluorosis is a chronic progressive disease of human beings who are exposed to different levels of excess fluoride from drinking water and food. This disease manifests as dental fluorosis affecting the teeth with mottled enamel, skeletal fluorosis affecting the bone and joint with osteosclerosis, exostosis formation2 and non skeletal fluorosis affecting soft tissues of different organs. The present paper deals with characteristic clinical findings of skeletal fluorosis from the examination of 60 persons (38 males and 22 females).
MATERIALS AND METHODS
Sengotur is a known endemic area for fluorosis in Salem district of Tamil Nadu in India and we went and examined patients with skeletal fluorosis. Rural population in this village drink fluoride water from two wells and they drink the water continuously for a long time, more than 30 years. The level of fluoride was estimated by ion selective electrode and the fluoride level was found to be 7.5 ppm in one well and 5.2 ppm in another well. Suspected people with skeletal fluorosis exposed to 7.5 ppm of drinking water were examined clinically with inspection and palpation of Skeletal system, physical appearance, movement of head and neck, movement of chest and lumbar area, joint movements of upper and lower extremities, bone changes and deformities, walking movements, and the positive findings were recorded. Pain and restricted movements of joints were elicited. Palpation was carried out in muscular and tenderness areas. In addition to this examination, patients were asked for their food habits, digestion, urine and bowel frequency etc were recorded.
RESULTS AND CLINICAL FINDINGS
In Sengotur village our study has not revealed any changes of skeletal fluorosis in children though they drink the same fluoride water. People after 22 years have developed mild body ache on exertion. This vague pain and tiredness affects their routine functions but they are not totally obstructed from their house hold and other job oriented works. Our study has showed skeletal fluorosis after 30 years with different signs and symptoms.
Changes in Head and Neck
The skeletal changes were progressive and classical changes were seen as first in head and neck. Normal patients move head upward, downward, forward, right side, left side and total rotatory movement. The movement of head is brought out by the movements of cervical vertebrae. Cervical vertebrae are arranged one over the other and united with soft intervertebral disc. In skeletal fluorosis the patient develops progressive neck rigidity and stiffness resulting in the restricted movements of head. The patient cannot move his head downwards and cannot raise his head upwards. If the patient wants to see the sky, he cannot raise the head upwards, but he can raise his eyeballs above to see the sky. The patient cannot turn towards right side or left side and the rotatory movement of head is stopped. His head is fixed in one position along with neck. In case if he wants to see anything on one side he has to turn the whole body towards that side. The neck rigidity and the head fixidity is due to the fusion of vertebral bones in the cervical areas. The cause for the fusion is the progressive deposition of fluoride in the vertebral bone and also in the intervertebral disc. The intervertebral disc gets calcified and the vertebrae fuse together giving an appearance of Bamboo. The entire process of neck rigidity and fixidity of skull is progressive, depending upon the amount of fluoride deposited in the bone and disc.
Changes in the Thoracic region
When the thoracic vertebrae are affected, the patient develops in addition to neck rigidity, stiffness and pain in the back in the area of thoracic vertebrae. Though for some time the patient can stand straight and walks with the involvement of cervical and thoracic vertebrae, in the course of time the chest will bend forward and downward with rigidity of neck and thorax. When the patient walks, one can see the forward and downward bend of chest. They develop Kyphosis – abnormally increased convexity in the curvature of thoracic vertebrae as viewed from side. They also develop scoliosis – lateral curvature of vertebral column, they can’t turn their chest right or left side and these patients have pain in the back in the area of vertebral column. In skeletal fluorosis once they have developed forward bend, they cannot straighten the chest to normal straight position and the forward bend is permanent and irreversible. The rigidity of thoracic vertebral column is due to the fusion of vertebrae as fluoride deposit and causes calcification in the vertebral bone with the intervertebral disc.
Changes in the lumbar region
Every patient can bend downward and raise his chest upward. If anybody wants to take something in the floor they bend downward and after taking raise their body straight to the normal position. People with skeletal fluorosis develop bend of the lumbar area towards downwards. Once they have a bend they cannot raise their chest to the normal position because totally the thoracic and lumbar vertebrae fuse together and become rigid with inability to move upward for straight position. The patients cannot move the head, chest, lumbar area and bend downwards to see the floor. They walk with this bend if their joints and extremities are not affected. These patients can see only the soil in the floor and not the sky. They have pain in the vertebral column and this pain increases by taking any hard substances. However though their chest is bending downwards the patient is able to take food in sitting position
Changes in the sacral and coccygeal area
Changes in sacral and coccygeal region will occur progressively to the affected patients and the characteristic clinical finding is more bend towards floor. They will have pain in and around the vertebral column and walk with this bend if the hip joints are not affected.
Changes in the Joints
In our observation small joints are little painful but no stiffness and fixidity were found with normal movements of fingers.
Joints in Upper Extremities
Elbow joints and shoulder joints are very much affected in the form of progressive pain and stiffness. Normal individuals can raise and stretch both arms and bring both hands to touch the occipital area of the skull by joining the fingers, but patients with skeletal fluorosis cannot raise their hands and bring both hands to touch the occipital region. They also cannot bend the hands back to touch the middle of the back. While they walk theywill move the hands slowly and not freely. Pain in the elbow and shoulder joints are common and they cannot lift heavy things in their hands. Hip Joint Hip joints play an important role for normal individual to bend his chest and abdomen downwards and rise upwards to the normal position, but when the hip joints are affected the joints are stiff and painful restricting the movement of hip initially and causes difficulty to walk. While walking, the patient will move the right leg towards left and left leg towards right with the characteristic SCISSORS GAIT. Patients walk by holding sticks in both hands as an aid. The cross leg in walk may be due to neural affection in the hip joint. When the hip joint is more affected the patients will be crippling patients. Knee Joint Whenever knee joint is affected, the joint will have pain and restricted movement with flexon deformity. The joint space between two knee joints is widened as characteristic GENU VARUM. In few severe cases the patient had immovable knee joint either a single or both. Crippling of patient The patient is a crippled patient in skeletal fluorosis if his joints are very much affected and not able to move and lie down in the bed. In our observations we have seen 2 patients, 1 male and 1 female; they simply sit down in the village cot and can’t stand up and lie down in the bed. They hold a stick in hand; they pass urine and faeces in the sitting position to the commodes kept underneath the village cot. 2 patients both ladies lying down in the floor and can’t get up with right leg towards left and left leg towards right in Scissors Gait. 3 patients had a very slow walk with sticks and bend his thorax, abdomen downwards due to the involvement of vertebrae and hip joint. Patients with skeletal fluorosis looks like a living monuments giving problems to the family members Changes in the Neural System The vertebral column is more susceptible for fluoride toxicity. Apart from deposition of fluoride in the cancellous bone, Exostosis- a peripheral outgrowth of bone and osteophyte develop. They compress the spinal cord causing Paraesthesia of extremities, hemiplegia or quadriplegia7 . In our observation we have seen more than 20 patients with mild paraesthesia and only 1 patient with quadriplegia. We have not any patient with deafness, as it has been reported in the literature that osteosclerosis causes compression of auditory nerve. Though bone formation pressures the Optic nerve causing visual impairment and Auditory nerve to cause deafness as in Paget’s disease, we have not seen such visual and auditory impairments in skeletal fluorosis.
DISCUSSION
Skeletal fluorosis develops only after a prolonged and continuous exposure to toxic levels of fluoride in drinking water or food in rural population who are residing permanently without moving to other places.2 Our observation shows the skeletal fluorosis develops progressively after 25 years. This may be due to the slow bone remodelling in adult patients. We have not seen children with skeletal fluorosis, particularly by neck rigidity and skull fixidity but Tiotio M and Tiotio SPS9 have recorded skeletal fluorosis in six children aged 11 – 13 years. The less incidence of skeletal fluorosis in children is that during childhood, the metabolic activity of bone for remodelling to maintain the physiological equilibrium of bone is more active. This helps to prevent the retention of fluoride in the bone. The early changes occurs in skeletal fluorosis in cervical vertebrae as the cervical vertebrae being a cancellous bone with vertebral disc a soft tissue are very much susceptible for fluoride deposition and calcification for fusion of vertebrae. The vertebral column cannot be straightened from the bend position because of the fusion of vertebrae by calcification with fluoride.2 Our observation in the endemic area revealed that the severity and intensity of fluorosis varies from group of individuals in rural area though they are taking same level of fluoride content water. People who are economically poor with deficient dietary habits have developed skeletal fluorosis faster and the severity is more, but the people who are socio economically sound and take rich nutrition develop fluorosis slowly and not much severely. This shows that the development of skeletal fluorosis depends upon the nutritional status of the patient. Calcium, Vitamin C and Antioxidants plays an important role in the genesis of fluorosis and this has to be studied in depth. In our observation, we find few patients particularly ladies suffering from skeletal fluorosis do not have dental fluorosis but the remaining patients, both males and females have shown both dental fluorosis and skeletal fluorosis. Dental fluorosis develops affecting the enamel, during the development of tooth. The fluoride incorporated with calcium in enamel remains as it is after the enamel is fully calcified. Hence the dental fluorosis cannot be corrected and remain as a marker. The reason why few ladies have no dental fluorosis is that these ladies have taken drinking water free from fluoride during their childhood, preserving their tooth without fluorosis, but when they migrated to other places after marriages, they have taken fluoride rich water developing skeletal fluorosis. Though we have not recorded any deafness in skeletal fluorosis due to pressure of exostosis in auditory canal, perceptive type of deafness was noted in case of skeletal fluorosis, due to the result of pressure caused by exostosis on eighth nerve in the internal auditory meatus reported by ABN Rao and Siddique in 19623 A patient with skeletal fluorosis had developed paraplegia and it was suspected by spinal cord tumour but after the death of the patient autopsy was done and found no spinal cord tumour but a bony projection exostosis was found from the margin of the foramen magnum and piercing the spinal cord. The paraplegia suspected in that patient is due to the spinal projection of bony projection due to fluorosis in the margin of foramen magnum reported by Janarthanan et al 1957 4. Spinal compression due to skeletal fluorosis causing neurologic condition was reported by GV Satyanarayana et al7 . Compression of spinal cord and nerve roots from osteophytosis and sclerosed vertebral column and ossified ligaments were reported by Raja Reddy et al 15 In skeletal fluorosis not only the cervical and thoracic vertebrae fuses with one another by calcification of bone and intervertebral disc but also the vertebrae fuses with ribs and pelvic bone by the autopsy findings of Lyth 1946 6 In the present study it was found that one male patient who was suffering from severe skeletal fluorosis and not able to stand has shown abdominal breathing. On thorough examination by physician the lung condition was normal. The patient had rigidity of thoracic vertebrae and it was concluded that the abdominal breathing was due to the restricted movement of thoracic wall due to stiffness in chest caused by fluoride deposition. This type of abdominal breathing due to fixation of thoracic wall in skeletal fluorosis was reported by Short et al 12 The present clinical study has revealed that muscles and tendons in the area of bony attachment are abnormally prominent, tender and painful. Weather this prominence of muscle and tendon is due to fluoride deposition or pressure of bony projection is to be elicited. But the prominence of muscles and tendons with pain was due to the pressure of multiple exostosis and irregular bone laid down as seen in the skeleton of the patient with skeletal fluorosis as autopsy findings by Singh et al 19625 but muscles, tendons and capsules also gets calcified reported by S.P.S Tiotio et al 13 In certain osteodystrophies of bone the growth of long bones are affected causing stunted growth as in rickets, achondroplasia etc, but in our observation no such stunted growth were recorded but bend of bones were seen in few cases. The fluoride though causes bend but not involve in the calcification of enchondral ossification Overall our observation we found the skeletal fluorosis is progressing and lead to skeletal changes with deformity and crippling but not involving any vital functions of the organ
CONCLUSION
Careful clinical evaluation of patients with skeletal fluorosis reveals that the patient initially have tiredness, and fatigue. Later on they develop neck rigidity, skull fixidity with restricted movements. In the course of time the patients slowly develop forward and downward bending of chest, the characteristic scoliosis and Kyphosis. Involvement of lumbar vertebrae produces total bend of chest towards the floor and failure to see the sky. Progressive pain and restricted movements of upper extremities results in inability to raise the hands. Knee joints are affected with genuvarum and bowing of legs. Neural involvement causes Paraesthesia in early and later possibility in developing quadriplegia and paraplegia. Neural involvement in the hip cause’s scissors gait of legs, abdominal breathing was recorded in chest rigidity of skeletal fluorosis. It is not a killing disease but a crippling disease and skeletal fluorosis can be diagnosed by characteristic clinical findings.
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. Source of funding: Self funding Conflict of interest: Nil
Englishhttp://ijcrr.com/abstract.php?article_id=696http://ijcrr.com/article_html.php?did=6961. A Teartise on Fluorosis; Prof. (Dr) A.K. Susheela; Fluorosis Research and Rural Development Foundation; New Delhi
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12. Shortt, H.E; Mc Robert, G.R; Barnard, TW and Nayar, A.S.M. Endemic fluorosis in the Madras Presidency. Indi, J. Med. Res. 25:553-568, 1937
13. Teotia SPS, Endemic fluorosis in India. A challenging national health problem; J. Assoc . Phys India; 1984;32:347-52
14. SPS Teotia, M Teotia; Highlights of forty years of research on endemic skeletal fluorosis in India; 4th International workshop on fluorosis Prevention and Defluoridation of water, March 2004
15. Raja Reddy; Compression of spinal cord and nerve roots from osteophytosis, sclerosed vertebral column and ossified ligaments; Neurology of endemic skeletal fluorosis; Neurology India 2009, Vol 57, Issue 1.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareSTUDY OF VARIATIONS OF COELIAC TRUNK IN WESTERN MAHARASHTRA POPULATION
English3643Sachin Phoolchand YadavEnglish Rashmi S. SinhaEnglish Tushar PatilEnglishAim: Aim was to study the variations of coeliac trunk and its branches. Methodology: Fifty embalmed donated cadavers (24 male and 26 female) were dissected in Department of Anatomy. Variations in branching pattern of coeliac trunk were observed. Diameters of coeliac trunk and its branches left gastric, splenic and common hepatic arteries along with that of superior mesenteric artery were studied. Length of coeliac trunk from its origin to origin of its first branch and of its last branch were taken. Distance between origin of coeliac trunk and superior mesenteric artery was measured on abdominal aorta. Sex differences for all these parameters were also studied. Photographs were taken for proper documentation.
Results: Normal branching pattern of coeliac trunk was found in 88%. More than three branches arising from coeliac trunk were found in 8%. Incomplete coeliac trunk was found in 2% where common hepatic artery arose from superior mesenteric artery (hepatomesenteric trunk). 2% case showed absence of coeliac trunk. Mean diameter of coeliac trunk was 8.0 mm; left gastric artery 5.0 mm; splenic artery 6.9 mm; common hepatic artery 6.6 mm and superior mesenteric artery 8.3 mm. Mean length of coeliac trunk was 28.6 mm. Mean distance between coeliac trunk and superior mesenteric artery was 19.3 mm. Splenic artery diameter has shown statistically significant difference between male and female.
Conclusion: The knowledge of anatomy of coeliac trunk and its branches are of utmost importance for various surgical and radiological procedures to prevent any complications.
EnglishCoeliac trunk, Left gastric artery, Splenic artery, Common hepatic artery, Superior mesenteric arteryINTRODUCTION
The coeliac trunk (coeliac axis, coeliac artery) is one of the unpaired visceral branches of the abdominal aorta. Superior and inferior mesenteric arteries are other two unpaired visceral branches [1p590]. The coeliac trunk typically arises from the anterior surface of the abdominal aorta at about the level of upper part of the first lumbar vertebra [1p591]. The coeliac trunk is a large, short trunk only some 1 to 3 cm long, which typically arises from the aorta while aorta lies between the two crura of the diaphragm. While the coeliac trunk typically arises a short distance above the superior mesenteric artery, these two vessels sometimes have a common stems known as coeliacomesenteric trunk [1p452]. In the embryonic life, yolk sac is supplied by vitelline arteries. Later these arteries gradually fuse and help in formation of the arteries dorsal to the mesentery of the gut. In the adult, they are developed as coeliac trunk, superior mesenteric and inferior mesenteric arteries [2p292]. These arteries supply the derivatives of foregut, midgut and hindgut respectively. Coeliac trunk supplies the parts of the foregut like liver, stomach, pancreas, spleen and proximal part of duodenum [Fig. 1 - 4]. Arterial diameter of coeliac trunk and hepatic branches has gained importance especially due to development of techniques for liver transplantation. Hepatic artery thrombosis is one of the most devastating postoperative living-related liver transplantation complications and this risk is related to the use of small diameter arteries (< 2 mm) [3]. Preoperative information on the anatomical features of the hepatic arteries is very important in hepatobiliary surgery, because there is no anastomosis between hepatic arteries and an injury to these vessels during operation would result in hepatic damage with serious morbidity [4]. The vascular variations are usually asymptomatic. These are important in patients undergoing coeliacography, prior to procedures like transcatheter therapy and chemoembolization of pancreatic and hepatic tumours [5].
Keeping in mind all these factors, this study was undertaken to observe the branching patterns and diameter and length of coeliac trunk and its branches along with superior mesenteric artery.
MATERIALS AND METHODS
1. The present study was conducted on total of fifty adult embalmed cadavers allotted to M.B.B.S. and B.D.S. students from medical and dental colleges in Western Maharashtra region. Out of these cadavers, 24 were male and 26 female. We excluded cadavers which showed signs of any trauma or surgical scars on the abdomen.
2. Instruments used were- Scissors (pointed, blunt, curved, 4” and 6” size), Scalpel (blade no. 23), Forceps (plane and tooth), Thread, Divider, Measuring scale etc [Photographs 1 and 2].
3. Each cadaver was dissected in supine position and numbered and sex was noted. Dissection was carried out according to guidelines of “Cunningham’s Manual Of Practical Anatomy” volume two, fifteenth edition [8p91-127]. A midline skin incision from the xiphisternal junction to the pubic symphysis, encircling the umbilicus, was made. Then a transverse incision from the xiphoid process to a point on the midaxillary line was made. Skin incision was extended from pubic symphysis to anterior iliac spine followed by extension upto to a point on midaxillary line. The skin was reflected from medial to lateral aspect towards the midaxillary line. Anterior abdominal wall was dissected layer wise. Muscles of anterior abdominal wall were incised and reflected laterally. Peritoneal cavity was opened and branches of coeliac trunk were identified. As dissection proceeded these branches were traced to their origins and coeliac region was dissected and cleared of nervous and connective tissue network and thus coeliac trunk was completely exposed on abdominal aorta.
1) Superior mesenteric artery was identified below the origin of coeliac trunk posterior to pancreas and was exposed.
2) The sites of origins of coeliac trunk and its all branches were noted and the branches were traced and variations were recorded. Origin of Superior mesenteric artery was also noted.
3) Circumferences of coeliac trunk, its all branches and superior mesenteric artery at their origin were measured with help of thread and measuring scale. Thereafter diameter was calculated from value of circumference with help of formula, “diameter = circumference/3.14”. [Circumference = 2πr and diameter = 2r where ‘r’ is radius and π = 3.14. Hence Circumference = 3.14 x Diameter; therefore Diameter = Circumference/ 3.14.]
4) Distance from origin of coeliac trunk to origin of its first branch, its last branch and to the origin of superior mesenteric artery was measured with help of divider and measuring scale. The length of coeliac trunk was considered as distance between origin of coeliac trunk and origin of its last branch.
5) Percentage was calculated for the branching patterns of coeliac trunk.
6) Means, standard deviations and significance of difference between two means of independent samples were calculated for quantitative data and data was analyzed by unpaired t test as test of significance.
7) A ‘p’ value of Englishhttp://ijcrr.com/abstract.php?article_id=697http://ijcrr.com/article_html.php?did=6971. Hollinshead WH. Anatomy For Surgeons, volume 2. New York: A Hoeber – Harper Book; 1956.
2. Moore KL, Persaud TVN. The Developing Human – Clinically Oriented Embryology. 8th edition. Saunders Elsevier; 2011.
3. Douard R, Ettorre GM, Chevallier JM, Delmas V, Cugnenc PH, Belghiti J. Celiac trunk compression by arcuate ligament and living-related liver transplantation: a two-step strategy for flow-induced enlargement of donor hepatic artery. Surgical and Radiologic Anatomy; 2002 December; 24(5): p. 327 – 331.
4. Nagino M, Hayakawa N, Kitagawa S, Dohke M, Nimura Y. Right anterior hepatic artery arising from the superior mesenteric artery: a case report. Hepato-Gastroenterology; 1993; 40(4): p. 407 – 409.
5. D’Souza AS, Vijayalakshmi, Hemalatha, Pugazhandhi, H Mamatha. Anatomical variations in the branches of the coeliac trunk. Journal of Clinical and Diagnostic Research. 2012 May (Suppl-1), 6(3): p. 333 – 335.
6. Warwick R, Williams PL. Gray’s Anatomy. 35th edition. Edinburgh: Longman; 1973; p. 660 – 661.
7. Schoenwolf GC, Bleyl SB, Brauer PR, and Philippa H. Larsen’s Human Embryology. 4th edition. Francis-West: Churchill Livingston/ Elsevier. 2009; p. 408 – 410.
8. Romanes GJ. Cunningham’s Manual of Practical Anatomy. 15th edition. Oxford Medical Publications; 2004.
9. Rossi G, Cova E. Studio morfologico delle arterie dello stomaco. Arch Ital di Anat e di Embryol 1904; 3: p. 485 – 526.
10. Song SY, Chung JW, Yin YH, Jae HJ, Kim HC, Jeon UB, Cho BH, So YH, Park JH. Celiac axis and common hepatic artery variations in 5002 patients: systematic analysis with spiral CT and DSA. Radiology. 2010 April; 255(1): p. 278 – 288.
11. Prakash, Rajini T, Mokhasi V, Geethanjali BS, Sivacharan PV, Shashirekha M. Coeliac trunk and its branches: anatomical variations and clinical implications. Singapore Medical Journal. 2012 May; 53(5): p. 329 – 331.
12. Michels NA. Collateral arterial pathways to the liver after ligation of the hepatic artery and removal of the celiac axis. Cancer. 1953 July; 6(4): p. 708 – 724.
13. Michels NA. Variational anatomy of the hepatic, cystic, and retroduodenal arteries. American Medical Association Achieves of Surgery. 1953 January, 66(1): p. 20 – 34.
14. Mburu KS, Alexander OJ, Hassan S, Bernard N. Variations in the Branching Pattern of the Celiac Trunk in a Kenyan Population. International Journal of Morphology. 2010 March; 28(1): p. 199 – 204.
15. Petrella, S, Rodrigues CFS, Sgrott EA, Fernandez GJM, Marques SR, Prates JC. Origin of inferior phrenic arteries in the celiac trunk. International Journal of Morphology. 2006 June; 24(2): p. 275 – 278.
16. Rio Branco P. Essai sur l’anatomic et la medecine operatoire du trone coeliaque et de ses branches de l’artere hepatique en particulier G. Steinheil. Paris 1912, 828. 17. Venieratos D, Panagouli E, Lolis E, Tsaraklis A, Skandalakis P. A morphometric study of the celiac trunk and review of the literature. Clinical Anatomy. 2013 September; 26(6): p. 741 – 750.
18. Michels NA. The hepatic, cystic and retroduodenal arteries and their relations to the biliary ducts. Annals of Surgery. 1951 April; 133(4): p. 503 – 524.
19. Chitra R. Clinically relevant variations of the coeliac trunk. Singapore Medical Journal. 2010 February; 51(3): p. 216 – 219.
20. Ugurel MS, Battal B, Bozlar U et al. Anatomical variations of hepatic arterial system, coeliac trunk and renal arteries: an analysis with multidetector CT angiography. British Journal of Radiology. 2010 August; 83(992): p. 661 – 667.
21. Silveira LA, Silveira FBC, Fazan VPS. Arterial diameter of the celiac trunk and its branches: anatomical study. Acta Cirurgica Brasileira. 2009 January – February; 24(1): p. 43 – 47.
22. Malnar D, Klasan GS, Miletic D, Bajek S, Vranic TS, Arbanas J, Bobinac D, Coklo M. Properties of the celiac trunk— anatomical study. Collegium Antropologicum. 2010; 34(3): p. 917 – 921.
23. Salve VM. Coeliaco-mesenteric trunk: a rare case report. Journal of Morphological Science. 2012; 29(4): p. 262 – 264.
24. George R. Topography of the Unpaired visceral branches of abdominal aorta. Journal of Anatomy. 1935 January; 69(2): p. 196 – 205.
25. Pant P, Mukhia R, Haritha Kumari N, Mukherjee A. Variant Anatomy of the Coeliac Trunk and Its Branches. Global Research Analysis. 2013 June; 2(6): p. 179 – 180.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareFREQUENCY OF PLACENTA PREVIA IN MULTIGRAVIDA AT TERTIARY CARE HOSPITAL
English4448Shahida ShaikhEnglishBackground: Placenta previa is a localization of placenta in the lower uterine segment, near or over the internal os. Multigravida is one of the risk factors of placenta previa. The aim of study is to look for current frequency of placenta previa in multigravida, so that further improvement in diagnosis and treatment modalities can be made in order to decrease the morbidity and mortality related to it in this group. Objective: To determine the frequency of various grades of placenta previa in multigravida at a tertiary care centerMethodology: This is a cross sectional study conducted from 28th December 2012 to 27th June 2013 at the department of Gynecology and Obstetrics, Sheikh Zaid Women, Chandka Medical College Hospital, Larkana Sindh Pakistan. A total of 208 patients enrolled in the study with non -probability purposive sampling technique. All pregnant women with singleton pregnancy of 25-35 years of age in their second or more pregnancy with gestational age ? 34 weeks were included. Exclusion criteria observed for patients with multifetal pregnancy, previous history of cesarean section, dilatation and curettage, cervical cone biopsy, myomectomy or any pelvic surgery. All pregnant women had trans-abdominal ultrasound. The presence or absence of placenta previa was reported by an experienced sonologist. The data was analyzed using SPSS version 12. Results: Among the total recruited patients, mean age of these multigravidas was 30.1±5.6 years. The mean parity of our population was 4.02±1.2. The gestational age noted was 38±1.4 weeks as mean. Median Body mass index (BMI) of registered participants was 28.40±5.9. The frequency of placenta previa was 13 (6.3%) and type IV was the most common type.
Conclusion: It is concluded from this study that the frequency of placenta previa in patients of multigravida was 6.3% and apartfrom other risk factors, multigravidity is an independent risk factor for placenta previa.
EnglishPlacenta previa, Multigravida, Age, Body mass indexINTRODUCTION
Placenta previa is in fact localization of placenta in the lower uterine segment, over or near the internal os, which is not a normal site of placental attachment.1 It undertakes clinical significance due to its adherent risk of maternal and perinatal morbidity and mortality. The frequency of placenta previa is reported as 3-5 per 1000 pregnancies and it is globally and statistically mounting due to swelling risk factors.2 In Pakistan prevalence is 3.5%,whereas this figure surges to 65% in mothers having history of previous caesarean section.3 The predisposition for occurrence of placenta previa is observed more in past era chiefly because of higher caesarean section rate and unconventionally late maternal age at conception4 .Even though origination of placenta previa stagnantly remains ambiguous, but multiple threatening elements can reveal its happening embracing Caesarean Section, high parity, increasing age and previous abortions.5 Life style of women also plays its role, likewise if mother is having history of smoking and cocaine during pregnancy ,these too have been seen escalating the possibility of placenta previa.6 Observation is that, there occurs a defect in endometrial lining causing its atrophy due to previous scarring or inflammation in the endometrium, ensuing in unusually low implantation of the placenta at the level of internal uterine os with ample blood supply.7 There are 4 grades of placenta previa. All the grades of placenta previa can cause painless vaginal bleeding during second or third trimester at any time, that further may result in postpartum hemorrhage, air embolism and ascending infection compromising maternal status and maternal mortality, fetal growth retardation, congenital malformation, fetal anemia, malpresentation and un expected fetal death.8,9 Multiparty has been considered as an important risk factor for placenta previa. These women are prone to have sixteen times more chances of placenta previa as compared to nullipara.10, Maternal and fetal mortality can be reduced by identifying the high risk patients and educating them for care about next pregnancy.11 For the diagnosis of placenta previa, although trans vaginal ultrasound is gold standard but trans-abdominal is also having75% accuracy in identification.12 The overall prevalence of placenta previa in setup like ours is 3.5%. 11 Though lots of studies have been done on placenta previa, but studies specifically on placenta previa in multigravida are scarce in Pakistan, as well as internationally. Aim of our study is to look for current frequency of placenta previa in multigravida in order to have further improvement in the diagnosis and treatment modalities, hence to decrease the morbidity and mortality related to it.
SUBJECTS AND METHOD
This cross sectional study was conducted at the department of Gynecology and Obstetrics, Sheikh Zaid Women Hospital Chandka Medical College , Larkana Sindh province of Pakistan during the period from 28th December 2012 to 27th June 2013 after taking formal approval from institutional ethical committee.The sample size obtained with non -probability purposive technique calculated by using World Health Organization sample size determination software with 95% confidence interval, 2.5% level of precision considering the prevalence of placenta previa as 3.5%.11 Accordingly we enrolled 208 patients in this study, after fulfilling following selection criteria as follows
INCLUSION CRITERIA
• All pregnant women of 25-35 years of age in their second or more pregnancy.
• Gestational age ≥ 34 weeks.(ultrasound based)
EXCLUSION CRITERIA
• Previous history of cesarean section (CS).
• Past history of dilatation and curettage (D and C).
• History of cervical cone biopsy.
• History of myomectomy or other any pelvic surgery.
• Multifetal pregnancy
The data was collected after explaining the study protocol and informed written consent. This was an observational study so no women denied. Confidentiality regarding patients’ medical and nonmedical details was maintained. All possible effect modifying variable as parity, maternal age, gestation age, and body mass index (BMI) was noted. All pregnant women underwent trans-abdominal ultrasound. Trans-vaginal ultrasound experts are available at our institute but patients usually refuse due to social constraints so we did not offer them. The presence or absence of placenta previa was reported by an experienced sonologist with 8 years’ experience in relevant field. All the collected data was transferred to predesigned Performa and analysis of data done through SPSS version 12.
RESULTS
A total of 208 patients were enrolled in this study during six months period. The age assortment of women considered was from 25 to 35 years. Equal number of patients was found to be in group of 25-30 years 104 women (50%) and same figure of 104 in 31-35 year as well. Therefore their mean age was 30.1±5.6 years. We had included patients more than 34 weeks, so there were majority of patients (156/208) at 38 -39 weeks of gestation with mean gestational age was 38±1.4 weeks. The important figure of exploration was parity Thus 52% patient had parity beyond 5 and mean parity was 4.02±1.2 ranging from 1 to 5. The number of multigravida women who had placenta previa was 13 and that made 6.3% of frequency at our setup. The type IV placenta previa was the most common type; further distribution shown in figure 1 Stratified analysis of placenta previa based on age, body mass index, is summarized in table I Among 156 patients having gestational age 38-39 weeks, 10 (6.4%) had placenta previa as compared to 1 (4.8%) woman in the group of patients with gestational age 34- 35 weeks. Of 109 patients of parity >5, we had 11 women with (10.1%) making 84% of total (11/13) patients with placenta previa compared to 1 woman (6.7%) in group of primiparity. Break up is also shown in table II.
DISCUSSION
Hemorrhage in pregnancy is still the commonest cause of maternal deaths in the parts of world with low incomes.13Placeta previa in symptomatic women may cause some times furious bleeding risking both mother and baby. Advancing maternal age is a recognized hazardous issue for abnormally situated placenta. It has been established that women at or beyond 35 years of age are vulnerable population to have placenta previa.14 The pathophysiology, how advanced maternal age impedes normal placental expansion is not well agreed. The potential description is, that the proportion of sclerotic changes on intramyometrial arteries escalates with increasing age, thus plummeting blood supply to placenta.15 In our study also, we have observed that higher maternal age is a risk factor of placenta previa (PP). We found that in women of 31-35 years of age, the frequency of placenta previa was 9.6% compared to 25-30 years of age, where the frequency of placenta previa was 2.9%. This difference has likewise been noticed by study involving two centers of Sindh province and others as well.16, 17 We found in our results, the frequency of placenta previa in patients with body mass index (BMI) >30 was 10.3% in comparison to 4.8% patients with body mass index 5 the frequency of placenta previa(PP) was 10.1% compared to 6.7% in primiparous. It makes 84% of total (11/13) women having placenta previa (PP). The difference of proportion of said condition between two groups is quite significant. These observations are also instituted in studies conducted in national and international levels as well, where reportedly 60% of their patients of placenta previa were multiparous.4, 22 Another author has similar findings in her study sharing same social scenario of highest turnover of those women who never practice contraception and end up in complicated pregnancy with placenta previa.2 In one other study, 23 it was concluded that the women having less parity halves the chances of Placenta Previa than those with or higher than 3 and identical with findings of our study.
CONCLUSION
The finding of this study highlights that apart from other complications in multiparous women, placenta previa also poses a great threat to mother as an independent risk. Antenatal diagnosis of Placenta previa may help in planning mode of delivery and saving fetomaternal lives. Being part of low resource setting, we must emphasize on capacity building to have emergency obstetric services available to mothers everywhere.
ACKNOWLEDGEMENT
Author acknowledges the enormous help received from the scholars whose articles have been cited and incorporated in references. Author is also grateful to authors / editors /publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. Source of funding: None Conflict of interest: None declared
Englishhttp://ijcrr.com/abstract.php?article_id=698http://ijcrr.com/article_html.php?did=6981. Raheel R, Tabassum R, Bhutto A, Riaz H, Hanif R. Fetal outcome in the cases of placenta previa – A retrospective study. Medical Channel 2010; 16(2):256-59.
2. Khursheed F, Shaikh F, Das CM, Shaikh RB. Placenta previa: an analysis of risk factors. Medical Channel 2010; 16(3):417-9.
3. Tabassum R, Raheel R, Bhutto A, Riaz H, Hanif F. The risk factor associated with placenta previa in patients presented to civil hospital Karachi- a case report control study. Medical Channel 2010; 16(2):276-9.
4. Shoukat A, Zafar F, Asghar S, Nighat, Ayoub A, Ambreen N, et al. Frequency of placenta previa with previous Csection:[internet].2011.Available from: http:/pjmhsonline. com/frequency_of_placenta_previa_wit.htm.
5. Hung TH, Hsieh CC, Hsu JJ, Chiu TH, Lo LM, Hsieh TT. Risk factors for placenta previa in an Asian population. International Journal of Gynecology and Obstetrics 2007; 97,26–30
6. Handler AS, Mason ED, Rosenberg DL, Davis FG. The relationship between exposure during pregnancy to cigarette smoking and cocaine use and placenta previa. Am J Obstet Gynecol1994; 170:884-9.
7. Oya A, Nakai A, Miyake H, Kawabata I, Takeshita T. Risk factors for peripartum blood transfusion in women with placenta previa: a retrospective analysis. J Nippon Med Sch. 2008; 75 (3):146-51.
8. Kean L. antepartum haemorrhage. In: Luesley DM, Baker PN.Editors Obstetrics and Gynecology. Evidence-based Text Book for MRCOG. London: Arnold Publishers; 2004: 302- 16.
9. Narti OB, Konje JC. Bleeding in late pregnancy. In: James DK Steer, Weiner CP, Gonik B, Crowther C, Robson SC, editors. High risk of pregnancy, management option. London; Elsevier. 2011:1037-52.
10. Malik AM, Siddique S, Shah IA. Placeta previa: a study to determine responsible factors. Professional Med J. 2007; 14 (3):407-10.
11. Nasreen F. Incidence causes an outcome of placenta previa. J Postgrad Med Inst. 2003; 17(1):99-104.
12. Oppenheimer L, Society of Obstetricians and Gynaecologists of Canada. Diagnosis and management of placenta previa. J Obstet Gynaecol Can 2007; 29:261.
13. Obstetrics hemorrhage. In: Cunningham FG, Leveno KJ, Bloom SL, Hauth JP, Rouse DJ, Spong Cy, editors. Williams Obstetrics. 23rd Ed. New York: The McGraw-Hill Companies 2010: 757-803.
14. Ananth CV, Wilcox AJ, Savitz DA, Bowes WA Jr, Luther ER .Effect of maternal age and parity on the risk of uteroplacental bleeding disorders in pregnancy.ObstetGynecol 1996; 511-6.
15. Zhang J, Savitz DA. Maternal age and placenta previa: a population-based, case-control study. Am J ObstetGynecol 1993;168:641-5
16. Memon S, Kumari K, Yasmin H, Bhutta S. Is it possible to reduce rates of placenta previa. Journal of the Pakistan Medical Association 2010; 60(7): 566-9.
17. Cleary-Goldman J, Malone FD, Vidaver J, Ball RH, Nyberg DA, Comstock CH, et al. Impact of Maternal Age on Obstetric Outcome. Obstet Gynecol 2005; 105:983-90.
18. Tosson, Madiha M, Tarek K. AL-Hussaini.The impact of maternal obesity on pregnancy outcome at Assiut University hospital. Ass. Univ. Bull. Environ Res 2005; 8(2) :1-11
19. Choden P, Bhutia,Lertbunnaphong T, Wongwananuruk T, Boriboonhirunsarn D. Prevalence of Pregnancy with Placenta Previa in Siriraj Hospital. Siriraj Med J 2011; 63(6):191-5.
20. Faiz AS, Ananth CV. Etiology and risk factors for placenta previa: an overview and meta-analysis of observational studies. J Maternal Fetal Neonatal Med 2003; 13:175.
21. Ojha N. Obstetric factors and pregnancy outcome in placenta previa. Journal of Institute of Medicine 2012; 34: 38-41.
22. Mgaya et al. Grand multiparity: is it still a risk in pregnancy? BMC Pregnancy and Childbirth 2013; 13:241.
23. Tuzoviæ L, Djelmiš J Ilijiæ M. Obstetric Risk Factors Associated with Placenta Previa Development: Case-Control Study Croat Med J 2003;44:728-733
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareSTUDY ON PATTERN AND MECHANISM OF ROAD TRAFFIC INJURY IN HOSPITALISED INJURY VICTIMS AND ITS ICD CLASSIFICATION
English4953P. Subhas BabuEnglish T. S. RanganathEnglishObjectives: To stratify the different categories of road users sustaining Road traffic Injuries and admitted to Victoria hospital, Bangalore and to classify the Road traffic Injuries according to ICD-10th classification of diseases.
Methods: Cross Sectional, Hospital based descriptive study, conducted in Victoria Hospital, attached to Bangalore Medical College and Research Institute, Bangalore. All Road Traffic Injury Victims admitted as inpatients at Victoria Hospital from 1st April 2006 to 31st March 2007 were the study population. Cases were interviewed using purposive sampling method. A semi structured questionnaire, developed and standardized after initial pilot study, was used to capture study variables. Available medical records and MLC register were also used to collect and corroborate information. Study sample was 866 based on availability of victims of RTI. Results and Discussion: 866 patients were interviewed of the total 1409 patients who were admitted to the hospital during the study period. Majority of the victims were in the age group of 15 to 50 years (77.7%), with 25-39 years (35.1%) most affected among this group. 88.8% of the victims were males with 11.2% of them being females. Majority of the victims were two wheeler occupants (riders or pillions) ICD 10 code V20-V29 and pedestrians ICD Code V01-V09 constituting 34.2% and 31.6% respectively. Conclusion: Majority of the victims being in the productive age group, places an economic burden on the family. Among the road users injured majority of them are two-wheeler users and pedestrians and are vulnerable road users along with cyclists.
EnglishICD classification, Road traffic injuries (RTI), Vulnerable road usersINTRODUCTION
Deaths due to RTIs are among the 2 to 6th leading causes of death in the age groups within 5-60 years. During 1975-1998 mortality attributed to RTI increased by 79% in India, 237% in Columbia, 243% in China and 384%in Botswana. 1 In India the reported number of deaths due to Road “Accidents” were 80,262 in 2001, 84059 in 2002 and 84430 in 2003.2,3 The Integrated Disease Surveillance Programme highlights that Road Traffic Injuries are the sixth leading cause of death in India (IDSP-2005).4 Certain categories of road users like pedestrians, cyclists and motorized two wheeler users are more vulnerable to road traffic injuries, which has been found from studies conducted in major cities like Bangalore, Delhi and Puducherry.5,6,7 Uniformity in recording of category of road users injured in road traffic injuries and mechanism of injuries sustained ensures comparison of injury data across various settings and identifying specific intervention measures. The International Classification of Diseases – 10th revision is a useful tool for recording of Road traffic Injuries which are classified as external causes of Morbidity and mortality under transport accidents. The classification extends from V01-V99 and is structured in 12 sub groups.
OBJECTIVES
1. To identify the different categories of road users sustaining Road traffic Injuries and admitted to Victoria hospital, Bangalore.
2. To classify the Road traffic Injuries according to ICD-10th classification of diseases
METHODOLOGY
Study Design: Cross Sectional, Hospital based descriptive study. Setting: Victoria Hospital, attached to the Bangalore Medical College and Research Institute, Bangalore. The Hospital is a referral centre catering to the needs of people from different strata of society, but predominantly to lower and lower middle class. The Hospital is a reference centre for almost the whole of Bangalore Urban and Rural districts. Study population: All Road Traffic Injury Victims seeking care at Victoria Hospital as inpatients. Sample Population: Victims of Road Traffic injury, admitted to Victoria Hospital. Cases were interviewed on all days including on Sundays and Holidays. Purposive sampling method was used and those cases which were present at the time of the visit (between 8.00 am to 6.00pm) to the Hospital were interviewed.
Exclusion criteria
• Victims brought dead due to road traffic injuries.
• Victims who were immediately referred to higher centre.
• Victims who did not consent to be a part of the study.
Data collection tools: A semi structured questionnaire, developed and standardized based on an initial pilot study, to capture study variables. Available medical records and MLC register. Study duration: From 1st April 2006 to 31st March 2007. Statistical methods: Frequencies and proportions Data analysis: Data sets were coded and Windows® ExcelTM spread sheet, was used for data entry and analysis. The Study The study was carried out between April 1, 2006 and 31st March 2007 after obtaining clearance from the Institutional Ethics Committee of Bangalore Medical College and Research Institute. Patients were visited in the emergency wards, casualty, orthopedic and surgery wards. The victims were interviewed after obtaining an informed consent. When the condition of the patients did not permit the interview, the parents, relatives or attendants were interviewed. The information collected consisted of patient identification data, time day and class of vehicle involved in the Road Traffic injury, protective gears worn and category of road user. In addition, the type and severity of injury suffered by the victims was also recorded using the data collection tool.
OPERATIONAL DEFINITIONS
Injury The word injury as defined by Baker et al “…….. is the transfer of one of the forms of Physical energy (mechanical, chemical, thermal, etc) in amounts or at rates exceeding the threshold of human tolerance. And the term accident is to be used in the exceptional event of describing a primary event in a sequence that leads ultimately to injury if that event is genuinely not predictable. 8 Recent reports have indicated that deaths are under reported by 5-10% and injuries are under reported by more than 50% in police records. Persons injured in road accidents occupied nearly 10-30% of beds in the hospitals.9 Road Traffic Injury: It has been defined as injury which took place on road (including the side walk or foot path) between two or more objects, one of which must be any kind of a moving vehicle.10
Definitions for identifying different “accidents11
1. A transport accident (V01- V99) is any accident involving a device designed primarily for or being used for conveying persons or goods from one place to another 2. Other definitions like public highway (traffic way) or street, a roadway, pedestrian, driver, passenger, person on outside of vehicle, A pedal cycle, A pedal cyclist, A motorcycle, A motorcycle rider, A three-wheeled motor vehicle, A car (automobile), A pick up truck or van, A heavy transport vehicle, A bus, A special vehicle were obtained as per the ICD – 10 classification of external causes of mortality and morbidity. 3. Traffic accident (injury) is any accident occurring in the public highway (i.e. is originating on, terminating on, or involving a vehicle partially on the highway.) A vehicle accident is assumed to have occurred on the public highway unless another place is specified, except in the cases of injuries involving only off road motor vehicles, which are classified as non-traffic injuries unless the contrary is stated. 4. A non-traffic accident is any vehicle accident that occurs entirely in any place other than a public highway.
Categorization of Road Traffic Injury
Road Traffic Injuries are classified under land transport accidents (V01-V89) which reflect the victim’s mode of transport and are subdivided to identify the victim’s counterpart or the type of event. Sub-classification of the injuries has not been made in this study.
The vehicle of which the injured person is an occupant is identified in the first two characters since it is seen as the most important factor to identify for prevention purposes. The International classification of diseases (ICD 10) classifies road traffic injuries according to external causes of morbidity and mortality from code V01 to V89 in chapter XX and injury consequences of external causes from code S00 to T14 in chapter XIX.11
RESULTS AND DISCUSSION
A total of 1409 patients were admitted during the study period, but only 866 patients could be interviewed as the casualty could not be visited on 24 hour basis and because of referrals. As evident from Table 1 and Fig 1, majority of the victims were in the age group of 15 to 50 years (77.7%), and 25- 39 years (35.1%) being most affected among this group. Children less than 14 yrs and elderly (>60yrs of age) made up a little under 5% each. According to the study done by Nilamber J et al in JIPMER7 maximum injuries were in the age group of 20-29 years (31.3%) and 71% of the victims were under 40 years of age. In another hospital based study by Ganveer GB10 majority of the victims were in the age group 18-37 years. In the study conducted at NIMHANS by Gururaj G et al5 highest number of Traumatic Brain Injuries with Road Traffic Injury was in the age group of 21-35 years (43%) with a male to female ratio of 4:1. This finding is in agreement with various studies which have found out that most of the victims are in their most productive agegroups. In the study done in the Municipal Corporation of Delhi6 of the total injuries 69% occurred in the age group of 15 to 35 years and males were four times more affected than females. It is evident that the victims are predominantly from a productive age group with the Road Traffic Injury resulting in a compromise in their quality of life. As evident from table 2. 88.8% of the victims were males with 11.2% of them being females. According to the study done by Nilamber J et al in JIPMER7 study 83% (603) were males and 123 (85.8%) were females. The central India study carried out by Ganveer GB10 found that 85.8% were males and 14.2% were females. Male to female ratio being 6:1. As males are more exposed to driving and go out for work they are at a higher risk of sustaining a RTI. In the study done in the Municipal Corporation of Delhi6 of the total injuries 69% occurred in the age group of 15 to 35 years and males were four times more affected than females. This difference may probably be due to the reason that males tend to travel more for work related and other purposes. As evident from table 3, majority of the victims were two wheeler occupants (riders or pillions) and pedestrians 34.2% and 31.6% respectively. Occupants of Auto and Light Motor vehicles made up 6.2% and 6.7% respectively. Occupants of Heavy motor vehicles accounted for 9.8% of the victims. Cyclists accounted for 5.8% of the victims. Rest of them were made up by occupants of tractors 3.6% and other vehicles 2.2%. According to the NIMHANS5 study 26% of the victims were pedestrians, 31% of them were two-wheeler riders 12% of them were two-wheeler pillions, 8% of them were bicycle users and passenger were 5%. As evident from table 4, majority of the victims were two wheeler occupants (riders or pillions) ICD 10 code V20-V29 and pedestrians ICD Code V01-V09 constituting 34.2% and 31.6% respectively. According to a community based study done by Pramod KV and Tewari KN in Delhi6 majority of the victims were Two-wheeler users 46.3% (315) and pedestrians 24.9%(169), followed by cycle users (14.1%), In the JIPMER7 study pedestrians constituted 22%, drivers (35%) and occupants of vehicles (45%) among the different type of vehicles 38.6% were bicycle users, 31.1% were motor cycle rides. Occupants of Buses (48%; 150) were the highest number of victims involved in Road Traffic Injuries, followed by truck occupants (12.6%).
CONCLUSION
Majority of the victims being in the productive age group, places an economic burden on the family apart from the physical pain and mental suffering. Among the road users injured majority of them are two-wheeler users and pedestrians. They are to be considered vulnerable road users along with cyclists. Pedestrian crossing needs to be increased and other road users need to be aware of pedestrians’ right of way. Though riders of vehicles have also suffered injuries, passengers (especially pillion riders on two-wheelers) are also vulnerable.
LIMITATIONS OF THE STUDY
1. Information is based entirely on the data collected from victims
2. As it is a Hospital based study it is not representative of the exact burden of Road Traffic Injury in the community.
3. Due to referral of cases to other institutions, some patients getting themselves discharged against medical advice and resource (time, single investigator) constraints not all victims could be interviewed.
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. Ethical Clearance: The study was cleared by the Institutional Ethics Committee of Bangalore Medical College and Research Institute, Bangalore. Informed consent: obtained from all the subjects/ relatives who were interviewed (only those who consented were the study sample) Source of funding: The authors did not receive any funding from any external agency for the conduct of the study. Conflict of interest: The authors hereby declare that there is no conflict of interest with regard to this article and/or the research with which it is associated.
Englishhttp://ijcrr.com/abstract.php?article_id=699http://ijcrr.com/article_html.php?did=6991. Peden M, Scurfield R, Sleet D, Mohan D, Hyder A, Jarawan E, et al. World Report on Road Traffic Injury prevention. Geneva: World Health Organization; 2004 2. Accidental Deaths and Suicides in India. National Crime Records Bureau, Ministry of Home Affairs. Available from: http://www.ncrb.nic.in/ADSI2005 /accident05.pdf Accessed on, June 4th 2007.
3. Health Information of India-2004. New Delhi: Controller of Publications; 2005 (Directorate General of Health and Family Welfare).
4. Park K. Park’s Textbook of Preventive and Social Medicine. 19th ed. Jabalpur, India: M/s Banarasidas Bhanot Publishers, 2007; 340-345
5. Gururaj G, Kolluri SVR, Chandramouli BA, Subbakrishna DK, Kraus JF. Traumatic Brain Injury. Publication No. 61. Bangalore 560029, India: National Institute of Mental Health and Neurosciences; 2005: 17-23.
6. Pramod KV, Tewari KN. Epidemiology of Road Traffic injuries in Delhi: Result of a survey. Regional Health Forum. Delhi. WHO- SEAR 2004; 8 (1): 4-14.
7. Nilamber J, Goutam R, Jagadish S. Epidemiological study of road traffic cases: A study from south India. Indian Journal of Community Medicine 2004 Jan-Mar; xxix(1): 20-24
8. Barry PI, Brent EH. Injury Prevention: A Glossary of terms. J Epidemiol community Health 2005; 59: 182-185.
9. Health Situation in the South East Asian Region 1998- 2000, New Delhi: World Health Organization. Regional office for South East Asia, 2002: p 165-166.
10. Ganveer GB, Tiwari RR. Injury Pattern among non-fatal Road Traffic Accident cases: a cross sectional study in central India. Indian J Med Sci [serial online] 2005, [cited 2007 July 27]; 59(1), 9-12. Available from: http:// www.indianjmed.org/text.asp?2005/59/1/9/13812 Accessed on January 20th 2007.
11. International Statistical Classification of Diseases and Related Health Problems 10th revision.2nd ed. Geneva, Switzerland. World Health Organization; 2004.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareEFFECT OF HEALTH INTERVENTION ON GLYCEMIC STATUS OF DIABETIC PATIENTS
English5458M. S. K. SwarupaEnglish Sudha BalaEnglish Vimala ThomasEnglish A. ChandrasekharEnglishObjectives: Diabetes mellitus (Type 2) has been an emerging public health problem in India. Lifestyle related risk factors play an important role in the development of diabetes and its related complications. Therefore, a study has been taken up with an objective to assess the effect of health intervention on glycemic status of diabetics. Methods and material: A descriptive epidemiological interventional study conducted over a period of three months at urban health centres of Deccan College of Medical Sciences, Hyderabad. During this study a health intervention on lifestyle modifications was given and its impact was assessed on the fasting blood glucose levels of already known patients of Diabetes Mellitus. Statistical analysis: Data was entered in Microsoft excel 2007 and interpreted by using SPSS 20. Mean, percentages and paired t test applied wherever appropriate. Results: A total of 104 diabetic patients were enrolled in our study. Majority of them were females (71.15%), belonging to upper lower socioeconomic status according to BG Prasad s classification. Family history of diabetes mellitus was found among 76.42% with higher body mass index and about 72.12% adopted sedentary type of lifestyle. There was a significant improvement in lifestyle and self care practices of the diabetic patients after health intervention. The mean fasting blood sugar level in pre intervention phase was 177.29 ± 72.01 mg/dl. Post intervention, this decreased to 133.29 ± 36.81 mg/dl which is statistically significant. Conclusions: Diabetic patients have to be educated about various risk factors causing diabetes and their modification measures by simple effective strategies to reduce the blood glucose level which has got a greater impact on further development of complications associated with type 2 diabetes mellitus.
EnglishType 2 Diabetes mellitus, Glycemic status, Health interventionINTRODUCTION
Many developing countries including India is facing “dual burden of diseases”- both communicable and non communicable disorders due to the epidemiological and the nutritional transition. Among these non communicable diseases, Diabetes Mellitus is one of the most daunting challenge. According to WHO the top three countries in terms of number of type 2 diabetes mellitus individuals with diabetes are India (31.7 million in 2000; 79.4 million in 2030), China (20.8 million in 2000; 42.3 million in 2030) and the USA (17.7 million in 2000; 30.3 million in 2030).1 With this increasing prevalence, type 2 diabetes is posing a major public health problem affecting both mortality and morbidity. Majority of the disability adjusted life years are lost in developing countries due to limited health care budget.2 The rise of diabetes is largely attributed to the epidemic of obesity, unhealthy dietary practices, sedentary lifestyle and genetic factors. It may be a life threatening disease with associated complications such as coronary artery, cerebrovascular, retinal, neurological and renal diseases; but the main initiating factor is the exposure of tissues to chronic hyperglycaemia.3 These are amenable by simple preventive strategy such as lifestyle health education component to reduce the plasma glucose levels. Majority of these education programs including Indian diabetes programme have typically focussed on weight loss, greater intake of fibre content, reduced intake of saturated fat and increased physical activity.4 Hyderabad city, a capital hub of diabetes in India,5 has a higher share of urban slums in Telangana always goes ignored. It is therefore, very important that effort should be made to identify the area that needs urgent attention to modify the lifestyle and promote self care practices about diabetes and its complications. Therefore, the objective of this study was to assess the impact of intervention measures like health education, dietary advice and encouraging physical activity on the glycaemia status of diabetics.
METHODOLOGY
The study was conducted at two Owaisi urban health centres namely Bhavani Nagar and Hassan Nagar, a field practice area of department of community medicine of Deccan College of medical sciences, Hyderabad, India. It was a four months interventional study conducted from October 2012- December 2012.All the type 2 diabetic patients attending the urban health centres over a period of two weeks were interviewed using semi structured interviewed schedule which was relevant to the study. This interview schedule was pretested by pilot study on twenty patients attending outpatient clinic at Owaisi hospital. A questionnaire schedule was developed after pilot test and the necessary changes were incorporated. Voluntary consent form was prepared in urdu language. Among the total one thousand and hundred patients attending the urban health centre during two weeks, identified existing cases of type 2 diabetes of at least one year duration and on treatment for at least an year among resident adults>20 years of age based on history of disease or history of taking anti diabetic drugs or documentary proof (prescription or report of blood sugar levels) of type 2 diabetes were included ie a total of hundred and four patients were taken. The information was collected about various socio demographic factors, family history, addictions, duration of disease, physical activity(daily activity + exercise), associated disorders, complications, symptoms, lifestyle, self care factors by the investigator. Height, weight, blood pressure and fasting blood sugar were measured using appropriate technique. Body mass index was calculated as a measure of obesity as per Asian guidelines of obesity. At the same sitting educational intervention with counselling was done on one to one basis in local vernacular Urdu language. A pamphlet with health education information regarding diabetes printed in Urdu is distributed to all patients. After a period of three months, their improvement in their lifestyle and self care factors were assessed using the same proforma for over two weeks along with their fasting blood sugar level after intervention at urban health centre. Intervention measures include: 1. Health education: patients were given basic information about diabetes and its complications and how to control blood sugar levels and prevent its complications. Patients were given information about hypoglycaemia, how to prevent it and what to do during the episodic spell. 2. Dietary advice: they were given information on different types of foods which are beneficial or harmful, spacing of meals and frequent intake of small quantity of food. Restriction of sweets and oily food. 3. Physical activity: Patients were asked to practice at least 45minutes of walk or practicing yoga at regular intervals for thrice a week on daily basis were advised. 4. Self care of foot, cutting down the addictions, importance of regular eye checkups and importance of regular treatment.
STATISTICAL ANALYSIS
The collected data was numerically coded and entered in Microsoft excel 2007 and then analysed using SPSS version 20. The statistical measures obtained were proportions, percentages, mean scores and paired t test wherever appropriate to see the association between various parameters both pre and post intervention.
RESULTS
Socio demographic characteristics: A total of 104 diabetic patients were examined, consisting of 30(28.85%) males and 74(71.15%) females. Majority of patients 28(26.92%) were in the age group of 40-45 years with the mean age of patients was 50.21± 11.32yrs ; 51(49.04%) subjects were from upper lower socio economic status(according to Modified BG Prasad classification). Most of the patients 56 (53.85%) were illiterate. Housewives accounted the highest 63 (60.58%), followed by skilled workers 13 (12.5%) and semi skilled 10 (9.6%);family history of diabetes was reported by 80(76.92%). Table 1 Personal habits, life style and Body Mass Index: Among these diabetic patients more than half of them 69(66.39%) had personal habits such as tobacco chewing 34(32.69%), 23(22.12%) were smoking and 12(11.50%) consumed alcohol. Majority of them had adopted sedentary lifestyle 75 (72.12%) followed by moderate lifestyle 27(25.96%). As per Asian standards classification of Body Mass Index, about 35(33.65%) were overweight and 30(28.85%) were obese. Table 2 After assessing their knowledge about symptoms associated with diabetes mellitus, it was found that 62(59.61%) had polyphagia,54(51.92%)
had fatigue,48(46.15%) had Polyurea,45(43.27%) polydypsia and 37(35.58%) had weight loss. Regarding complications, it was found that peripheral neuropathy was found among 56(53.81%), diabetic retinopathy among 13(9.62) and cardiovascular diseases among 10(9.29%).
Modification factors in pre and post intervention phase:
Table 3 and 4 show significant improvement in lifestyle factors and self care adoption after interventions. Diet restriction has improved from 32% (pre intervention) to 90% (post intervention); frequent meal intake from 32% (pre intervention) to 83% (post intervention); regular exercise from 34% (pre intervention) to 76% (post intervention); regular intake of medicine from 60% (pre intervention) to 87% (post intervention; regular blood sugar monitoring from 21% (pre intervention) to 75% (post intervention; treating hypoglycaemic spells from 75% (pre intervention) to 87% (post intervention); care of feet from 15% (pre intervention) to 96% (post intervention) and compliance to the dose from 38% (pre intervention) to 80% (post intervention).
Effect of health intervention on fasting blood sugar (FBS)
Table 5 depicts the mean fasting blood sugar level in pre intervention phase was 177.29 ±72.01 mg/dl. After health intervention the mean fasting blood sugar level decreased to 133.29 ± 36.81 mg/dl which is statistically significant (P value 0.001).
DISCUSSION
The present descriptive epidemiological interventional study was conducted at an urban health centre in Hyderabad, which is a field practice area of department of community medicine, Deccan College of Medical Sciences. It was conducted over a period of three months selecting 104 known cases of type 2 diabetes mellitus by adopting simple random sampling method. Total 104 diabetic subjects were examined with mean age of 50.2yrs.In the present study, majority of the diabetic patients attending the urban health centre were females(71.15%). Also noted that most of them (49.04%) belonged to upper lower socio economic status as per modified BG Prasad’s classification and about 53.85% were illiterates. Housewives catered the majority (60.58%), followed by skilled workers(12.5%) and semi skilled workers (9.6%) respectively. Similar findings were observed by George. H et al in their study conducted among diabetics attending secondary care hospital in Vellore, Tamil Nadu where the majority attending the centre were females (61%) and the mean age of the participants was 54.45 years (SD 6.1). Of the study participants, 25.5% had not received any formal education. Housewives accounted for 45% of the study participants, unskilled workers 17% and farmers, shop owners, and clerical job holders 11.3%.6 It was observed in our study that 76.92% of them had positive family history of diabetes mellitus and had personal habits such as to tobacco chewing 34(32.69%), 23(22.12%) smoking and 12(11.50%) alcohol consumption. Priya D et al had found 44.2% of them had family history of diabetes mellitus among diabetics attending diabetic clinic at government medical college, Nagpur, Maharashtra. In the same study they also found current tobacco chewing, smoking and alcohol consumption among 19%, 10.2% and 30.3% respectively.7 According to Asian classification of nutritional status we found 33.65% of them over weight and 28.85% of them obese. Similarly Hemant Mahajan et al in their study conducted in urban slums of Mumbai depicted total 178 (59.3%) had Body mass index (BMI) more than or equal to 25 kg/m2.8 Present study had observed significant improvement in lifestyle, self care practices and fasting blood glucose status of patients after health intervention. Bhuwan Sharma et al has conducted study in eastern suburb of Mumbai in the field practice area of Grants medical college had observed an improvement in their lifestyle and self care factors after health intervention such as maintaining diet from pre intervention 28.68% to post intervention 56.62%; doing regular exercise from 33.46% to 43.04% ; regular treatment from 59.2% to 81.98%; regular checking of blood sugar levels from 20.22% to 31.61% and treating hypoglycaemic spells from 12.5% to 26.11%.9 Similarly Sultan R Ahmed also found significant improvement in lifestyle, self care practices and glycaemia status of patients (both fasting and post prandial blood glucose levels) after health intervention.10 Balagopal et al in their diabetes prevention and management program me in rural India found that the lifestyle modifications were effective in reducing some of the risk factors for type 2 diabetes and improving self management of the disease.11 Englert.H observed that 35% of fasting blood sugar reduction among diabetics in their 4-week, communitybased intensive educational lifestyle intervention programme (CHIP) at Rockford, Illinois, USA.12
CONCLUSIONS
From the present study we can conclude that significant improvement in the glycaemic status can be achieved among diabetic patients by health interventions such as health education, dietary advice and encouraging physical activity to bring out lifestyle and self care modification. One of the limitation of the study was Glycosylated HB (Hb1Ac) which is a good indicator of glycemic control but in this study it is measured with only fasting blood sugar level due to financial constraints. These findings highlight the need of health intervention programme to improve the quality of life and prevent further complications associated with Type 2Diabetes Mellitus.
ACKNOWLEDGEMENT
Authors sincerely thank Dr Sultan Rizwan Ahmed, Associate professor, Department of Community Medicine, Deccan College of Medical Sciences for his immense support in the study. Authors would also thank Mohammed Faiyazuddin, Medico social worker, Deccan College of Medical Sciences for his contribution in health education among diabetic patients in local language and all the staff members of urban health centre’s for their cooperation. Authors humbly acknowledge all the diabetic participants for their cooperation in the present study
Englishhttp://ijcrr.com/abstract.php?article_id=700http://ijcrr.com/article_html.php?did=7001. Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53
2. Jonsson B. The economic impact of diabetes. Diabetes care 1998;21: C7-10
3. Diabetes Mellitus. In: K.Park’s, Textbook of Preventive and Social Medicine. M/s Banarsidas Bhanot Publication, Jabalpur, 21st Edition 2011:362-366
4. Ramachandran A, Snehalatha C, Mary S, Mukesh B, Bhaskar AD, Vijay V,Indian Diabetes Prevention Programme (IDPP): The Indian diabetesprevention programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia 2006, 49:289–297
5. Mohan and R.Pradeepa. Epidemiology of diabetes in different regions of India. Health Administrator Vol: XXII Number 1and 2 - 2009 : 1- 18 .
6. George H, Rakesh P S, Krishna M, Alex R, Abraham VJ, George K, Prasad JH. Foot care knowledge and practices and the prevalence of peripheral neuropathy among people with diabetes attending a secondary care rural hospital in southern India. J Fam Med Primary Care [serial online] 2013 [cited 2014 Oct 19];2:27-32. Available from: http:// www.jfmpc.com/text.asp?2013/2/1/27/109938
7. Priya D, Hiwarkar P.A,Khakse G.M., Wahab S.N.Self-Health Care Practices Among Type 2 Diabetes Patients Attending Diabetes Clinic in India: A Descriptive Cross-Sectional Study. International Journal of Recent Trends in Science And Technology.2012,4;116-119
8. Hemant Mahajan1,Tejashri Kambali, Manish Chokhandre, Amod Borle, Maya Padvi. Health Intervention Impact Assessment on Glycemic Status of Diabetic Patients International Journal of Diabetes Research 2012, 1(5): 73-80
9. Bhuwan Sharma, Hemant Mahajan and Naresh Gill. impact of health education on knowledge, attitude, self care practices and life style modification factors in diabetic patients . International Journal of General Medicine and Pharmacy 2013;2:29-38
10. Sultan r Ahmad, Gajanan d velhal, Yasmeen k kazi. Impact of life style modifications among diabetics in an urban slum of Mumbai.National journal of community medicine 2012;3:631-636
11. Balagopal P, Kamalamma N, Patel TG, Misra R.A community-based diabetes prevention and management education program in a rural village in India.Diabetes Care 2008;31(6):1097-104
12. Heike S. Englert, Hans A. Dieh, Roger L. Greenlaw, Steve Aldana. The Effects of Lifestyle Modification on Glycemic Levels and Medication Intake: The Rockford CHIP. INTECH Open Access Publisher, 2012
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareA DETAILED STUDY TO KNOW ABOUT THE OCCURRENCE OF CHRONIC DIARRHEA IN ADDITION TO SEVERE ANAEMIA AND SEVERE EOSINOPHILIA IN PATIENTS HAVING HOOKWORMS IN DUODENUM WHILE DOING UPPER GASTRO-INTESTINAL ENDOSCOPY IN HEALTHCARE INSTITUTE
English5963Govindarajalu GanesanEnglishObjective: Severe anaemia and severe eosinophilia are commonly reported to occur in hookworm infection. But chronic diarrhea is not commonly reported to occur in hookworm infection. Hence a detailed study was done to know about the occurrence of chronic diarrhea in addition to severe anaemia and severe eosinophilia in patients having hookworms while doing upper gastro-intestinal endoscopy in our institute. Methods: A study of 1259 patients who had undergone upper gastro-intestinal endoscopy in our institute for a period of 5 years from May 2009 to April 2014 was carried out in order to find out the occurrence of chronic diarrhea in addition to severe anaemia and severe eosinophilia in patients having hookworms in duodenum while doing upper gastro-intestinal endoscopy. Results: Of these 1259 patients, as many as 18 patients were found to have hookworms in duodenum while doing upper gastrointestinal endoscopy. Of these 18 patients, 4 patients were lost for follow up and full details about their investigations were not available. Among the remaining 14 patients, one patient was found to have severe anaemia but without chronic diarrhea. Three patients were found to have severe eosinophilia or hypereosinophilia [absolute eosinophil count or aec more than 1000 cells/
cu.mm] but without chronic diarrhea. But interesetingly, one patient was found to have severe anaemia and severe eosinophilia [absolute eosinophil count or aec -1100 cells/cu.mm]along with chronic diarrhea . Hence full details about this patient with chronic diarrhea in addition to severe anaemia and eosinophilia is thoroughly analysed and discussed in detail in this article. Conclusion: Severe anaemia and eosinophilia are commonly reported to occur in hookworm infection. But chronic diarrhea also occurs rarely in hookworm infection. It is a well known fact that hookworm infection should be suspected strongly in patients with significant anaemia and eosinophilia. But hookworm infection should also be suspected in patients with chronic diarrhea, especially in tropical and subtropical countries.
EnglishSevere anaemia, Severe eosinophilia, Chronic diarrhea, Hookworms in duodenum, Upper gastro-intestinal endoscopyINTRODUCTION
There has been many reports of finding severe anaemia in patients with hookworm infection diagnosed by upper gastro -intestinal endoscopy (1-8). There has been also many reports of finding severe eosinophilia in patients with hookworm infection[(7-14). But chronic diarrhea is reported to occur only rarely in hookworm infection (9, 14). In our study also, only one patient with hookworm infection was found to have chronic diarrhea. This patient with chronic diarrhea was also found to have severe anaemia and severe eosinophilia and multiple hookworms in endoscopy. Hence upper gastro-intestinal endoscopy should always done in all patients with chronic diarrhea associated with eosinophilia or anaemia to confirm the presence of hookworms in tropical and subtropical countries.
MATERIALS AND METHODS
This study was conducted in the department of general surgery, Aarupadai Veedu Medical College And Hospital, Puducherry. A study of 1259 patients who had undergone upper gastro-intestinal endoscopy in our institute for a period of 5 years from May 2009 to April 2014 was carried out in order to find out the occurrence of chronic diarrhea in addition to severe anaemia and severe eosinophilia in patients having hookworms in duodenum while doing upper gastro-intestinal endoscopy. Severe eosinophilia or hypereosinophilia is defined as eosinophils>1000 cells/cu.mm(10). In each of these 1259 patients, the first and second part of duodenum were carefully examined to find out the presence of hookworms. Then a detailed study was made to know about the occurrence of chronic diarrhea in addition to severe anaemia and severe eosinophilia in patients having hookworms in duodenum and the results were found out as given below.
RESULTS
Of these 1259 patients, as many as 18 patients were found to have hookworms in duodenum while doing upper gastro-intestinal endoscopy. Of these 18 patients, 4 patients were lost for follow up and full details about their investigations were not available.
a. Severe anaemia but without chronic diarrhea
Among the remaining 14 patients, one patient was found to have severe anaemia [haemoglobin 2.1g%] but without chronic diarrhea.
b. Severe eosinophilia but without chronic diarrhea
Three patients were found to have severe eosinophilia or hypereosinophilia [absolute eosinophil count or aec1000,1260 and 1246] but without chronic diarrhea.
c. Severe anaemia, severe eosinophilia and chronic diarrhea all occurring together in one patient
But interesetingly, one patient was found to have severe anaemia [hb 3.2g%] and severe eosinophilia [absolute eosinophil count or aec-1100 cells/cu.mm] along with chronic diarrhea . Hence full details about this patient with chronic diarrhea in addition to severe anaemia and eosinophilia is thoroughly analysed and discussed in detail in this article. A 47 year old female patient was admitted in our hospital on 04/07/2012 with chronic diarrhea and upper abdominal pain for 6months. Her haemoglobin was 3.2g% [ normal range12-16g%], Absolute Eosinophil Count or AEC was 1100 cells/cu.mm [normal range 40- 440 cells/cu.mm], Red Blood Cells or RBC count 2.09 million cells/ cu.mm[normal range 4.2-5.4 million cells/ cu.mm], mean corpuscular volume or MCV50.7 femolitres or fl [normal range 82-92 fl] and mean corpuscular haemoglobin or MCH15 picograms or pg [normal range 27-32pg]. Her peripheral smear showed severe microcytic, hypochromic anaemia and severe eosinophilia. Her stool examination for ova and cyst was negative. She was treated with two pints of blood transfusion, haematinics and mebendazole 100mg twice daily for 3 days. Another course of mebendazole was given after 2 weeks. After one month her haemoglobin improved significantly to 9g%, but her chronic diarrhea persisted. After 6 months on 28/02/2013, she was again admitted with history of loose stools 5 times daily for one week. She was given intravenous fluids and antibiotics along with metronidazole for her diarrhea. Her haemoglobin was 9.2g%, but her severe eosinophilia persisted with absolute eosinophil count more than 1000 cells/cu.mm. But her stool examination for ova and cyst was again negative. But since she was having persistent severe eosinophilia along with chronic diarrhea for many months, she was subjected to upper gastro-intestinal endoscopy on 06/03/2013to rule out any worm infestation. Very interestingly, multiple hookworms were found in the first part of duodenum(Fig1 , 2) . Hence her severe iron deficiency anaemia at her initial admission was due to severe hookworm infection and the diagnosis of hookworm infection was completely missed at that time since upper gastro-intestinal endoscopy was not done at that time. The two full courses of mebendazole treatment given to her has failed to eradicate her hookworm infection and hence she was treated this time with a single dose of 400mg of albendazole along with haematinics and and she started showing much clinical improvement.
1. Haemoglobin
Our patient had very severe anaemia and her haemoglobin was only 3.2g%. Various other studies have also shown the presence of severe anaemia in patients with hookworm infection diagnosed by upper gastro-intestinal endoscopy (1-8). The haemoglobin of the patients in the first three studies were 3.4g%, 3.7g % and 6.5g% respectively.
2. Haemoglobin and iron deficiency anaemia
Hookworm infection produces iron deficiency anaemia and iron deficiency anaemia is defined by low haemoglobin (18-22). In our patient also with severe hookworm infection, haemoglobin is very low-3.2g% [ normal range12-16g%].
3. Mean corpuscular volume or mean red cell volume [MCV]
Our patient also had very low levels of mean red cell volume or MCV50.7 femolitres or fl [normal range 82- 92 fl] in addition to low levels of haemoglobin. In one study also, patients with hookworm infection had very low levels of mean red cell volume or MCV in addition to low levels of haemoglobin(22).
4. Mean corpuscular haemoglobin or MCH
Mean corpuscular haemoglobin or MCH was also very low 15 picograms or pg [normal range 27-32pg] in our patient . In one study also, patients with hookworm infection had low levels of mean corpuscular haemoglobin or MCH in addition to low levels of haemoglobin (23).
5. Severe eosinophilia or hypereosinophilia Eosinophilia means
Absolute Eosinophil Count or AEC more than 500 cells/cu.mm and hypereosinophilia means Absolute Eosinophil Count or AEC more than 1000 cells/cu.mm (10). The patient had severe eosinophilia or hypereosinophilia [Absolute Eosinophil Count or AEC – 1100 cells/cu.mm]. Various other studies have also shown the presence of severe eosinophilia in patients with hookworm infection (7-14). Eosinophilia is significantly associated with the presence of intestinal helminthes and especially with hookworm infection (11, 12) , but not with the presence of ecto parasites(10).
6. Chronic diarrhea
The patient also had chronic diarrhea. Chronic diarrhea is reported to occur only rarely in hookworm infection (9, 14). But other studies have shown the presence of acute diarrhea in patients with hookworm infection (13,15-17). In one study,the ova of necator americanus was found in the diarrheic stool. (17). In another study, hookworm constituted 10.2% of the intestinal parasites in diarrhoeal disease in children(16). In another study also, hookworm ova was found in addition to the ova or cyst of the intestinal parasites in diarrhoeal disease in children(15). In three studies, watery diarrhea was found in patients with hookworm infection (9,13,14). 7. Albendazole is more effective than mebendazole In the patient, the two full courses of mebendazole treatment given to her at her initial admission has failed to eradicate her hookworm infection and hence she was treated subsequently with a single dose of 400mg of albendazole and she started showing much clinical improvement. One very important study has also clearly shown that albendazole is more effective than mebendazole against hookworm infection (24). Other studies have also clearly shown that albendazole cleared hookworm infection completely (25, 26).
8. Anaemia, eosinophilia and diarrhea all occurring together
Anaemia and eosinophilia occur commonly in hookworm infection (7). Anaemia and eosinophilia occur commonly in many children with hookworm infection (8). Diarrhea along with eosinophilia is only rarely reported to occur in hookworm infection. But anaemia, eosinophilia and diarrhea all occurring together in a single patient with hookworm infection like in our patient is extremely rare and is only very rarely reported. In only one study, a 55 year old dutch male patient who has returned from Philippines with severe hookworm infection was reported to have chronic diarrhea, severe anaemia and extremely severe eosinophilia (9) almost like our patient. 9. Though anaemia and eosinophilia occur commonly in hookworm infection (7,8), anaemia, eosinophilia and diarrhea all occurring together in a single patient with hookworm infection like in our patient is extremely rare and is hence highlighted in this article.
DISCUSSION
a. Haemoglobin
Hookworm infection produces iron deficiency anaemia and iron deficiency anaemia is defined by low haemoglobin [18-22]. Anaemia is defined as the reduction in haemoglobin concentrations below the expected values [WHO,1972] [ref 20]. In our patient haemoglobin is very low 3.2g%[ normal range12-16g%] .
b. Mean corpuscular volume or or mean red cell volume [MCV]
Our patient also had very low levels mean red cell volume or MCV in addition to low levels of haemoglobin.
c. Mean corpuscular haemoglobin or MCH
Mean corpuscular haemoglobin or MCH was also very low 15 picograms or pg [normal range 27-32pg] in our patient.
d. Red blood cells or RBC count
Our patient had also undergone red blood cells or rbc count which was very low -2.09 million cells/ cu.mm [normal range 4.2-5.4 million cells/ cu.mm] . e. Peripheral smear Our patient had also undergone peripheral smear examination which showed severe microcytic, hypochromic anaemia and severe eosinophilia. Thus our patient had undergone 5 investigations to confirm her severe anaemia and the type of her anaemia namely
1. blood haemoglobin concentration, 2. mean red cell volume or mean corpuscular volume or MCV, 3. mean corpuscular haemoglobin or MCH, 4. red blood cells or RBC count- all of which showed very low values and 5. peripheral smear examination which showed severe microcytic, hypochromic anaemia. Thus our patient had undergone extremely detailed and thorough investigations to confirm her severe anaemia and the type of her anaemia and the interpretations of her various results are discussed below in detail. 1. Anaemia is defined as the reduction in haemoglobin concentrations below the expected values[WHO,1972] [20]. In our patient haemoglobin is very low 3.2g%[ normal range12-16g%]. 2. Mean corpuscular volume or MCVis the mean volume of all red blood cells or RBCs counted in the sample. Normocytic means blood with a normal mean corpuscular volume or MCV. When the mean corpuscular volume or MCV is low, the blood is said to be microcytic. 3. Mean corpuscular haemoglobin or MCH represents the mean mass of haemoglobin in the red blood cells or RBCs. Since small red blood cells [microcytic or low mean corpuscular volume] have less haemoglobin [low mean corpuscular haemoglobin] than large red blood cells, low mean corpuscular volume [ MCV] corresponds to low mean corpuscular haemoglobin [ MCH]. Thus variation in mean corpuscular haemoglobin [ MCH] corresponds to variation in mean corpuscular volume[ MCV] . 4. Our patient had also undergone red blood cells or RBC count which was very low. 5. Our patient had also undergone peripheral smear examination which showed severe microcytic, hypochromic anaemia.
CONCLUSION
Severe anaemia and eosinophilia are commonly reported to occur in hookworm infection. But chronic diarrhea is not commonly reported to occur in hookworm infection. In our study also, only one patient with hookworm infection was found to have chronic diarrhea. It is a well known fact that hookworm infection should be suspected strongly in patients with significant anaemia and eosinophilia. But hookworm infection should also be suspected in patients with chronic diarrhea, especially in tropical and subtropical countries. The patient with chronic diarrhea was also found to have severe anaemia and severe eosinophilia and multiple hookworms in endoscopy in our study. Hence upper gastro-intestinal endoscopy should always done in all patients with chronic diarrhea associated with eosinophilia or anaemia to confirm the presence of hookworms in tropical and subtropical countries.
ACKNOWLEDGEMENT
The author sincerely thanks Venkatachalapathy Arunkumar, Computer Programmer of our institue for the immense help he has offered in preparing the figures of this article. The author acknowledges the immense help received from the scholars whose articles are cited and included in references of this manuscript. The author is also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed. The author is extremely grateful to IJCRR editorial board members and IJCRR team of reviewers who have helped to bring quality to this manuscript
Englishhttp://ijcrr.com/abstract.php?article_id=701http://ijcrr.com/article_html.php?did=7011. Hyun HJ, Kim EM, Park SY, Jung JO, Chai JY, Hong ST . A case of severe anemia by Necator americanus infection in Korea. J Korean Med Sci. 2010 Dec;25(12):1802-4.
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4. Zaher, T. I., Emara, M. H., Darweish, E., Abdul-Fattah, M., Bihery, A. S., Refaey, M. M.,and Radwan, M. I. Detection of Parasites During Upper Gastrointestinal Endoscopic Procedures. Afro-Egypt J Infect Endem Dis 2012; 2 (2): 62-68.
5. Basset D, Rullier P, Segalas F, Sasso M. Hookworm discovered in a patient presenting with severe iron-deficiency anemiaMed Trop (Mars). 2010 Apr;70(2):203-4.
6. Lee TH, Yang JC, Lin JT, Lu SC, Wang TH. Hookworm Infection Diagnosed by Upper Gastrointestinal Endoscopy: —Report of Two Cases with Review of the Literature—. Digestive Endoscopy, 1994 6(1): 66–72.
7. Kato T, Kamoi R, Iida M, Kihara T.Endoscopic diagnosis of hookworm disease of the duodenum J Clin Gastroenterol. 1997 Mar;24(2):100-102.
8. Anjum Saeed, Huma Arshad Cheema, Arshad Alvi, Hassan Suleman. Hookworm infestation in children presenting with malena -case seriesPak J Med Res Oct - Dec 2008;47(4) ):98-100.
9. Verboeket SO1, van den Berk GE., Arends JE, van Dam AP, Peringa J, Jansen RR. Hookworm with hypereosinophilia: atypical presentation of a typical disease. J Travel Med. 2013 Jul-Aug;20(4):265-7.
10. Heukelbach J, Poggensee G, Winter B, Wilcke T, Kerr-Pontes LR, Feldmeier H Leukocytosis and blood eosinophilia in a polyparasitised population in north-eastern Brazil. Trans R Soc Trop Med Hyg. 2006 Jan;100(1):32-40. Epub 2005 Sep 23.
11. Nutman TB, Ottesen EA, Ieng S, Samuels J, Kimball E, Lutkoski M, Zierdt WS, Gam A, Neva FA. Eosinophilia in Southeast Asian refugees: evaluation at a referral center. J Infect Dis. 1987 Feb;155(2):309-
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13. Lawn SD1, Grant AD, Wright SG Case reports: acute hookworm infection: an unusual cause of profuse watery diarrhoea in returned travellersTrans R Soc Trop Med Hyg. 2003 Jul-Aug;97(4):414-5.
14. Wang CH, Lee SC, Huang SS, Chang LC. Hookworm infection in a healthy adult that manifested as severe eosinphilia and diarrhea. J Microbiol Immunol Infect. 2011 Dec;44(6):484-7. Epub 2011 May 23.
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16. Adedoyin MA, Awogun IA, Juergensen T Prevalence of intestinal parasitoses in relationship to diarrhoea among children in Ilorin. West Afr J Med. 1990 Apr-Jun;9(2):83-8.
17. Tinuade O, John O, Saheed O, Oyeku O, Fidelis N, Olabisi D. Parasitic etiology of childhood diarrheaIndian J Pediatr. 2006 Dec;73(12):1081-4.
18. Stoltzfus RJ1, Albonico M, Chwaya HM, Savioli L, Tielsch J, Schulze K, Yip R. Hemoquant determination of hookwormrelated blood loss and its role in iron deficiency in African children. Am J Trop Med Hyg. 1996 Oct;55(4):399-404.
19. S Pritchard DI, Quinnell RJ, … Keymer AE Hookworm (Necator americanus) infection and storage iron depletion Trans R Soc Trop Med Hyg 1991 Mar-Apr; 85(2):235-8.
20. Crompton DW1, Whitehead RR. Hookworm infections and human iron metabolismParasitology. 1993;107 Suppl:S137-45.
21. Stoltzfus RJ1, Chwaya HM, Tielsch JM, Schulze KJ, Albonico M, Savioli L. Epidemiology of iron deficiency anemia in Zanzibari schoolchildren: the importance of hookworms Am J Clin Nutr. 1997 Jan;65(1):153-9.
22. R M Hopkins, M S Gracey, R P Hobbs, R M Spargo, M Yates, R C Thompson The prevalence of hookworm infection, iron deficiency and anaemia in an aboriginal community in north-west Australia Med J Aust. 1997 Mar 3;166 (5):241- 4.
23. Watthanakulpanich D1, Maipanich W, Pubampen S, SaNguankiat S, Pooudouang S, Chantaranipapong Y, Homsuwan N, Nawa Y, Waikagul J Impact of hookworm deworming on anemia and nutritional status among children in Thailand. Southeast Asian J Trop Med Public Health. 2011 Jul;42(4):782-92.
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10HealthcareCOMPUTED TOMOGRAPHIC ASSESMENT OF DIAMETERS OF ASCENDING AND DESCENDING AORTA IN INDIAN SUBJECTS
English6467Syed Naziya P.English Althaf Ali S.English Syed Imran S.English Anand AbkariEnglish Murthy G. S. N.EnglishBackground: An enlargement of the aortic diameter exceeding at least 50% of the normal range results in aneurysm formation. Endovascular stent grafting is a newer form of treatment for thoracic aortic aneurysms that is less invasive than open surgery and has the success rate around 95%. The ratio of stent graft size to aortic diameter should be of the order of 1.1–1.15; higher diameters have to be avoided in order to limit the vessel wall stretch which may result in antegrade or retrograde dissection or perforation. After reviewing the literature thoroughly, it was found that even though the diameter of ascending and descending aorta has a wide range of clinical implications and applications, there is dearth of literature pertaining to the quantitative measurements of the diameters of ascending and descending aorta in Indian subjects. Aim: • To measure the diameter of ascending aorta (DOAA) and diameter of descending aorta (DODA) at the level of pulmonary artery bifurcation in Indian subjects using computed tomography. • To establish the upper normal limits of DOAA and DODA; to rule out aneurysm of thoracic aorta. Materials and Method: The CT chest images of 76 patients (44 males and 32 females) were studied. The DOAA and DODA were measured at the level of pulmonary artery bifurcation; across a line joining the ascending and the descending aorta. Results: 1. The average DOAA was 33.44 mm ± 1.12 mm in males and 31.43 mm ± 1.52 mm in females; the upper normal limits of DOAA were 35.68 mm for males and 34.47 mm for females. 2. The average DODA was 25.11 mm ± 1.34 mm in males and 23.04 mm ± 1.58 mm in females; the upper normal limits of DODA were 27.79 for males and 26.20 for females. Conclusion: A quantitative assessment of the diameters of ascending and descending aorta has been presented which will help the clinicians for diagnostic and therapeutic purpose especially in Indian subjects.
EnglishAscending aortic diameter (DOAA), Descending aortic diameter (DODA), Pulmonary artery bifurcation, Indian subjectsINTRODUCTION
The aorta represents a complex organ system which begins in the aortic ring adjacent to the aortic root with the origin of the two major coronary arteries, and ends at the iliac bifurcation.1 The aorta as an organ can be regarded as a biological ‘‘windkessel’’, storing kinetic energy during systole which is delivered during diastole in order to maintain a relative constant mean aortic pressure. The size of the aorta decreases with distance from the aortic valve in a tapering fashion.1 The ageing of the aorta is accompanied by a loss of compliance, and an increase of wall stiffness caused by structural changes including an increase in the collagen content and formation of intimal atherosclerosis with calcium deposits.2, 3 An enlargement of the aortic diameter exceeding at least 50% of the normal range results in aneurysm formation.1
Thoracic aortic aneurysm is a common, potentially lethal, but treatable disease, particularly if detected before dissection or rupture. Multiple imaging modalities are available for assessing the thoracic aorta, including X-ray angiography, transesophageal echocardiography (TEE), computed tomography (CT), and magnetic resonance imaging (MRI). Although all of these modalities have diagnostic value, CT has evolved to be the mainstay of evaluation owing to its accuracy and reproducibility, as well as its speed, simplicity, and true 3-dimensional capabilities. To distinguish the normal from the enlarged aorta, it is necessary to standardize the values of “normal” aortic dimensions.4 Accurate assessment of aortic size is a key component in this detection and in guiding therapeutic decisions.5 The importance of aortic diameter in determining risk for complications have been well established; 6 cm for the ascending aorta and 7 cm for the descending aorta.1, 5 Surgery is recommended well before these levels are reached. Endovascular stent grafting is a newer form of treatment for thoracic aortic aneurysms that is less invasive than open surgery and has the success rate around 95%.6, 7 The endovascular stent is placed inside the thoracic aorta to help reinforce the blood vessel and prevent the aneurysm from rupturing. Once placed in the correct location, the stent graft expands to fit within the diameter of the thoracic aorta and provides a new path for the blood flow.8, 9 The ratio of stent graft size to aortic diameter should be of the order of 1.1–1.15 with healthy areas before and after the aneurysm neck. Higher diameters should be avoided to prevent the vessel wall stretch which may result in antegrade or retrograde dissection or perforation.1 After reviewing the literature thoroughly, it was found that even though the diameter of ascending aorta and descending aorta has a wide range of clinical implications and applications, there is dearth of literature pertaining to the quantitative measurements of the diameters of ascending and descending aorta. Therefore, our aim was to determine the normal limits for ascending and descending thoracic aorta diameters in Indian subjects.
MATERIALS AND METHOD
Materials: The CT chest images using Somatom, four row CT scanner (Siemens) of 76 patients (44 males and 32 females) investigated in a private hospital were studied. Criteria of Inclusion / Exclusion: Only the patients of age group 18-60 years with normal CT report were included in the study. The patients with any space occupying lesion of mediastinum or any lung disease, patients with known coronary heart disease, hypertension, chronic pulmonary and renal disease, diabetes and severe aortic calcification were excluded. Method: It was a prospective study. The patient’s informed consent was taken to participate in the study. Patient was put in a supine position with both arms abducted and was instructed to hold the breath in full inspiration. 5mm thin sections were taken and the data obtained was analyzed at the work station of reporting room.
The diameter of ascending aorta and descending aorta were measured at the level of pulmonary artery bifurcation. The diameter were measured perpendicular to a line joining the ascending and the descending aorta; i.e. along the axis of rotation of aorta (Figure 1). The dimensions of arch of aorta were not studied because of lack of any specific level for its measurement. All these data were recorded as per the Performa in a master chart. Statistical Analysis: All these measurements were statistically analyzed by calculating the Mean and Standard Deviation (SD) using software SPSS version 22.0.
RESULTS
The following observations were made: The Diameter of Ascending Aorta The DOAA at the level of pulmonary artery bifurcation was measured and the findings were as shown in Table 1. The DOAA at the level of pulmonary artery bifurcation ranged between 30.94 mm and 35.92 mm in males and between 29.64 mm and 34.82 mm in females. The average DOAA was found to be 33.44 mm ± 1.12 mm in males and 31.43 mm ± 1.52 mm in females. The upper normal limits (mean + 2 standard deviations) of DOAA were 35.68 mm for males and 34.47 mm for females. The Diameter of Descending Aorta The DODA at the level of pulmonary artery bifurcation was measured and the findings were as shown in Table 2. The DODA at the level of pulmonary artery bifurcation ranged between 22.91 mm and 27.89 mm in males and between 20.12 mm and 26.48 mm in females. The average diameter was 25.11 mm ± 1.34 mm in males and 23.04 mm ± 1.58 mm in females. The upper normal limits of descending aorta diameter were 27.79 mm for males and 26.20 mm for females.
DISCUSSION
Kahraman et al, 10 in their study on 25 subjects from Turkey found the average DOAA to be 32.58 mm ± 3.2 mm and DODA to be 28.88 mm ± 3.45 mm. Hager et al, 3 in their study on 70 German subjects found the average DOAA to be 30.19 mm ± 4.1 mm and DODA to be 24.7 mm ± 4.0 mm. Mao et al11 studied 1422 cases and found out the average diameter of ascending aorta in males to be 33.6 mm ± 4.1 mm and 31.1 mm ± 3.9 mm in females. In present study the average diameter of ascending aorta was found to be 32.69 mm ±1.61 mm and that of descending aorta as 24.33 mm ± 1.74 mm. The average DOAA and DODA found in present study closely correspond to that found in the study by Kahraman et al 10 and Hager et al.3 However some of the differences from prior CT studies are related to differences in imaging methods including image acquisition modes, measuring site, imaging temporal resolution. Typically, invasive angiography and echocardiography use the intra-luminal diameter, while conventional cross sectional imaging includes the wall thickness. CONCLUSION Further studies with larger sample size are needed to rationalize the present findings. With more application of cardiac CT and thoracic CT, it is essential to define the normal thoracic aortic diameter changes with aging in both genders; especially in Indian subjects. Gender specific and age adjusted normals for aortic diameters are necessary to evaluate pathologic atherosclerotic changes and aneurysms of aorta.
Englishhttp://ijcrr.com/abstract.php?article_id=702http://ijcrr.com/article_html.php?did=7021. Raimund Erbel, Holger Eggebrecht. Aortic dimensions and the risk of dissection. Heart 2006; 92:137-142.
2. Aronberg DJ, Glazer HS, Madsen K, et al. Normal thoracic aortic diameters by computed tomography. J Comput Assist Tomogr 1984; 8:247–50.
3. Hager A, Harald K, Ulrike RB, Sebastian B, Karl R, Thomas M. Bernhardt, Galanski M and Hess J. Diameters of the Thoracic Aorta throughout Life as Measured with Helical Computed Tomography. Journal of Thoracic and Cardiovascular Surgery. 2002; 123:1060-1066.
4. Wolak A, Gransar H, Louise EJ, Thomson et al. Aortic Size Assessment by Noncontrast Cardiac Computed Tomography: Normal Limits by Age, Gender, and Body Surface Area. Journal of American College of Cardiological Imaging, 2008; 1:200-209.
5. Himanshu J. Patel and G. Michael Deeb. Ascending and Arch Aorta: Pathology, Natural History, and Treatment. Circulation. 2008; 118:188-195.
6. Eggebrecht H, Nienaber CA, Neuhauser M, et al. Endovascular stent-graft placement in aortic dissection: a metaanalysis. Eur Heart J 2005.
7. Nienaber CA, Eagle KA. Aortic dissection: new frontiers in diagnosis and management; Part II: therapeutic management and follow-up. Circulation 2003; 108:772–8.
8. Ince H, Nienaber CA. Endovascular stent-graft prosthesis in aortic aneurysm. J Cardiol 2001; 90:67–72.
9. Herold U, Piotrowski J, Baumgart D, et al. Endoluminal stent graft repair for acute and chronic type B aortic dissection and atherosclerotic aneurysm of the thoracic aorta. Eur J Cardiothorac Surg 2002; 22:891–7.
10. Kahraman H, Ozaydin M, Varol E, Suleyman M, Aslan, Dogan A, Altinbas A, Demir M, Gedikli O, Acar G and Ergene O. The Diameters of the Aorta and Its Major Branches in Patients with Isolated Coronary Artery Ectasia. Texas Heart Institute Journal. 2006; 33(4): 463-468.
11. Mao SS, Beckmann D, Annie C, Luan N, Ferdinand R and Matthew J. Normal Thoracic Aorta Diameter on Cardiac Computed Tomography in Healthy Asymptomatic Adults: Impact of Age and Gender. Academic Radiology. 2008; 15(7): 827-834.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10General SciencesTHE EFFECTS OF GIBBERELLIC ACID ON QUALITY AND SHELF LIFE OF BANANA (MUSA SPP.)
English6874Tolossa DugumaEnglish Meseret C. EgiguEnglish Manikandan MuthuswamyEnglishBanana (Musa spp.) is one of the most important fruit crops of the tropical and subtropical areas over the world. Worldwide, postharvest losses in fruits and vegetables range from 25 to 40% and this high loss is due to lack of packaging, storage facilities andpoor means of transportation. So, this experiment aimed at evaluating the efficiency of postharvest treatments to improve the storage of banana fruits by using gibberellic acid (GA3). Mature green banana fruits were treated by immersion in 100, 200 and 300ppm of GA3 for 15 minutes. The control fruits were immersed in distilled water the same way. Then, all fruits were stored in the lab at about 13±2°C temperature for 35 days and evaluated for different quality parameters over six periods (0, 7, 14, 21, 28 and 35 days). All fruits treated with GA3 delayed in ripening in concentration dependent manner when compared to control fruits. The ripening of fruits treated with 300ppm GA3 delayed more than other treatments. The treatment with higher concentration of gibberellic acid delayed peel color changes, weight loss, ethylene, CO2 production and total sugar content as compared with control groups. In the meanwhile, the pulp to peel ration and total soluble solids were increased with increasing the concentration of gibberellic acid treatments. This indicate that gibberellic acid prevent the fruit ripening. Therefore, postharvest application of gibberellic acid was an efficient method to delay banana fruit ripening. As gibberellic acid concentration increased, ripening was further delayed.
EnglishPostharvest loss, Gibberellic acid 3, Ripening, Musa spp.INTRODUCTION
Banana is cultivated in more than 120 countries over about 10 million hectares. It ranks first in global fruit production with just over 106 million tons being produced annually worldwide. Currently, banana is most exported fruit and ranks second after citrus fruits in terms of value over the world. Total world exports of banana in 2006 accounted for 16.8 million tons (FAOSTAT, 2006). In Ethiopia, banana is one of the widely produced and used tropical fruits. From introduced and locally collected varieties, Dwarf Cavendish, Giant Cavendish, Poyo and Ducasse hybrid were recommended for production in Ethiopia (Seifu, 1999). The area under cultivation and the total annual production of banana in the year 2000 were 15,000 ha and 100,000 tones, respectively. This grew to 39,428 ha and 260,000 tones, respectively in 2008. Most of the banana produced in Ethiopia are consumed locally with only a few exported to Djibouti, Saudi Arabia and Somalia (FAO, 2010. IJCRR Section: General Science Banana is a fragile, perishable fruit and cannot be preserved for longer time after harvesting (Taiwo and Adeyemi, 2009). It is highly desirable to delay or postpone the ripening and senescence until they are to be consumed (Ramana et al., 1989).Therefore, the current study is aimed at extending the shelf life and keeping quality of banana fruits by using different concentrations of gibberellic acid 3 (100, 200 and 300ppm).
MATERIALS AND METHODS
Banana fruits of Giant Cavendish cultivar were obtained from Melkassa Research center, Ethiopia. From the collected banana fruits, approximately equal sized fruits with no bruises or damage were selected for treatments with different concentrations of gibberellic acid GA3 (100, 200 and 300ppm) separately. The experimental design was a complete randomized design with three replications. For each GA3 treatments, 10 banana fruits were randomly assigned to prepared concentrations and immersed into their respective concentrations for 15 minutes. After 15 minutes of immersion, fruits were made to dry in air for 30 minutes. The control group was only washed with distilled water and air dried in the same way and then all fruits packed into labeled carton box, and stored for 35 days at temperature of 13 + 2 o C in the lab. Thereafter, fruit quality assessments with respect to the following parameters were carried out 6 times in7 day’s interval.
FRUIT COLOR DETERMINATION
Fruit peel color analysis was assessed visually by matching the peel color with standardized color charts that describe the seven ripening stages, and color score were assigned accordingly;1 = full green, 2 = green with yellow tip, 3 = greener than yellow, 4 = more yellow than green, 5 = yellow with green tip, 6 = fully yellow, 7 = yellow with black spots. The banana was considered unripe at stages 1-4, and ripe at stages 5-7 (Li et al., 1997).
Determination of Pulp to Peel Ratio and Physiological weight loss
The ratios of pulp to peel of each finger was calculated and mean value were recorded (Dadzie and Orchad, 1997). The physiological weight loss was determined by using method indicated by Teferra et al. (2007) Ethylene and CO2 Determination Ethylene production was measured as described by Jiang et al. (2004). Banana fruit was placed in a sealed 1.5 L jar at 20°C and incubated for 1hr to accumulate ethylene. 10ml of gas was then taken from the headspace of the jar using a gastight syringe, and injected into a gas chromatograph (Type CG, 9002 German) equipped with a flame ionization detector to determine the identity of ethylene and quantify it. For CO2 analysis, 1mL of gas was taken from the headspace of the jar using a gastight syringe and was injected into a gas chromatograph equipped with a flame ionization detector to determine its identity and quantity. Known concentrations of ethylene and CO2 standards both in synthetic air were used to generate calibration curves so as to estimate their concentrations.
Measurement of Vitamin C (Ascorbic acid) Content and Titratable Acidity (TA)
Ascorbic Acid (AA) content of banana was determined by the 2, 6-dichlorophenolindophenol method (AOAC, 2000). Measurement of titratable acidity was calculated as percentage of malic acid since it is the dominant acid in banana (Dadzie and Orchad, 1997).
Measurement of Total Soluble Solid and Total sugar content
Total soluble solids (TSS) were determined following the procedures described by Wasker et al. (1999). Total sugars were estimated by using the techniques of Seyoun (2002).
Statistical Analysis
Data obtained were subjected to analysis of variance and mean comparison using the SAS computer software version 9.1. Pearson’s correlation test was used to determine the correlation between each parameter. The p-value less than 0.05 were considered statistically as significant.
RESULTS AND DISCUSSION
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Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-5241623EnglishN2014December10General SciencesSEED SPROUTING: A WAY TO HEALTH PROMOTING TREASURE
English7579Omi LailaEnglish Imtiyaz MurtazaEnglishSeed sprouting is gaining importance commercially because it not only improves the nutritional and antioxidant value of seeds but also removes some anti-nutrients like enzyme inhibitors in them and thus makes them safer for diet. Sprouts are the richest source of proteins, carbohydrates, fats, vitamins, minerals as well as secondary metabolite composition (including phenols, flavonoids, steroids and alkaloids) and thus serve as a better source of nutrients and antioxidant rich phytochemicals as compared to seeds. Improvement of nutritional and nutraceutical value of seeds by sprouting is beneficial for human health and can be incorporated in Pharmaceutical preparations or can be directly consumed as a functional food. Such dietary constituent are preferred over drugs as comparatively they pose very little or no possible side effect even though consumed for long time. Due to their simple and inexpensive solutions to the global health problems their use in prevention and treatment of common oxidative stress linked diseases such as diabetes, cardiovascular disease and certain cancers is emerging. However, there remains much work to be done for an optimal outcome and in gaining their dietary acceptability as drug if handled properly in accordance to safety guidelines
EnglishSeed sprouting, Bioactive compounds, Oxidative stress, Antioxidant activity, Functional foodINTRODUCTION
Sprouts are four to ten days old seedlings formed from seeds during germination and are termed to be authentic “super” foods, that are really easy to grow, and don’t require an outdoor garden. Sprouts mainly originate from the Leguminosae family and there are different varieties of sprouts existing in the market, such as the alfalfa, mung bean, radish, and soy sprouts [1]. As the sprouts are consumed at the beginning of the growing phase, their nutrient concentration remains very high [2]. They have long been used in the diet as “health food”. It has been widely reported that sprouts provide higher nutritive value than raw seeds and their production is simple and inexpensive [3]. Although the use of sprouts as a food source for man is as old as the use of seeds, it is only in recent times that science has begun to unravel the chemistry of a sprouting seed, and its potential significance in both human and animal nutrition. Epidemiological studies have shown that consumption of sprouts may help to protect against certain chronic diseases and cancers. Due to the high content of bioactive agents that function as natural antioxidants and aid in cancer prevention[4]. Thus, consumption of sprouts can bring about a host of IJCRR Section: General Science health benefits. However, due to number of outbreaks associated with sprouts due to presence of pathogenic organisms, proper safety guidelines should be followed.
DISCUSSION
Nutritional benefits of sprouts When a seed sprouts, the original composition essentially changes during the germination process and the nutrientdensity of a seed is enhanced at the expense of calories. The stored food and enzymes needed for growth of the mature plant are mobilized. The protein, carbohydrate and fat are broken down to free amino acids, simple sugars and soluble compounds [5]. The quantity of the protein fraction significantly changes; the proportion of the nitrogen containing fractions shifts towards the smaller protein fractions, oligo-peptides and free amino acids. Beyond this, the quantity of the amino acids (some of them increase, others decrease or do not alter) is altered and some of the non-protein amino acids are also produced during germination. In consequence of these changes, the biological value of the sprout protein increases, and greater digestibility has been also established in the animal experiments. The vitamins including A, B-complex (B-12), C, E and K, increase to meet the growth needs of a young plant whereas, the essential minerals including calcium, magnesium, iron and zinc are supplied in organic form, “chelated” for better assimilation [6]. The composition of the triglycerides also changes, owing to their hydrolysis to free fatty acids originates and can be considered as a certain kind of pre-digestion. Generally, the ratio of the saturated fatty acids increases compared to unsaturated fatty acids, and the ratio within the unsaturated fatty acids shifts to the essential linoleic acid. The quantity of the anti-nutritive components such as the flatulence-producing α-galactosides, trypsin and chymotrypsin inhibitors, which affect the digestion of proteins, are reduced after germination, while as the utilization of the macro and micro elements are increased due to germination [7,8]. Furthermore, in addition, to being a rich source of nutritional compounds, the sprouts contain as many phytochemicals (sulphoraphane, sulphoraphene, isothiocyanates, glucosinolates, enzymes, antioxidants, vitamins) as an entire plant. Research has shown that phytochemical rich foods possess diverse disease preventive and health promoting properties [9]. Therefore, the improvement of nutritional and nutraceutical value of seeds will be beneficial for human health [10]. In the last decades of the past century, the attention of experts dealing with the healthy nutrition turned more and more towards the determination of the biological value of the nutritionally rich sprouts [11]. Thus, overall germination can lead to the development of such functional foods that have various positive effects on the humans and thus can be helpful in maintaining the proper health [12]. Enhanced phytochemical composition of seeds due to sprouting During the recent years, an increased interest in the area of research related to secondary metabolite production during the germination process has arisen, which can have valuable health promoting properties and can act as bioactive or functional components in foods. All this requires knowledge and know-how of the germination process and the biochemistry behind it. Among the secondary products of plant metabolism, phenolic compounds have attracted more and more attention as potential agents for preventing and treating many oxidative stress-related diseases [13]. Several studies have been conducted to compare the phenolic content, flavonoid content, antioxidant activity and antioxidant enzyme activity in seeds and sprouts of various leguminous plants. In a recent study, Chon et al [6] studied the effect of sprouting on total phenols and antioxidant activity of soybean, mungbean and cowpea and observed that sprouting increased the nutritive value of seeds, in terms of phenolics and flavonoids in a natural way. The total phenols content and total flavonoid levels were found to be highest in soybean sprout extracts, followed by cowpea and mung bean sprout extracts while DPPH (1,1-diphenyl-2-picryl hydrazyl radical) free radical scavenging activity was higher in cowpea or mung bean sprouts than in soybean sprouts. Similar kind of results were also obtained [14] while demonstrating the effect of sprouting on phenolic content and antioxidant activity in chickpea seed. Guoet al [15] also reported that germination dramatically increased total phenols, total flavonoids and antioxidant activity in mung bean sprouts in a time dependent manner, upto 4.5, 6.8 and 6 times higher respectively than the original concentration of mung bean seeds. In another important study, total phenolics, quercetin and ascorbic acid in buckweed sprouts were reported to be maximized on 8th day of germination, when compared to their un-germinated counterparts [16]. Likewise, fenugreek sprouts have also been found to show significant increase in their total phenol content as well as their antioxidant activity through elicited sprouting [10, 17, 18]. Natural elicitors also play a great role in increasing the phytochemical content in sprouts. Recently, Perez-Bablibrea et al [19] proved that elicitation of broccoli sprouts with salicylic acid solution increased their flavonoids. In the salicyclic treatments flavonoids content including rutin and quercetin of buckwheat sprouts was found to maximise drastically on seventh day during the germination process [20]. Literature survey also suggests that the germination caused a clear increase of saponin content of seeds as the germination proceeds. In one of the studies, Jyothi et al [21] reported that compared to seeds, the saponin content was increased to almost 3.2 times after soybean germination. In parallel to this, while studying the sapogenin make up of fenugreek plant at various stages of growth along with the different parts of the seeds, the seedlings were found to have the highest diosgenin (and other steroid sapogenin) content, compared to all other stages of growth [22]. In a recent report, Guajardo-Flores [23] concluded that the saponin concentration was increased in sprouts and cotyledons of germinated black beans to 1.9 and 2.1-fold, respectively. Germination, in addition to cause increase in protein content, dietary fibre, vitamins and bioavailability of trace elements and minerals, is one of the most common processes for the reduction of some anti-nutritive compounds, [24]. In one of the study, in comparison to their seeds, the anti-nutritional factors of lupin sprouts including oligosaccharides (RFOs),alkaloids, globulin and residual fraction content showed a clear decrease during the germination process whereas, a distinct increase of their non-protein fraction was observed [25]. A decrease in trigonelline content (alkaloid) in germinating beans, lentils and peas as well as in cotyledons of germinating mungbean (Phaseolusaureus) seeds has also been documented [26]. Kamal and Ahmad [27] also observed a time dependent decrease of alkaloid content in Nigella Sativa during germination.
Health benefits of sprouts Currently, there is much work underway to develop proper treatments for various oxidative stress related diseases. The seeds and sprouts represent excellent examples of such functional foods, defined as lowering the risk of various degenerative diseases including diabetes and several types of cancers [6]. Therefore, the consumption of seeds and sprouts has become increasingly popular among people interested in improving and maintaining their health status by changing dietary habits. A number of reports documented till date supports that sprouts can act as a potential anti-diabetic functional food. One of the recent studies on phenolic enriched pea sprouts suggests them to possess much higher hypoglycemic activity than their seeds, in relation to diabetes management. Sprouts including mung bean sprouts [28, 29], broccoli sprouts [30], sunflower sprouts [31], buckwheat sprouts [32], Macunapruriens sprouts [33] and chickpea sprouts [34] have been demonstrated to exhibit a strong antidiabetic activity under in vivo conditions. In a four weeks randomized double-blind clinical trial, broccoli sprouts have been found to improve insulin resistance among type 2 diabetic human patients [30]. Similarly, anti-diabetic mung bean sprouts improves glucose tolerance and increases insulin immunological reactivity as five weeks dietary intake of mung bean sprout has been reported to lower blood glucose, cholesterol and triglycerides in diabetic KK-A(y) mice [35]. Likewise, wheat sprouts are reported to be therapeutic for diabetes through the stimulation of insulin secretion [34]. As dietary sprouts possess potential benefits to ameliorate blood glucose levels, and reduces the production of hazardous AGEs that damage tissue physiology. Thus, consumption of sprouts in diet can be also helpful to decrease the incidence of secondary complications associated with diabetes [37]. In this regard, sunflower sprouts are anti-glycative and it potentially inhibits the formation of advanced glycation end products and strongly scavenges damaging free radicals caused by excess blood glucose [38]. Sprouts are also known to improve serum lipid profile and protect against coronary diseases. In one of the study, buckwheat sprouts on the eighth day of germination are reported to contain optimal nutrients for lowering plasma cholesterol and triglyceride levels (39). The sprouts of broccoli [40], alfalfa [41], chickpea [34], and radish [42] also significantly improve fat metabolism, reduces blood cholesterol and lowers blood glucose levels. They are known to significantly increase the survival rates by reducing inflammatory hazards that precede obesity [43]. Dietary sprouts also possess protective effects against various types of cancers. Broccoli sprouts have been found to inhibit the development and growth of lung cancer, skin tumour urinary bladder cancer, prostate cancer cells, ovarian cancer and breast cancer [44, 45, 46]. Likewise, Japanese radish sprouts are reported to prevent breast cancer and flaxseed sprouts inhibit human breast cancer cell growth [47]. Similarly, antidiabetic mung bean sprouts suppresses human melanoma tumour and anti-diabetic wheat sprouts induces apoptosis of human cancer cells [48]. Thus, when handled and distributed in accordance to safety guidelines, sprouts are affordable and accessible solutions to the global burden of chronic diseases.
CONCLUSION
The present review indicates that germination can lead to the development of such type of foods which have various positive effects in the humans. If proper interventions are utilized to minimize pathogenic microbes and other risks in sprouts, such metabolites enriched foods can be incorporated in pharmaceutical preparations for maintaining optimal human health or can be directly consumed as a functional food. However, there remains much work to be done as their mechanism of action to protect against a certain kind of disease at a cellular, biochemical and molecular level have not been comprehensively defined. A better knowledge on the chemistry of bioactive compounds synthesised during sprouting process, their isolation, their characterisation and finally their molecular interactions with target may have much higher impacts for novel drug discovery.
ACKNOWLEDGMENT
Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed
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