DOI: 10.5958/2319-5886.2015.00048.X International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 27 July 2014 Research article Coden: IJMRHS Copyright@2014 ISSN: 2319-5886 th Revised: 5 Dec 2014 Accepted: 5th Jan 2015 THE INFLUENCE OF PERIPHERAL NEUROPATHY AND PERIPHERAL VASCULAR DISEASE IN THE OUTCOME OF DIABETIC FOOT MANAGEMENT – A PROSPECTIVE STUDY Sundar Prakash S1, Krishnakumar2, Chandra Prabha3 1 Assistant Professor, Department of General Surgery, Meenakshi Medical College and Research Institute, Kanchipuram. Final year General Surgery PG, Department of General Surgery, Meenakshi Medical College and Research Institute, Kanchipuram. 3 Final year PG, Department of Physiology, Meenakshi Medical College and Research Institute, Kanchipuram 2 Corresponding author email:
[email protected] ABSTRACT Objective: Peripheral neuropathy and Peripheral Vascular Disease are the risk factors for the development of diabetic foot. The aim of this study was to evaluate differences and predictors of outcome parameters in patients with diabetic foot by stratifying these subjects according to the severity of these risk factors. Materials and methods: This is a prospective study conducted in 70 patients in the age group of 30-90 years diagnosed as Type II Diabetes with foot ulcers. After detailed clinical examination the following tests were conducted in all the patients: Complete blood count (CBC), Haemoglobin (Hb), Random Blood Sugar (RBS), Erythrocyte Sedimentation rate (ESR), Chest X-ray(CXR), Electrocardiography (ECG), foot X-ray, pus culture, Neuropathy testing by Semmes Weinstein Monofilament Test and Vibration Perception Threshold and Peripheral vascularity assessment by Duplex Doppler. Then grading of the ulcers was done using Wagner's Grade. The outcome of the patients was assessed by recording the healing time, mode of surgery and amputation rates of the patients. Results: A total of 70 patients with diabetic foot were consecutively included into the study (65.7% male, age (31% in 51-60 years), mean diabetes duration (5.2 years), Ulcer Grade (37% in Grade IV), Foot lesions (45.7% in toe), Blood sugar levels (64% in 300-400 mg/dl), Neuropathy (84%), Peripheral vascular disease (67%), major amputation (7%) and mortality (1.4%). Conclusion: All diabetic patients should undergo testing for neuropathy and peripheral vascular disease apart from doing other tests. Key words: Diabetic foot, ulcers, neuropathy, peripheral vascular disease. INTRODUCTION Complications affecting diabetes are many with some of the most catastrophic ones affecting the lower extremities. Levin et al [1] estimated that 20% of all hospital admissions for diabetes were the result of foot problems. Warren et al[2] in their survey of the lower extremities amputations found that 91.8% of amputations were performed secondary to gangrene, necrosis, ulcer, nearly one half of these patients were diabetics. Apelquist J et al[3] in their study on importance of wound classification in the outcome of diabetic foot ulcer stated that the ulcer was classified on the basis of superficial, deep, minor or major gangrene and that the healing rate of superficial ulcer is (88%) and deep ulcers is(78%) 57%. In abscess and osteomyelitis it was (57%) and found that out all there was only marginal difference in primary healing rate between the ulcer sites. 258 Sundar et al., Int J Med Res Health Sci. 2015;4(2):258-264 The remarkable pathogenesis of diabetic foot is neuropathy, microvascular and macrovascular diseases. Their process may occur exclusively or they may occur together in varying degrees placing patients at risk for morbidity such as ulceration, gangrene and infection. This is especially true if these pathological changes are combined with a foot deformity, making patients more vulnerable to foot problems. Bauman et al 4 demonstrated that only slight pressure over a fixed bony deformity, such as a prominent metatarsal head or a hammer toe lead to ischemic necrosis and ulceration of skin. For this reason it is necessary to identify the patients at increased risk. Apart from other diabetic complications, one long term complication of diabetes is neuropathy, which causes foot ulceration in diabetic patients, despite considerable research; the pathogenesis of diabetic neuropathy remains undetermined. Current hypothesis regarding the etiology of diabetic neuropathy are centered on a combination of metabolic defects secondary to higher glycaemia and vascular changes that results in nerve hypoxia. Evidence for hypoxia as etiology is considerable and includes reduced endoneurial blood flow, increased vascular resistance, and decreased endothelial production of nitric oxide. Although microvascular dysfunction has been mainly implicated, the role of peripheral vascular disease remains considerable, as it appears likely that a decrease in total limb blood flow would potentiate nerve ischemia. Hence both peripheral neuropathy and peripheral vascular disease are the commonest etiology in diabetic foot ulcer, apart from other risk factors. Tests for neuropathy and peripheral vascular diseases were done and the outcome was assessed. Aims and Objectives 1. To study the influence of peripheral neuropathy and peripheral vascular disease in the outcome of diabetic foot management. 2. To ascertain the risk of peripheral neuropathy and peripheral vascular disease in diabetic patients with diabetic foot ulcer. 3. Evaluate all patients with diabetic foot ulcer for both peripheral neuropathy and peripheral vascularity. 4. Assessment of outcome of the diabetic foot ulcers regarding neuropathic/neuroischemic status. MATERIALS AND METHODS Prospective study was conducted in 70 patients in the age group of 30 to 90 years diagnosed as Type II diabetes with foot ulcer attending the diabetic OPD and surgical units of MMCH&RI during the period October 2011 to September 2013. Permission was sought from Ethical Committee and Informed consents were obtained from all the patients. All patients in the study group had detailed clinical history of their problem and the foot ulcers were examined in detail. Inclusion criteria Patients attending MMCH&RI surgery OPD and Diabetics clinic diagnosed as diabetic foot ulcers. Patients above 30 years. Not previously diagnosed as neuropathy or having peripheral vascular diseases. Exclusion criteria Patients below 30 years of age. Non-diabetic foot ulcers. Previously diagnosed to have peripheral neuropathy and peripheral vascular diseases. All patients had undergone Complete blood count (CBC), Haemoglobin (Hb), Random Blood Sugar (RBS), Erythrocyte Sedimentation rate (ESR), Chest Xray(CXR), Electrocardiography (ECG). Neuropathy testing was done using Semmes Weinstein Monofilament Test (Fig 1&2) and then they were tested for nerve conduction studies. Peripheral vascularity was assessed clinically and also by Duplex Doppler. After all the tests, grading of the ulcers was done using Wagner's Grade. Fig 1:Semmes-Weinstein monofilament 259 Sundar et al., Int J Med Res Health Sci. 2015;4(2):258-264 Fig 2:Semmes-Weinstein monofilament Wagner Grading System: Grade 1: Superficial Diabetic Ulcer Grade 2: Ulcer extension 1.Involves ligament, tendon, joint capsule or fascia 2. No abscess or Osteomyelitis Grade 3: Deep ulcer with abscess or Osteomyelitis Grade 4: Gangrene to portion of forefoot Grade 5: Extensive gangrene of foot The outcome of the patients was assessed by recording the healing time, mode of surgery, pus culture & sensitivity and amputation rates of the patients. All the above data were analyzed. Statistical analysis: All the data were analyzed using Graph Pad Prism Version 6. RESULTS AND OBSERVATION Sex distribution Out of 70 patients enrolled for the study, 46 (65.7%) were males and 24 (34.3%) were females patients. Age distribution In our study all the patients above 30 years were included. 30% of the patients were between 51 and 70 years of age. Fig 3 shows the details of age distribution in our study. Fig 3: Age distribution Duration of diabetes : Out of 70 patients enrolled in our study majority of the patients had diabetes for 4-6 years (Table 1). The mean duration of diabetes was 5.2 years. Table 1: Duration of diabetes Duration Number (%) (in year) of Patients 0-2 15 21.4 2-4 14 20.0 4-6 24 34.3 6-8 8 11.4 8-10 5 7.4 10-12 1 1.4 12-14 2 2.8 14-16 1 1.4 Distribution of surgeries done previously for foot problems: Out of 70 patients enrolled in the study, 10 (14.28%) patients had history of previous minor amputations, 2 (2.85%) patients had history of major amputation, 3(4.3%) had undergone other surgeries like Debridement, I & D, Fasiotomies etc (Table 2). Table 2: Distribution of surgeries done previously for foot problems Foot Number (%) problems of Patients Minor amputation 10 14.2 Major Amputation 2 2.9 Others* 3 4.3 No previous surgeries 55 78.6 *Debridement, I & D, Fasiotomies, Minor Surgery Predisposing external risk factors :Out of 70 patients enrolled in our study, 48 (68.5%) patients had history of minor trauma due to bare foot walking and ill-fitting foot wear, 3 (4.3%) had toenail infection, 13 (18.5%) had history of thorn prick (Fig 4). Fig 4: Predisposing external risk factors Distribution of grades of diabetic foot ulcers: Out of 70 patients our study diagnosed with foot 260 Sundar et al., Int J Med Res Health Sci. 2015;4(2):258-264 ulceration, grading was done based on Wagner’s grading and most of the ulcers were predominantly between grades II to Grave IV (Fig 5). Fig 5: Distribution of grades of diabetic foot ulcers Distribution of foot ulcers: Out of 70 patients in our study, 32 (46%) patients had ulceration in the toes and planter surface of toes, 28 (40%) had ulcers in plantar surface of foot, metatarsal head, mid foot and heel and 10 (14.0%) had ulcers in the dorsum of foot (Table 3). Table 3: Distribution of foot ulcers Foot lesions Number of patients (%) Toe (Dorsal and Plantar Surface) 32 45.7 Plantar, Metatarasal Head,Mid Foot, Heel Dorsum of Foot Multiple Ulcers 28 10 0 40 14.3 0 Distribution of scores related to blood sugar values: Out of 70 patients, 45 (64.3%) had elevated Random Blood Sugar values ranging from 300-400 (Table 4). Table 4: Distribution of scores related to blood sugar values Blood Sugar Number (%) Values (RBS)* of patients 200-300 15 21.4 300-400 45 64.3 ≥400 10 1.4 Distribution of neuropathy: Out of 70 patients, all were categorized for neuropathy using Semmes Weinstein monofilament. Graph 4 shows 59 (84%) patients suffered from peripheral neuropathy. Fig 6: Distribution of neuropathy Distribution of nerve conduction study scores: In our study, majority of the patients (89.8%) had both sensory and motor weaknesses (Table 5). Table 5: Distribution of nerve conduction study scores Neuropathic Number (%) type of patients Sensory 5 8.5 Motor 2 3.4 Sensory (+) 53 89.8 Motor Distribution of peripheral vascular status scores: In 70 patients, 23 (33%) had peripheral vascular disease while in 47 (67%) it was not present(Table 6). Table 6: Distribution of peripheral vascular status scores Peripheral Number Vascular Disease of patients (%) Present 23 33 Absent 47 67 Distribution of score related to Doppler study: According to our study, out of 23 patients, 18 (25.7%) had stenosis of peripheral arteries, 3 (4.3%) had occlusion and 2 (2.9%) had both (Table 7). Table 7: Distribution of score related to Doppler study B. Mode Duplex Number Doppler of patients (%) Normal 47 67.1 Presence of stenosis in peripheral arteries 18 25.7 Complete Occlusion of peripheral arteries 3 4.3 Presence of both stenosis and occlusion 2 2.9 of peripheral arteries 261 Sundar et al., Int J Med Res Health Sci. 2015;4(2):258-264 Distribution of score categorized in ulcer groups: In our study 36 (51.4%) patients had neuropathic foot lesions and 23 (32.8%) had neuro-ischemia (Table 8). Table 8: Distribution of score categorized in ulcer groups Categories No. of patients (%) Neuropathic 36 51.4 Neuro-ischemia 23 32.8 Infection (Non-ischemic/ 11 12.8 non-neuropathic) Distribution of patients who had undergone amputations: In our study majority of the patients who had undergone both minor and major amputations were in patients suffering from both neuropathy and ischemia (Table 9). As per our statistical analysis Chi square test was 21.40, 1 df and the P value was <0.0001. Hence the proportion of amputation cases among neuro-ischaemia patients was significantly higher than the amputation cases in neuropathy cases alone. Table 9: Distribution of patients who had undergone amputations Categories Minor amputations (Toe) Major amputations (Forefoot, BK, AK) Neuropathic (n=36) 4(11.1%) - Neuro-ischemia(n-23) 12 (52.2%) 4 (17.3%) Infection(Non-ischemic /non-neuropathic (n=9) 4 (44.4%) 1 (11.1%) Distribution of outcome of the patients: Outcome of the patients was calculated according to the healing time. All patients had excellent outcome owing to improvement in treatment modalities as seen in Table 10. Our analysis showed, Chi square 0.2658 and P value <0.6062. Hence the treatment pattern was same in all the cases. Table 10: Distribution of outcome of the patients Categories Healed * Unhealed ** Mortality *** Neuropathic (n=36) 34 (94%) 20 (87%) 2(6%) 2 (9%) 1 (4.3%) 9(82%) 2 (18%) - Neuro-ischemia(n-23) Infection(Non ischemic/Non neuropathic(n=9) *with in a period of 6 months either by full primary healing or by SSG, **healing time more than 6 months period going for further surgeries ***patient dead due to complication of the wounds DISCUSSION Aksoy et al5 in their study in Istanbul (turkey) on diabetic foot ulcerations enrolled 66 patients of which 39 (59%) men and 27 (41%) women. In another study by Unal et al6 on diabetic foot in 200 patients in Karachi found that the percentages of males were 65 and female were 35. In our study also the results were similar, males 46 (56.7%) and females 24 (34.3%). Hence the complications of diabetic foot ulcers are more common in males. Al Mahroos et al7 in their study on diabetic patients with foot problems in patients in Bahrain observed that the mean age of the patients were 57.3 + 6.32 years. Ahmed M et al8 in their study on evaluation of diabetic foot ulcer in 100 subjects observed that the age group of patients was between 40 - 60 years. In our study done on 70 patients with diabetic foot ulcerations majority of the patients fall between 51-60 years of age and mean age of these patients was 55 + 5 years. This is relevant to the above studies and our study proved that the complications of diabetes are more common in the older age group. Nalini Singh et al9 in their study on prevalence and determinants of foot ulceration in patients with type II diabetes observed that the mean duration of diabetes was 4.3 years. Kumar S et al[10] in their study on prevalence of foot ulceration and its correlation with type II diabetes showed that the mean duration of diabetes among the patients was 7.4 years. In our study the duration of diabetes was for 5.2 years, which signifies that as the duration of diabetes increases, the foot is prone for problems. In comparison to above studies our patients with diabetes tend to develop foot ulceration little earlier. Apelquist J et al3 in their study on external risk factors for foot ulcerations and the outcome of diabetic foot lesions in 314 patients demonstrated that the external precipitating factors were identified in 264 out of 314. Common factors like ill-fitting shoes, socks, acute mechanical trauma, stress ulcers and paronychia were named. In our study majority of the patients had history of minor trauma, either due to bare foot walking (or) ill-fitting foot wear, leading to minor trauma and ulceration and minor injuries like thorn prick. This signifies the need for education on personal care of foot by selfexaminations and general awareness of foot problems and measures to prevent them and stressing the importance of proper footwear in diabetic patients. 262 Sundar et al., Int J Med Res Health Sci. 2015;4(2):258-264 Imran S et al11 in their study on frequency of lower extremity amputations in diabetes with reference to glycaemia control and Wagner's grades in Karachi showed the following results. Grade O, 6 patients, 10 in grade I, 13 in grade II, 14 in grade III, 18 in grade IV and 9 in grade V. Rooh-Ul-Muqim et al12 in their study on evaluation and management of diabetic foot by Wagner's classification, out of the 100 cases, grade O (6), grade I (14), grade II (25), grade IV 30, grade V (4). In our study the results were Grade O (1), grade I (1), grade II (24), Grade III (17), grade IV (26) and grade V (1). This shows that most of our patients present in later part of the disease. If they were treated in earlier grades the results would have been much better. Apelquist J et al3 in their study of the long term progress for diabetic patients with foot ulcer observed that the results of patients with lesions in the Toe (dorsal and Plantar surface) was 51%, plantar surface, metatarsal head and foot and heel was 28%, Dorsum of foot 14% and multiple ulcers was 7%, out of 314 subjects. Reiber et al13 in their study on the burden of diabetic foot ulcers based on severity of lesions found that 52% of patients had lesions in toe (dorsal and plantar surface), 37% had lesions on plantar, metatarsal head, mid foot and heel and 11 % in the dorsum of foot. In our study, 46% of the foot lesions were in the toes (dorsal and plantar surface) and 40% on the plantar and metatarsal head, mid foot and heel. This shows that the toes and sole of feet are vulnerable to ulceration, which signifies that the diabetic foot needs frequent self-evaluations. Oyiboso et al14 in their study on the outcome of diabetic foot ulcers in 194 subjects observed that 67% of the ulcers were due to neuropathy and 26.3% were neuro-ischemic. Ramani A et al15 in their study on etiology of diabetic foot ulceration found that peripheral neuropathy was seen in 78 % of the subjects and vascular insufficiency was seen in 49.3%. Kumar S et al10 in their study on prevalence of foot ulceration in type II diabetic patients showed that the prevalence of neuropathy was 41.6% and prevalence of PVD was 11%. In their study 20 were purely neuropathic 13 were neuroischemic, 5 pure vascular and 5 unclassified. Mohan et al16 in their study on diabetic foot ulcerations using measures of ABPI and Doppler estimated that 21.3% of the subjects were diagnosed to have PVD. Rooh-Ul-Muqim et al12 in their study on diabetic neuropathy, foot ulceration, peripheral vascular disease and their potential risk factors among the patient with diabetes demonstrated that diabetic neuropathy was found in 36.6% of patients and PVD in 11.8% of cases. In our study, 84% of the population had peripheral neuropathy in comparison with other studies. Our patients in the study population had higher incidence of peripheral neuropathy compared to their study. 33% of the patients had presence of PVD in comparison with other studies which is higher. In the ulcer groups the neuropathic ulcer were more common (51.4%), compared to the group neuro-ischemic (32.87%) and others (12.8%). In analyzing the outcome of these patients' in the above three groups the amputation rates were higher in neuro-ischemic group (69.4%) when compared to other two groups and the healing rate was better in the neuropathic group (94%) compared to neuro-ischemic (87%). This signifies that the presence of neuropathy increase the chance of foot ulceration and the presence of ischemia worsen the presentation and which further affects the outcome of the ulcer. Hence both play an important role in the prognosis of the disease apart from other associated risk factors like higher glycaemia, infection, osteomyelitis, and deformity. From our study we confirm that peripheral neuropathy is the predominant factor for foot ulceration, as the insensate foot is prone for undue trauma. The presence of ischemia due to peripheral vascular disease increases the morbidity and mortality of the diabetic foot. PVD also increases the amputation rates and reduces the healing time. CONCLUSION Male population (65.7%) is predominantly affected compared to female (34.3%). The mean age of patients in the study population with foot ulceration was between 55 + 5 years. The mean duration of diabetes was 5.2 years in patients who suffered from foot ulceration. Majority of the patients present with foot problems with G l to G IV (Wagner's Grades). Most of the ulceration occurs in toes, metatarsal head and mid foot. It was more common in deformed foot due to alteration of weight bearing. Most of the patients had blood sugar values more than 200. The duration of diabetics more than the level of sugar is the cause of foot disease. 263 Sundar et al., Int J Med Res Health Sci. 2015;4(2):258-264 Neuropathy was present in 84% of the population in the study. Nerve conduction study shows majority of the patients suffer from both sensory and motor neuropathy. 33% of the population in the study had peripheral vascular disease. 51.4% of the ulcer were neuropathic and 32.8% were neuro-ischemic and 12.8% were due to infection alone. Total amputation rate was higher (69.4%) in the neuro-ischemic group, (66.5%) in the infection group and lowest (11.1%) in the neuropathic group. Healing rates were higher in neuropathic ulcers (94%) when compared with neruo-ischemic (87%) and others (82%). Control of diabetes with soluble insulin with combination of antibiotics provides a better result. Hence apart from routine foot examination, both neuropathy and peripheral vascularity should be assessed in all patients with foot ulcerations. In conclusion "Prevention is better than Cure" Hence the insensitive diabetic foot should be protected by proper patient education, early assessment, which timely management and proper design of foot wear can avoid further (or) recurrent foot ulceration. Conflict of Interest: Nil REFERENCES 1. Levin M E, O'Neal L W, the Diabetic Foot, 3rd Ed. St.Louis CV Mosby Co. 1983; 2, 1-55. 2. Warren R, Kinn R, A survey of lower extremity amputation for ischemia surgery. 1968; 63; 10720. 3 Apelguist J, laasson J, Agardh CD. The Importance of peripheral pulses, peripheral edema and local pain for the outcome of diabetic foot ulcers, Diabetic Med.1990; 7(7); 590-4. 4. Bauman J, Girling J, Brand P Pantar, Pressures and tropical ulcertations, J Bone Joint Surgery, 1963;45B; 652-73. 5. Aksoy D Y, Gürlek A , Çetinkaya Y, Change in the Amputation Profile in Diabetic Foot in a Tertiary Reference Center: Efficacy of Team Working, Exp Clin Endocrinol Diabetes, 2004; 112(9); 526-30. 6. Unal SN, Birinci H, Baktiroğlu S, Cantez S, Comparison of Tc-99m methylene diphosphonate, Tc 99m human immune globulin and Tc-99m-labeled white blood cell scintigraphy in the diabetic foot, Clinical Nuclear Medicine 2001, 26(12); 1016-21. 7. Al-Mahroos, K Al-Roomi, Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care, Ann Saudi Med. 2007; 27(1); 25-31. 8. Ahmed SR, Zuberi BF, S Afsar, Frequency of sensory neuropathy in foot of asymptomatic type2 diabetic patients using Semmes-Weinstein monofilament, Pak J Med Sci, Apr-June 2009; 25 (3); 349-52. 9. Nalini Singh, David G. Armstrong, Benjamin A. Lipsky, Preventing Foot Ulcers in Patients With Diabetes, JAMA, January 12, 2005; 293 (2); 21728 10. Kumar S, Asheha, Parnell LN, Fernando DS, Tsigos C, Young RJ, The prevalence of foot ulceration and its correlates in type II diabetic patients a population based study, Diabetic Medicine, 1994; 11 (5); 480-84. 11. Imran, Danish, Taherzadeh, Omeed, Anthony, Use of gallipot for débridement, Plastic & Reconstructive Surgery, 2004; 113 ( 2) ; 797-98. 12. Rooh-Ul-Muqim, Samson Griffin, Mukhtar Ahmed, Evaluation and management of diabetic foot according to Wagner’s classification study of 100 cases, JAMC, 2009; l 4 (3); 234-45. 13. GayleE Reiber, BenjaminA Lipsky, GaryW Gibbons, The burden of diabetic foot ulcers, The American Journal of Surgery, 1998, 176(2) (1); 5S–10S. 14. Oyiboso, Jude E B, Tarawneh I, Nguyen H C, Armstrong D G, Harkless L B, Boulton A J, The effect of ulcer size and site, Patient’s age, sex and type and duration of diabetes on the outcome of diabetic foot ulcer, Diab Med, 2001; 18 (2); 1338. 15. Ramani A, Kundaje GN, Aetiology of diabetic foot ulceration, J Assoc Physician India, 1990; 38 (11); 843-45. 16. Mohan V, Premalatha G, Sastry NG, Peripheral vascular disease in non-insulin-dependent diabetes mellitus in South India, Diabetes Research and Clinical Practice, 1995, 27(3); 235– 40 264 Sundar et al., Int J Med Res Health Sci. 2015;4(2):258-264 DOI: 10.5958/2319-5886.2015.00049.1 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 26 Aug 2014 Research article Coden: IJMRHS Copyright@2014 ISSN: 2319-5886 th Revised: 15 Sep 2014 Accepted: 25thJan 2015 A STUDY ON PRESCRIPTION OF ANTIBIOTICS UTILIZATION IN NEONATAL INTENSIVE CARE AT A TERTIARY CARE CENTER Subash KR1, Shanmugapriyan S2 1 Associate Professor, Department of Pharmacology, Sri Padmavathi Medical College for Women, Tirupati, Andhra Pradesh, India 2 Assistant Professor, Department of Pharmacology, Meenakshi Medical college Hospital & Research Institute, Kanchipuram, Tamil Nadu, India *Corresponding author email: subbu2207@ yahoo.com ABSTRACT Introduction: The aim of this study is to analyze the utilization of antibiotics at our neonatal intensive care unit (NICU). Neonatal sepsis is one of the most common causes of admission in NICU and the causative bacteria and their respective sensitivity patterns based on the culture sensitive reports helps in achieving the antibiotic policy. Methods: This study was done after obtaining the approval from Institutional Human Ethical Committee (IHEC) of Sri Padmavati Medical College Hospital and Research Institute. The study was carried out during the period of February 2013 to April 2013 at Department of Pediatrics, Neonatology division, the total number of antibiotics used in neonatal intensive care unit (NICU) during the study period was identified and the percentage of the antibiotic prescriptions, individual and fixed dose drug combinations is evaluated. Results: Ampicillin and Gentamicin were the maximum (50%) empirically administered followed by the fixed dose combination of Piperacillin and Tazobactam was used in nearly 16% of the babies. Conclusion: The study concludes the prescription pattern at our neonatal intensive care unit complies with international studies and standards. Key words: Antibiotics, Neonatology, Intensive care Unit, Prescription. INTRODUCTION The most common groups of drugs prescribed in hospitals are antimicrobial agents. The major admission particularly at neonatal intensive care unit (NICU) is sepsis[1]. Major neonatal mortality and morbidity worldwide is due to septicemia is a recorded fact comprising various systemic infections of the newborn such as septic shock, meningitis, pneumonia, arthritis, osteomyelitis, and urinary tract infections[2]. Empirical antibiotic therapy should begin immediately on suspicion of septicemia followed by cultures and sensitivity, later based on report reevaluation of antibiotic treatment provided Subash et al., can be done[3]. Prescriptions and drug utilization monitoring can identify the problems and provide feedback to physicians so as to create awareness about irrational use of drugs[4]. These studies are useful for obtaining information about drug usage patterns and data for future reference to streamline antibiotic policy5. Currently the data about drug usage patterns is not satisfactory. There is lack of data on prescription pattern studies and it is essential to define prescribing The present study was designed to assess and procure a data of the prescription pattern in the NICU of Sri 265 Int J Med Res Health Sci. 2015;4(2):265-268 Padmavati Medical College Hospital and Research Institute to assess the prescriptions pattern in the context of their adherence to prescription format and rationality of prescription. MATERIALS AND METHODS This study was done after obtaining the approval from Institutional Human Ethical Committee (IHEC) of Sri Padmavati Medical College Hospital and Research Institute. The study was carried out in collaboration with the Department of Paediatrics, Neonatology division, The Inclusion Criteria were Neonates suspected or diagnosed to have sepsis or probable sepsis in newborn babies admitted in the NICU. The exclusion criteria includes Neonates with surgical problems, major congenital malformations, on antibiotics or those whose mothers have received antibiotics before delivery, were excluded from the present study. The Study was Prospective and observational conducted at SPMCH & RI. This study was done from February 2013 till April 2013. During this period, newborn babies admitted in the neonatal intensive care unit diagnosed or suspected to have sepsis or probable sepsis were analyzed for culture and sensitivity pattern and choice of empirical antibiotics. Details of obstetric history, maternal risk factors, and physical examination were recorded meticulously. Empirical antibiotics were started after taking blood for culture and sensitivity and then changed accordingly. RESULTS Gender Distribution male babies were at a slightly higher preponderance (42.38%) in ratio than female babies (57.62%) who were treated for neonatal sepsis. The majority of babies who were admitted 90. % were preterm as per the gestational age and more than 90% of babies had the onset of sepsis within 72 hrs of birth .There were 61% Gram negative organism which included Klebsiella pnemoniae, Escherichia coli, enterobacter and pseudomonas. The rest 39% included Gram Positive organisms Staph aureus, Staph epidermidis in neonatal intensive care unit during the study period 83% and 9.52% respectively with 2.38% sterile culture(fig:1). The chief organisms revealed in blood culture report are Klebsiella pnemoniae and pseudomonas The antibiotics used in NICU during the study period were 6 antimicrobials and 2 fixed drug dose combinations.They are Ampicillin, Gentamicin, Cefotaxime, Amikacin, Ciprofloxacin, and Metronidazole, Piperacillin with Tazobactam and Imipenem and Cilastin respectively (Table-1). 39% G.Negative G.Positive 61% Fig1: Prevalence of isolated bacteria in neonatal sepsis Table 1: Prescription pattern of antibiotics in NICU Sl. Antibiotics Number of No Prescription % n =250 1 Ampicillin 55 21.73 2 Gentamicin 55 21.73 3 Amikacin 50 20.10 4 Cefotaxime 28 11.43 5 Ciprofloxacin 16 06.52 6 Metronidazole 04 01.63 % -percentage of antibiotic utilization Table 2: Prescription pattern of Fixed dose drug combination Antibiotics in NICU Sl. Antibiotics Number of % No Prescription n =250 1 Piperacillin + 39 15.76 Tazobactam 2 Imipenem + 3 01.08 Cilastin % -percentage of antibiotic utilization Among the prescribed antibiotics Ampicillin, Gentamicin and Amikacin were utilized high at 21.73%, 21.73 and 20.10% respectively, followed by Cefotaxime 11.43%, ciprofloxacin 6.52%, and 266 Subash et al., Int J Med Res Health Sci. 2015;4(2):265-268 Metronidazole 1.63%. Among the fixed Dose drug combinations piperacillin with tazobactam 15.76% and Imipenem with cilastin 1.08%. DISCUSSION The infant mortality rate of India is 47/1000 live births, of which 70 % of deaths is in neonatal period with sepsis being one of the leading causes of death[6]. In our study, both male and female babies were equally affected and babies who had late onset neonatal sepsis were predominantly male. This was similar to a study conducted by Remington et al[7]. The present study revealed 92.85% were preterm as per the gestational age. This is a main indicator that preterm babies are more prone for neonatal sepsis than the term babies and more than 90% of babies had the onset of sepsis within 72 hrs of birth, similarly in a study conducted by Sidiropoulus et [8] al ., neonatal sepsis was much predominant in preterm babies and showed significant reduction in mortality rate. In our study also neonatal sepsis rate was found more than 90 % in preterm and low birth weight babies. The blood culture reports established Klebsiella in 4 cases followed by Pseudomonas in 2 cases. But major portion of the isolate were sterile, confirming the chief organisms Klebsiella and pseudomonas in our neonatal intensive care unit during the study period. This result adds strength to empirical treatment provided. This was similar to a study conducted in Bangalore by Shenoi et al[9]. Another study done by Viswanathan et al in 2011 at Vellore, reported Klebsiella as the chief organism causing neonatal sepsis followed by Staphylococcus aureus[10]. The total numbers of antibiotics used in our NICU during the study period were 6 individual drug and 2 fixed dose drug combinations. Of the 250 prescriptions, Ampicillin and Gentamicin were the maximum with each 40 in number as they were started empirically. This was followed by Amikacin and Cefotaxime based on the progress of clinical features like cyanosis, feeding difficulty, breathing difficulty (grunting), fast breathing (respiratory rate >60 bpm), abnormal behavior and fever/temperature >38°C. Ciprofloxacin and metronidazole were initiated only if the culture and sensitivity report Subash et al., demands its use and not empirically for a period of 10 days. The fixed dose combination of Piperacillin and Tazobactam was used in 29 babies ie for nearly 16% of the babies. Another fixed dose combination of Imipenem and Cilastin was given for 2 babies because of resistant strains. The above prescription pattern of antibiotics was similar to study on antibiotic utilization pattern done by Fanos V et al[11].. Another study done by Liem et al [12]. by collecting data from all tertiary care NICU s of Netherlands, reported that 6 out of 10 NICUs used extended-spectrum penicillins (amoxicillin and amoxicillin/clavulanic acid), b-lactamase-resistant and sensitive penicillins (flucloxacillin and benzylpenicillin, respectively), amino glycosides (gentamicin and amikacin), cephalosporins(1st and 3rd generation) and glycopeptides (vancomycin and teicoplanin). The limitations of the study are small group and seasonal infections may vary where in this observation is done during a short period and not throughout the year. The study of antibiotic utilization pattern showed that β lactam group of antibiotics, cephalosporins and amino glycosides were used more in our NICU. CONCLUSION The study concludes the prescription pattern at our neonatal intensive care unit complies with international studies. ACKNOWLEDGEMENT We are thankful to Department of Paediatrics, NICU Staff and Medical record Section staff of Proposed Sri Padmavathi medical College – Renigunta for their co-operation. Conflict of Interest – Nil REFERENCES 1. Lawn JE, Cousens S, Zupan J; 4 million neonatal deaths: Lancet; 2005:365:891–900 2. Kaistha N, Mehta M, Singla N, Garg R, Chander J. Neonatal septicemia isolates and resistance patterns in a tertiary care hospital of North India. J Infect Dev Ctries.2009; 41: 55- 7. 3. Yurdakök M. Antibiotic use in neonatal sepsis. Turk J Pediatr 1998; 40: 17- 33. 267 Int J Med Res Health Sci. 2015;4(2):265-268 4. Pradhan SC, Shewade DG, Shashindren CH, et al. Drug utilization studies. Natl Med J Ind. 1: 1988, 185-189. 5. Marshner JP, Thurmann P, Harder S, et al. Drug utilisation review on a surgical intensive care unit. Int J Clin Pharmacol Ther. 1994, 32:447-51. 6. Park K. Health information and basic medical statistics. Park‘s textbook of Preventive and Social Medicine, 21st ed. 529, 2012. 7. Remington JS, Klein JO. Infectious Diseases of the Fetus and Newborn Infant 5th Ed. WB Saunders, Philadelphia 2000; Page no. 8. Boehme U, Sidiropoulos, Muralt GV, et al. Immunoglobulin supplementation in prevention and treatment of neonatal sepsis; Pediatric Infectious disease journal;1986;5: 193-95 9. Shenoi A, Nagesh NK, Maiya PP, Bhat SR, Subba Rao SD. Multicenter randomized placebo controlled trial of therapy with intravenous immunoglobulin in decreasing mortality due to neonatal sepsis; Indian Pediatr.J; 1999;36 (11) :1113-8 10. Viswanathan R, Singh AK, Basu S, Chatterjee S, Sardar S, Isaacs D; Arch Dis Child Fetal Neonatal Ed. 2012 ;97(3):182-7 11. Fanos V, Cuzzolin L, Atzei A, and Testa M. Antibiotics and antifungals in neonatal intensive care units: a review. J Chemother. 2007; 19(1):5– 20. 12. Liem TBY, Krediet TG, Fleer A, Egberts TCG, Rademaker CMA. Variation in antibiotic use in neonatal intensive care units in the Netherlands. J. Antimicrob. Chemother. 2010 Jun 1; 65(6):1270–5. 268 Subash et al., Int J Med Res Health Sci. 2015;4(2):265-268 DOI: 10.5958/2319-5886.2015.00050.8 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 20 Nov 2014 Research article Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 10 Jan 2015 Accepted: 16th Mar 2015 EVALUATION OF RISK FACTORS FOR PRETERM DELIVERY AND CREASY’S RISK SCORING Anand Nalini I1, *Modi Nikunj K2, Sharma Hariom M 3 1 Professor, Department of Obstetrics and gynecology, 2 Assistant Professor, Department of Biochemistry, GGG Hospital & M P Shah Govt. Medical College, Jamnagar, Gujarat, India 3 Professor & Head, Department of Biochemistry, Sir T Hospital & Govt. Medical College, Bhavnagar, Gujarat, India *Corresponding author: Modi Nikunj K Email:
[email protected] ABSTRACT Background: Preterm birth is a poorly understood domain so it is a one of the most serious problem encountered in case of pregnant women. Because of the incomplete knowledge of biochemical and molecular reasons for preterm birth, many authors have shown interest in various predicting risk factors of preterm birth. Aim: This study was undertaken to know risk factors for preterm delivery and to investigate the usefulness of the most widely used creasy scoring system in identifying the high risk group of women at the tertiary care center of India. In this study also included observation of perinatal mortality and morbidity associated with preterm deliveries. Material and Methods: In the present study of 175 women who gave birth to preterm babies, detail history was taken. Then all the Data were statistically analyzed based on percentage. Result: Preterm delivery is particularly affected by precipitating of some risk factors (Hb, weight, parity of mother etc.). Conclusion: so we can say that such risk factors acting as a precipitating factor for preterm deliveries. Awareness of such risk factors is essential to plan public education programs and to consider appropriate perinatal care options for women at potentially higher risk for preterm delivery. Keywords: Preterm birth, Creasy scoring, Perinatal death INTRODUCTION One of the most important unresolved issues currently confronting obstetricians is the prevention of preterm birth (birth before 37 completed weeks of gestation). Preterm birth is, worldwide, the most challenging problem in obstetrics, but the prevention of prematurity has been difficult and ineffective because of its multifactorial and partly still unknown etiology. Identification of those women who are likely to deliver before term requires use of simple diagnostic tools that can be applied to both asymptomatic and symptomatic pregnant women. [1] Many healthcare providers collect data on pregnant women for assessment of preterm birth risk. Current technology makes possible collection of a plethora of Nalini et al., data, yet a perinatal healthcare provider has no access to a general, reliable and valid method of preterm birth assessment. [2] Babies born before the 34th week of pregnancy, have the highest risk for early death and enduring health problems, but recent research has shown that even preterm infants (at 34 to 36 weeks of pregnancy) have greater health risks than full‐term babies. [3] The treatment of preterm labor, preterm delivery, and premature birth are not only major problems in obstetrics and pediatrics but also have major economic, psychological, and social impact. Most existing methods to assess preterm birth are based on risk scoring, done manually. These methods are 269 Int J Med Res Health Sci. 2015;4(2):269-273 between 17% and 38% predictive in determining preterm birth. This range of accuracy is obviously not satisfactory. Some authors conclude that-in generalmanual risk screening tools are not sufficient to be used in the prediction of preterm labor. [2] To improve the outcome of these very preterm neonates, we need to expand our knowledge of the etiology, prevention, and treatment of preterm labor and preterm delivery. However, the rate of preterm delivery has not decreased in the past 30 years Goldenberg et al., 2008, mainly because of failure to identify the highrisk group during routine prenatal care. [4] To identify women at risk of spontaneous preterm birth, clinicians use prior preterm birth, multiple pregnancy and prior cervical surgery as major risk factors. Useful clinical risk factors in predicting spontaneous preterm birth in nulliparous women with a singleton pregnancy are scant, except for a history of prior cervical surgery. [5] So the present study was with the aim of first, to see the effectiveness of the routine creasy risk scoring system in predicting the high risk group in local population and second, to find out the common high risk factors like Hb, weight, parity of mother associated with preterm labor. MATERIALS AND METHODS The department of Obstetrics and Gynecology, of Shri M. P. Shah Govt. Medical College and Guru Govindsinh General Hospital, Jamnagar, carried out the present study. Informed consent was taken from all individual subjects included into the study. In the present study of 175 women, who gave birth to preterm babies (in 1 yr duration) were included and classified as at low, medium or high risk for preterm labor according to the Creasy scoring system which is based on socioeconomic factors, previous medical history, daily habits, as well as aspects of the current pregnancy. [6] This scoring system is extensively used to identify preterm delivery. Socioeconomic class is assessed by Prasad’s social classification. All other term pregnancy was excluded from the study. The gestational age was assessed from the date of last menstrual period, provided she had regular ovulatory cycle previously. In others, clinical examinations like fundal height date of quickening, appreciation of fetal heart by stethoscope and ultrasonographic measurements were used for gestational age determination. Anthropometric measurements of the mother including weight, height were carried out by using standard techniques. Other data of socioeconomic status, personal history, past medical surgical, obstetric history and prenatal care were collected by interviewing the patients. Hospital records were also abstracted for relevant data and used for cross-check the reliability of information obtained during the interview. Physical examination, Blood pressure and hemoglobin by standardized acid haematin method were also done. Anemia in this study was defined as hemoglobin < 10 g/dl on one or more occasion. Chronic or pregnancy induced hypertension was defined as a blood pressure greater than 140/90 mmHg repeatedly, and, if the women also had proteinuria than pre-eclampsia was considered to exist. After delivery the newborn was examined within 6 hours and fetal maturity was assessed. Then all the Data were statistically analyzed based on percentage. RESULTS Finding of the present study are as under – First the relationship with the age of mother (in yrs) and preterm delivery compared, in that the age group are divided in < 20 yrs, 21-25 yr, 26-30 yr, 31-35 yr, 36-40 yrs and >40 yrs, out of them majority of preterm delivery was noticed in 21-25 yrs of age group. That is of 87 out of 175 preterm deliveries. Then the incidence was gradually declined with increase age. Then relationship with the gestational age of mother (in wks) and preterm delivery compared (Table 1), in that most of the preterm deliveries occurred in 31-34 weeks of pregnancy. Table: 1 Relationship of Gestational age with Preterm delivery. Gestational No of preterm Percentage age (in wks) delivery (out of 175) <30 19 10.8 % 31-34 85 48.5 % 35-37 71 40.7 % Then out of 175 preterm delivery, 76 were primi while 99 are multipara in that 94 were multipara and 05 were grand (>4) multipara. One of the important relationships of weight and preterm delivery (Table 2), in that 153 preterm delivery seen in < 55 kg wt 270 Nalini et al., Int J Med Res Health Sci. 2015;4(2):269-273 (out of them 28 have < 45 kg wt) and only 22 have preterm delivery with more than 55 kg weight. Table: 2 Relationship of Maternal Weight and Preterm delivery. Maternal Weight (in Kgs) < 45 45-55 >55 No of preterm delivery(out of 175) 28 85 22 Percentage 16 % 71.4 % 12.6 % In relation to the antenatal care 118 were unbooked and 57 were booked. In our study approximately 49% births were females and 51% males. According to socio economical class (Table 3), majority of preterm delivery was noticed in low socioeconomic class (84.57%) and that is of 148 out of the 175, and remaining 15.43% from middle class. Table: 3 Relationship of Socioeconomic class and Preterm delivery. Socioeconomic Class High Middle Low No of preterm delivery(out of175) 27 148 Percentage 15.4 % 84.6 % with Hb level < 10 g/dl (in that 25 have Hb < 8.0 g/dl). According to past history 29 have previous h/o of abortion, 20 have H/o preterm delivery and 09 have previous H/o both. In this study, according to creasy risk scoring system (primi + multi) (Table 4), in that (31 +3 = 34 in low risk), (21 + 8 = 29 in medium), (24 + 88 = 112 in high risk).With twin pregnancy (175 + 13 = 188) child born. Out of them 49 were still birth, 55 neonatal deaths and hence making 104 prenatal deaths. Table: 4 Creasy scoring and distribution by Parity. Total Gravida Low Medium High risk risk risk 76 Primi 31 21 24 99 Multi 03 08 88 17 Total 34 29 112 DISCUSSION Fig1: Relationship of Hb level and Preterm deliveries. According to Hb (Fig. 1) only 8 women have preterm delivery with Hb > 10 g/dl, and rest of the women The importance of preterm delivery as a major public health problem is easily demonstrated by virtue of its contribution to total perinatal mortality contributing 50% to 70% of all perinatal deaths in most data sets.[7] Early detection of preterm labour is difficult because initial symptoms and signs are often mild and may occur in normal pregnancies. Thus, many healthy women will report symptoms during routine prenatal visits, whereas others destined for preterm birth may dismiss the early warning signs as normal in pregnancy. The traditional criteria for preterm labour (persistent contractions accompanied by progressive cervical dilatation and effacement) are most accurate when contraction frequency is six or more per hour, cervical dilatation is 3 cm or more, effacement is 80% or more, membranes rupture, or bleeding occurs. [8] Though preterm birth occurs in approximately 5-15% of all deliveries, it accounts for the major bulk of perinatal and especially postnatal deaths. The risk of neonatal morbidity and mortality mainly depends on the gestational age at delivery. Survival rate increases with an increasing period of gestation. In a developing country like ours, where intensive care facilities are often unavailable, mortality figures would be much higher at a lower gestation period at delivery. [1] Some biochemical markers like fetal fibronectin, the thrombin cascade, Nalini et al., Int J Med Res Health Sci. 2015;4(2):269-273 In the present study of preterm delivery, 19 cases of PET – pre eclamptic toxemia, 18 cases of PROM premature rupture of membrane, 18 cases of APH (ante partum haemorrhage), 13 cases of twin pregnancy, 11 cases of UTI - urinary tract infection, 07 cases of Eclampsia were noticed. While some cases of fever, heart disease, cerebral malaria, hydroamnios, jaundice, anemia, congenital anomalies, uterine anomaly and uterine prolapsed. And 62 are from the unknown reason. In this study out of 175, 13 were twin delivered. 0% Hb > 10 g/dl 5% Hb 08 - 10 g/dl Hb < 08 g/dl 14% 81% 271 and maternal salivary estriol measured in asymptomatic women with and without risk factors for preterm birth. [8] In our study majority of preterm births were in mothers of age group 21-25 years and that was gradually decreasing with increasing age. It is comparable to many similar studies like Molly Phillip et al. and Trivedi et. Al. inspite of very high incident of prematurity among teenage patients, the total number of patients in this group remains low because of decreasing trend of teenage marriage and late age of marriage. Higher incident of prematurity in the older patients is likely to be due to malnutrition, anemia, increase physical work load and increased incidence of medical and obstetric complications. [9] Also presence chorioamnionitis, bacterial vaginosis, urinary tract infection were significantly associated with preterm labor. [10] Fibronectin, an extracellular matrix protein, acts as the “glue” that attaches the fetal membranes to the underlying uterine decidua. A positive fibronectin test (50 ng/mL or more) in a patient with symptoms suggestive of preterm labor has been associated with an increase in the likelihood of birth before 34 weeks and birth within 7–14 days of the test. [8] In our study preterm birth in primipara, multipara and grand multipara were 43.4%, 53.7% and 2.95% respectively. This result is somewhat similar to other work reported on this aspect. [11] In grand multipara it is combined effect of parity, preexisting poor maternal nutrition, anemia less spacing between two pregnancies, lack of antenatal care, associated medical and obstetric complication etc. also play a role. The distributions of preterm births by gestational age observed in the present study are quite comparable to those of jose et.al. [10, 11] The delivery probability profile incorporates data on fetal fibronectin, cervical length by ultrasound and a past history of preterm delivery to generate standard pregnancy survival curves. This information might also help in developing patient-specific strategies to help prevent prematurity. [12] It is observed that almost 87.5% preterm births were from mothers with pregnancy weight of less than 55 kg. in another study from India 52.5% preterm births were in mothers having weight of less than 45 kg. Pre-pregnancy weight of mother and weight gain during pregnancy also affects the birth weight. [13] The effect of regular antenatal care on the incidence of preterm birth observed in the present study is compared with some of the other studies. Incidence of preterm birth is markedly less in booked cases as compared to unbooked cases (who attended less than 3 antenatal care or none). Greenberg noted that prenatal care had a greater impact on pregnancy outcome in socially disadvantages women, a group of women who often obtain less prenatal care. [14] The prevention can be based on at risk approach – (a) Patient at high risk of preterm labour should be monitored carefully and (b) Patient with warning signs will go through prophylactic treatment like antibiotics, tocolytics, bed rest etc. to prevent preterm birth. The higher frequency of preterm births in lower social class might have been due to a number of factors. More than two thirds of the patients admitted to our hospital are from these social classes. Secondly those who are economically at disadvantages might be worse off as regards health, physique, knowledge and nutrition. Present study data and that reported by other studies clearly indicate that socio-economic status has got direct and profound influence in the preterm labor and birth. [15, 16, 17] Anemia has been documented to result in higher incidence of low birth weight babies as well as higher preterm births. Anemia could lead to T and B cell suppression and resulting immune suppression could lead to increased susceptibility to infection. [18] Similar results are also reported by kandeparker et al. with 54% cases having Hb less than 10.0 g%. [11] In agreement with other studies [19] we found that history of previous abortion and previous preterm delivery increase the risk of preterm delivery in next pregnancy. The ability of creasy’s score in predicting Preterm birth is significant but it also has its limitations when applied in Indian context, where no. of other parameters do play a major role in predicting Preterm birth. This study present that maternal age, socioeconomic class, parity, past history are important risk factors for Preterm birth. If added to the present scoring system they will greatly improve the predictability of the scoring system in Indian context. Similar study was also found by another author in India. [20] The total perinatal deaths were 104 (49 still birth + 55 neonatal death) giving an incidence of 55.3 % Nalini et al., Int J Med Res Health Sci. 2015;4(2):269-273 272 perinatal mortality. As compared to western studies it is much higher. This is due to the fact that they have lower rate of preterm birth and much better neonatal services including intensive care units for preterm and low birth weight babies. Regarding neonatal death our results are comparable with Khandeparkar el al study. [11] 6. 7. CONCLUSION Our data in this study shows the correlation with various risk factors to the preterm birth. From the present study, it is concluded that to make creasy risk score more specific and effective in the Indian context, it should be modified by giving higher score to women with low socioeconomic status, low pregnancy weight, physical work during pregnancy and low maternal age. A slightly modified scoring system needs to be devised for Indian population. More elaborate information about the components of the scoring system is required for understanding the need to devise it in Indian context. 8. 9. 10. 11. 12. ACKNOWLEDGEMENT – None Conflict of Interest – Nil 13. REFERENCES Claire T. Roberts. Risk Factors for Preterm Birth in an International Prospective Cohort of Nulliparous Women. PLoS ONE. 2012;7(7); 39154. Fernando Aries. Practical guide to high risk pregnancy and delivery. 2nd edition, 1993; 71-96. Hoffman JH, Bakketeig LS. Risk factors associated with the occurrence of preterm birth. Clin Obstet Gynecol. 1984; 27; 539. Jay D. Prediction and Early Detection of Preterm Labor. Elsevier, Obstet Gynecol 2003; 101; 402– 12. Philips. A study of premature births. Jr. of Obstet and Gynecol of India. 1970; 20; 66-77. Pandey Kiran, Bhagoliwal Ajay, Gupta Neena, Katiyar Geetanjaly. Predictive value of various risk factors for preterm labor. J Obstet Gynecol India. March / April 2010; 60, 2: 141-45. Kandeparker. Risk factors in prematurity. Jr of Obstet and Gynecol of India. 1987; 37; 237-42. James Kurtzman. The delivery Probability Profile: A new tool to predict PTD? Contemporary OB/GYN; 2008; 5(1) 1-6. Niswander K, Jackson EC. Physical characteristics of gravida and their association with birth weight and perinatal death. Am Jr Obstet Gynecol. 1974; 119; 306. Greenberg R S. The impact of perinatal care in different social groups. Am Jr Obstet Gynecol. 1983; 145; 797. Mukerjee S,Biswas S. A study of premature birth. Indian Journal of Pediatric. 1971; 38; 389. Achar ST, Yankauer A: Studies on the birthweight of South Indian infants. Indian J Child Health 1962; 11:157-67. Venketachalam P S. Preterm Delivery. Bull WHO. 1962; 26; 192-01. Prema. Immune status of anemic pregnant women. Br Jr Obstet Gynecol. 1982; 89; 222-5. Main D M. The epidemiology of preterm birth. Clin Obstet Gynecol. 1988; 31; 521-32. Deka. Significance of risk scoring system in the identification of pregnant women at high risk for preterm labour in india. Jr Obstet Gynecol. 1997; 47;487 1. Kore SJ, Parikh MP, Lakhotia S, Kulkarni V, Ambiye VR. Prediction of risk of preterm delivery by cervical assessment by transvaginal ultrasonography. J Obstet Gynecol India 2009; 59(2); 131-35. 2. Jerzy W. Grzymala-Busse. Improving Prediction of Preterm Birth Using a New Classification Scheme and Rule Induction. 18-th Annual Symposium on Computer Applications in Medical Care (SCAMC), Washington, DC; 1994 5–9; 730–34. 3. Martin JA, Hamilton BE, Sutton, P. D., Ventura, S. J., et al. Births: Final data for 2006. National Vital Statistics Reports, 2009; 57:7. 4. Jarek Beta, Ranjit Akolekar, Walter Ventura, Argyro Syngelaki, and Kypros H. Nicolaides. Prediction of spontaneous preterm delivery from maternal factors, obstetric history and placental perfusion and function at 11–13 weeks. Prenat Diagn 2011; 31; 75-83. 5. Gustaaf Albert Dekker, Shalem Y. Lee, Robyn A. North, Lesley M. McCowan, Nigel A.B.Simpson, 14. Nalini et al., Int J Med Res Health Sci. 2015;4(2):269-273 15. 16. 17. 18. 19. 20. 273 DOI: 10.5958/2319-5886.2015.00051.X International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 18 Nov 2014 Research article Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 20 Dec 2014 Accepted: 24th Jan 2015 ACCURACY OF LOW BIRTH WEIGHT AS PERCEIVED BY MOTHERS AND FACTORS INFLUENCING IT: A FACILITY BASED STUDY IN NEPAL *Shakya KL1, Shrestha N2, Bhatt MR3, Hepworth S4, Onta SR5 1,3 Department of Community Medicine and Public Health, 5Dean’s Office, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal 2 Valley College of Technical Sciences, Purbanchal University, Kathmandu, Nepal 4 Department of Health, University of Bath, Nepal *Corresponding author email:
[email protected] ABSTRACT Introduction: Birth weight is a key predictor for risk of childhood illnesses and chances of survival; however in developing countries less than half of newborns are weighed at birth. In Nepal, only 36% of children born were weighed at birth. Nearly two thirds (63%) of deliveries take place at home and birth weight may not be known for many babies, the mother’s estimate of the baby’s size at birth could be used as an alternative. Aim and Objective: This study assessed the accuracy of low birth weight as perceived by mothers and factors influencing whether their perceptions were accurate. Methods: The study wasa facility based descriptive study carried out in four hospitals with sample size of 1533. Hospital nurses interviewed mothers using a pre-tested tool. Data was entered into EpiData 3.1 and analyzed using SPSS version 17 software package. Results: A total of 1533 mothers were interviewed of which 75 did not respond. An overall 75% mothers accurately identified actual low birth weight; and 25% mother perceived normal for actual low birth weight. Less percent of mothers <20years (sensitivity=0.74), illiterate (sensitivity=0.74), and primigravida (sensitivity=0.74) identified actual low birth weight than mothers ≥20years (sensitivity=0.75), literate (sensitivity=0.75) and multigravida (sensitivity=0.77). Conclusion: The study concluded that 75% mothers recognized actual low birth weight of newborn, and 25% mother’s perceived normal for actually low birth weight. The percentage of women accurately identifying actual low birth weight was slightly lower among mothers <20years, illiterate and primigravida as compared to mothers ≥20years, literate and multigravida. Keywords: Lowbirth weight, Mother’s perception, Facility based study, Nepal INTRODUCTION Birth weight indicates the health status of both newborn and mother. Low Birth Weight (LBW), less than 2.5 kg[1]. is the consequence of small maternal size at conception; low gestational weight gain; premature delivery; and pregnancy among younger women2; and can have consequences on increasing newborn morbidity and mortality[2]. Additionally, knowing the birth weight can help providers and family to take care of newborn at right time. Shakya et al., Globally,15.5%ofallbirthsarebornwithLBW. Among them 95.6% areindeveloping countries[3]. About 80% intrauterine growth retarded (IUGR) newborns who are LBW and full term are born in Asia[3]. Nepal has an overall 21% LBW2 and little variation in different studies, 12.76%[5], 21.6%[6], 11.9%[7]; similar to prevalence of LBW in India 23%[7], 21.5%[9], 12.8%[7], and 17.3%[10]. More than half of infants in the developing world are not weighed after birth[1] as 274 Int J Med Res Health Sci. 2015;4(2):274-280 they born at home[1,11,12] and thus will not have a recorded birth weight. In the past, most estimates of LBW for developing countries were based on data compiled from health facilities, these estimates did not cover the weight of newborns who were born out of a health facility[1]. Since birth weight may not be known for many babies, the mother’s estimate of the baby’s size at birth was also obtained[13]. Nepal has taken the percentage of newborns with LBW as one of the indicators to demonstrate achievement of nutritional wellbeing, maintenance of a healthy life and socioeconomic development of the nation. Many nutritional policies; principles; and strategies are based on this indicator, such as, increased nutrition monitoring and counseling services at antenatal checkup to reduce LBW[2]. Hence, it is important to take birth weight of newborn and, where formal measurements are unavailable, validate the accuracy of mothers’ perception of birth weight as a possible alternative source of data. However, studies on validation on perceived birth weight is not available for Nepal in our knowledge, and mother’s perception about the size of baby has not been properly verified as a reliable estimate of birth weight. We questioned that is mother’s perception on weight of newborn is correct? Is her perception on weight of newborn is affected by her socio-demographic background? This study aimed to assess accuracy of birth weight perceived by mothers against actual birth weight recorded in hospital; and to find out any associated determinants. MATERIAL AND METHODS The study was approved by Institutional Review Board of Institute of Medicine, Maharajgunj Medical College. We also received approval from each hospital board; and consent from each mother before data collection. Hospital nurses interviewed mothers once they were comfortable following delivery. After interviewing, nurses gave information to mothers on breast feeding; keeping newborn warm, special care for infants who were LBW using Kangaroo mother care, family planning, and baby immunization. This was a hospital based descriptive study, carried from August 2012 to February 2013. We chose hospitals for this study as hospitals routinely record weight of newborn and therefore provided a comparison against which the accuracy of mothers’ perception on LBW could be assessed. We carried out this study in 4 hospitals: Tribhuvan University Teaching Hospital (TUTH), and Paropakar Maternity and Women’s Hospital located in central Kathmandu; Seti Zonal Hospital in Kailali district, far western region of Nepal, 723 km away from Kathmandu city; and Dhulikhel Hospital in Kavre district, 30 km away from Kathmandu city. We chose these hospitals purposively to represent geographical scope from far western plain area to central hill areas. Women within the reproductive age of 15-45 years were the target population for this study. The sampling unit was mothers who were recently delivered, had completed 37 weeks of gestation, single not multiple births and having a live birth. The dependent variable for this study was perceived birth weight, and independent variables were mothers’ age, education, and gravida. Sample size, data collection, management and analysis: The sample size was calculated using statistical formula14, 15,, at 95 percent confidence level; 25% of LBW based on birth weight by birth size11, and 2% confidence interval. Hence, sample size calculated using this formulae, SS = 1800 For sample size – finite population, where, population = 10350 (total average deliveries in 4 hospitals); SS=sample size=1800; the sample size calculated were1533. The tool was a structured questionnaire with open and close ended questions. We asked to mothers on how she felt the weight of her baby; what her estimation was for NBW measurement in her idea; and what causes small baby if she felt her baby was small. Prior to collecting data, we did pre-test of questionnaire in TUTH hospital and made corrections as required from pre-test. Hospital nurses who worked in maternity ward were trained in the study tool and data collection techniques. Trained hospital nurses briefed mothers of the objective of study; then interviewed mothers who met selection criteria using the pre-tested tool before they were told birth weight of their newborn baby in their respective duty shift from August 2012 to September 2013. The actual birth weight of the newborn was taken from the hospital maternity register. Data entry program was developed in EpiData 3.1 and checked for any inconsistencies; analyzed using the SPSS version 17 computer software package through running simple frequency, descriptive cross tabulations. Sensitivity and specificity was calculated. The sensitivity is the proportion of actual LBW in the 275 Shakya et al., Int J Med Res Health Sci. 2015;4(2):274-280 selected sample who are accurately identified as LBW by the mothers; and the specificity is the proportion of actual normal birth weight (NBW) of newborn who are so identified by the mothers[14,16,17, 18] . RESULTS We interviewed 1533 mothers regarding their perception on birth weight of newborn, 75 mothers did not response. Maternal age and perceived LBW: Referring to table 2, out of 1458 mothers, 205 (14.1%) mothers were age <20 years and 1253 (85.9%) were age ≥20years. Among the mothers who were <20 years (205), 84 (41%) mothers delivered LBW babies. Among them (84), 62 (73.8%) mothers accurately perceived weight of their newborn baby as low for actual LBW. Of the remaining 121 women <20 years who delivered NBW babies, 9 (7.4%) mothers perceived weight of their newborn baby as low, for actual NBW. Similarly, among mothers age of ≥20 years, 404 (32.2%) delivered LBW baby, 849 (67.8%) delivered NBW baby. Among 404, 302 (74.8%) mothers perceived weight of their newborn baby was low for actual LBW baby. Out of 849, 64 (7.5%) mothers perceived weight of their newborn baby as low for actual NBW. Mothers were better at estimating NBW rather than LBW. Maternal education and perceived LBW: Out of 1458, total of 142 (9.7%) mothers were illiterate, 1316 (90.3%) mothers were literate. Among the illiterate mothers, 57 (40.1%) delivered LBW babies and 85 (59.9%) had NBW babies. Out of 57, 42 (73.7%) mothers perceived weight of their newborn baby as low for actual LBW. Out of 85, 9 (10.6%) mothers perceived weight of their newborn baby as low for actual NBW. Among literate mothers, 431 (32.8%) delivered LBW babies and 885 (67.3%) delivered NBW babies. Out of 431, 322 (83.4%) mothers perceived weight of their newborn baby as low for actual LBW. Out of 885, 64 (16.6%) mothers perceived weight of their newborn baby as low for actual NBW. So, illiterate women were less likely to be accurate in identifying LBW than literate women (83.4% vs. 73.7%). Gravida and perceived LBW: Out of 1458, 956 (65.6%) were primigravid mothers and 502 (34.4%) were multigravid mothers. Out of 956 primigravid mothers, 347 (36.3%) delivered LBW babies and 609 Shakya et al., (63.7%) had NBW babies. Out of 347, 256 (87.7%) mothers perceived weight of their newborn baby as low as for actual LBW. Out of 609, 36 (12.3%) mothers perceived weight of their newborn baby as low for actual NBW. Among 502 multigravid mothers, 141 (28.1%) delivered LBW babies and 361 (71.9%) delivered NBW babies. Out of 141, 108 (74.5%) mothers perceived weight of their newborn as low for actual LBW. Out of 361; 37 (25.2%) mothers perceived weight of their newborn baby as low for actual NBW. Overall diagnostic indicators of LBW: As an overall (table number 1), out of 1458, 488 mothers gave LBW babies, 970 mothers gave NBW babies. Out of 488 mothers, 364 (74.6%) accurately diagnosed baby as LBW and 124 (25.4%) diagnosed as normal for actual LBW. Out of 970, 73 (7.5%) mothers diagnosed birth weight as low, and 897 (92.5%) diagnosed as normal for actual NBW babies. We found that 75% mothers identified actual LBW babies (sensitivity=0.75), 93% mothers identified actual NBW babies (specificity=0.93). Twenty five percent mothers perceived NBW for actual LBW; whereas, 8% mothers perceived LBW for actual NBW babies. Table 1: Concordance between low birth weight and perceived birth weight in two categories Perceived birthweight Actual LBW (%) Actual NBW (%) Total (%) Low 364 (74.6)* 73 (7.5) 437 (30) Normal 124 (25.4) 897 (92.5)** 1021 (70) Total 488 970 1458 *sensitivity at 95% CI (0.71-0.78), ** specificity at 95% CI (0.91-0.94) Maternal profile and diagnostic indicators of LBW: We found (table #2) there were no remarkable differences in relation to maternal age and education with diagnostic indicators on LBW (sensitivity and specificity). Seventy four percent mothers age <20 years (sensitivity=0.74 @ 95% CI: 0.64-0.82); and 75% mothers age ≥20 identified actual LBW babies (sensitivity=0.75 @95% CI: 0.70-0.78). Seventy four percent illiterate mothers (sensitivity=0.74 @ 95% CI: 0.61-0.83) identified actual LBW and for literate mothers were 0.75 (at 95% CI: 0.70-0.79), and 0.93 (at 95% CI: 0.91-0.94) respectively. Our study revealed that diagnostic indicators were varied slightly as differences in number of gravida. Seventy four percent primigravid mothers 276 Int J Med Res Health Sci. 2015;4(2):274-280 (sensitivity=0.74 @ 95% CI: 0.69-0.78), and 77% multigravida mothers (sensitivity=0.77 @95% CI: 0.69-0.83) identified actual LBW. Table 2: Number of mothers with their profile, perceived low birth weight, and diagnostic indicators Perception of Diagnostic Indicators Maternal Actual Actual Total mother on Factors LBW (%) NBW (%) (N=1458)(%) Sensitivity* Specificity* birth weight Low 62 (73.8) 9 (7.4) 71 (34.6) 0.74 0.93 Age <20 years Normal 22 (26.2) 112 (92.6) 134 (65.4) (0.64-0.82) (0.86-0.96) Total 84 (41.0) 121 (59.0) 205 (14.1) Low 302 (74.8) 64 (7.5) 366 (29.2) 0.75 0.92 Age ≥20 years Normal 102 (25.3) 785 (92.5) 887 (70.8) (0.70-0.78) (0.90-0.94) Total 404 (32.2) 849 (67.8) 1253 (85.9) Low 42 (73.7) 9 (10.6) 51 (35.9) 0.74 0.89 Illiterate Normal 15 (73.7) 76 (89.4) 91 (64.1) (0.61-0.83) (0.81-0.94) Total 57 (40.1) 85 (59.9) 142 (9.7) Low 322 (83.4) 64 (16.6) 386 (29.3) 0.75 0.93 Literate Normal 109 (11.7) 821 (88.3) 930 (70.7) (0.70-0.79) (0.91-0.94) Total 431 (32.8) 885 (67.3) 1316 (90.3) Low 256 (87.7) 36 (12.3) 292 (30.5) 0.74 0.94 Primigravida Normal 91 (13.7) 573 (86.3) 664 (69.5) (0.69-0.78) (0.92-0.96) Total 347 (36.3) 609 (63.7) 956 (65.6) Low 108 (74.5) 37 (25.5) 145 (28.9) 0.77 0.90 Multigravida Normal 33 (9.2) 324 (90.8) 357 (71.1) (0.69-0.83) (0.86-0.92) Total 141 (28.1) 361 (71.9) 502 (34.4) *calculated at 95% CI DISCUSSION This study assessed and analyzed perceived LBW and the maternal factors that influence on her perception on LBW. We asked mothers on her perception on birth weight before she was told weight of her newborn. We did not cover home based deliveries because the birth weight was not recorded in home delivery and thus cannot validate the perception of mother on LBW. We also did not include multiple births, preterm and still birth. Next, we are not aware of this kind of study conducted in Nepal before. It could be a unique study for Nepal. Though Nepal Demographic health Survey (NDHS) uses mother’s perception to identify low or normal birth weight, but to date there has been no study to determine whether this is an accurate proxy indicator. This study fills that gap. A study conducted in Korea to identify factors affecting the validity of self-reported data on health services from community health survey; and in some other countries have done similar studies using diagnostic indicators [11, 12, 19, 20]; UNICEF and WHO did LBW country, regional and global estimates in 2004[1]; and an evaluation of international estimates and updated estimation procedure11 were resources for this study. However, whilst it is important to know an accurate birth weight; data on it is often difficult to obtain in those countries where most babies are born at home, similarly in Nepal[13,21]. Many infants are never weighed at birth. Eighty-eight percent of newborns in Pakistan, and 70% in India in central and other Asia[11] were not weighed, while those weighed at birth are often not recorded. Nepal has been also facing a similar problem to assess an accuracy of birth weight as it is not recorded in home deliveries. It is difficult to evaluate the accuracy of birth weight data because there are hardly any comparable registration data available[12]. In Nepal, those available data showed that only 4% children are reported to be very small at birth, 12% were reported to be smaller than average, and 84% were reported to be average or larger in size on verbal autopsy[13]. Our study revealed that 75% mothers identified actual 277 Shakya et al., Int J Med Res Health Sci. 2015;4(2):274-280 LBW (sensitivity=0.75). In other word, 91% mothers recognized actual NBW (specificity=0.91). Hence, it showed that fewer mothers could recognize actual LBW in compare to actual NBW. We would like to suggest here that the next study could be “why more mothers could identify NBW rather than LBW?” We also found that 25% mothers perceived normal for actual LBW babies which is crucial from a programmatic viewpoint. In Nepal, birth weight is still not given a priority by family. An awareness on LBW among women who delivered during last year in Nepal was only 12.4% [22] . A similar kind of study conducted in Cameroon found that specificity for LBW (92.9%) was much higher than sensitivity (59.9%) and the negative predictive value (96.1%) was much higher than the positive predictive value (44.4%)[23]. Further analysis of data from DHS India showed that among babies who were reported as weighing <2500 grams, 53% were perceived by mothers as less than average size at birth and among babies who were reported as weighing ≥2500 grams, 91% babies were perceived by mothers as average or more than average size at birth. These numbers suggest that mother’s perception about size at birth was reasonably reliable[24]. Accuracy of perception of mothers on birth weight is influenced by her education, number of gravida, and her age. Maternal age, educational level correctly predicted just over 35% of LBW[20]. Blanc and Ward law examined these assumptions and documented that the characteristics of infants with numerical birth weights were not representative of all births[11]. Births that were weighed were more likely to involve mothers who were better educated and resided in urban areas. They were also more likely to be in a medical facility and with assistance from skilled health personnel. These characteristics are generally associated with higher birth weights and, therefore, the resulting estimates were still likely to underestimate the level of LBW[11]. We found that younger mothers age <20 years had difficulty in identifying LBW (sensitivity=0.74) as compared to older mothers age ≥20 years (sensitivity=0.74). The study conducted in Nepal showed 85% mother’s age between 20-34 estimated their child’s birth weight was average or normal[13]; maternal age was significantly related to the incidence of LBW[8]. Our study revealed that 75% literate mothers recognized actual LBW, which was slightly higher than 74% illiterate mothers recognized actual LBW. In other words, 93% literate mothers identified NBW against 89% illiterate mothers who recognized NBW. Studies in Nepal showed that awareness on LBW among women who completed secondary education; and who completed higher than it, was15.0% and 18.8% respectively in Nepal[22]; 86% mother’s having School Leaving Certificate and above estimated their child’s birth weight was average or normal[13]. Literate mothers can read health messages and understand easily the advice given by health providers. The report shown that literate mothers visited health provider more for ANC check-ups as well13. The occurrence of LBW decreased with rising education level of the mother[8,25],. So, the accuracy of perception of mothers is more among literate mothers than illiterate mothers. A study conducted in Cameroon found that concordant descriptions were associated with higher education (P = 0.008) and delivery in a health unit (P = 0.025) [23]. Analysis of population-based data from 10 centers in Burma, Thailand, China and Vietnam, have also shown a strong associations with LBW were found with maternal education[26]. The knowledge of mother on health increase as she delivers more. The study found that frequency of LBW infant is high at birth order 1 and 29. Our study revealed that recognition of actual LBW was higher among multigravida mothers (sensitivity=0.77) than in primigravida mothers (sensitivity= 0.74). Mother’s perception of birth weight as a proxy indicator: There is a strong debate on the use of mothers’ estimate of birth weight in developing countries where there is low formal measurement data. A possible solution to it is to use a proxy variable13; putting question on size of the infant at birth (i.e. low, normal or high). This approach is being used in DHS and Multiple Indicator Cluster Surveys. In these surveys, mothers are asked to classify the size of their newborn[12]. In many countries, birth weight information is collected through applying retrospective surveys [27] especially in DHS. Cambodia, Kazakhstan and Malawi the responses to this question using DHS surveys, were assessed to indicate the relationship between birth weight and mother’s perception12. The 278 Shakya et al., Int J Med Res Health Sci. 2015;4(2):274-280 results indicated that mother’s perception on size of newborn is a good proxy for birth weight12. Other surveys such as Multiple Indicator Cluster Surveys, Pan Arab Project for Child Development and Reproductive Health Surveys, a question is asked to the mother regarding the size of her child at birth, which has been considered as a proxy indicator for birth weight11. Further analysis of data from DHS India suggest that mother’s perception about size at birth was reasonably reliable[24]. As in other developing countries, still two-thirds of births (63%) take place at home in Nepal[25]. Only 36% of children were weighed at birth as the majority of births do not take place in a health facility in Nepal13. Nepal DHS has been using verbal autopsy from mothers on their newborn baby’s size; and birth weight was recorded in the questionnaire if available from either a written record or the mother’s recall. Since birth weight may not be known for many babies, the mother’s estimate of the baby’s size at birth was also obtained and useful proxy for the weight of the child[26]. Based on our study, 93% mothers recognized actual normal birth weight, and 75% mothers recognized actual LBW, and still 25 percent mothers could not recognize actual LBW. Hence, perceived birth weight could be used as proxy indicator when birth weight data are not available. We noticed that proxy indicator could be more reliable if mother were literate, aged ≥20 years. A study conducted in Cameroon indicated that recall of size, in Cameroonian women and in other low resource settings, should be used only in the absence of other sources of data [27]. A further similar study among mothers who delivered in home with an intervention of birth measurement is recommended to cover broader area and to ensure accuracy of perceived birth weight. CONCLUSION An overall, 75% mothers recognized actual LBW, and still 25% mothers perceived normal were actual LBW babies, which is crucial from programmatic view. A percent of identifying actual LBW was slightly lower among mothers <20 years, illiterate and primigravid as compared to mothers ≥20 years, literate and multigravida. Mothers’ perception on birth weight can be considered as proxy indicator for Shakya et al., birth weight of newborn as and when birth weight is not available. ACKNOWLEDGEMENTS We are grateful to University Grant Commission (UGC), Sanothimi, Bhaktpur for providing grant for this study; Seti Zonal Hospital,Kailali; TUTH, Kathmandu;Paropakar Maternity and Women’s Hospital, Kathmandu; Dhulikhel Hospital, Kavre for permitting us to collect data; thankful to the respective team in each hospital for collecting data for this study; and also thankful to Department of Community Medicine and Public Health, Institue of Medicine, Maharajgunj for technical and logistic support. Conflict of Interest: Nil REFERENCES 1. WHO, U., Low Birth Weight: Country, Regional, and Global Estimates. 2004. 2. DoHS, National Nutrition Policy and Strategy, D.o.H. Services, Editor. 2004. 3. Pojda JKL. Low Birthweight - Nutrition Policy2000; 18. 4. Ojha N, Malla DS. Low birth weight at term: relationship with maternal anthropometry. JNMA J Nepal Med Assoc, 2007; 46(166): 52-6. 5. Yadav DK, Chaudhary U, Shrestha N. Risk factors associated with low birth weight. J Nepal Health Res Counc, 2011; 9(2): 159-64. 6. Kayastha, S. and H. Tuladhar, Study of low birth weight babies in Nepal Medical College. Nepal Med Coll J, 2007;9(4): 266-9. 7. Misra M. Mishra S, Sharadamma. Epidemiology of low birth weight in an industrial area in India. J Trop Pediatr, 1995; 41(6): 374-6. 8. Mondal B. Risk factors for low birth weight in Nepali infants. Indian J Pediatr, 2000;67(7): 47782. 9. Rajanikumari J, TV Rao, SrikumariCR. Proportion of low birth weight infants in Visakhapatnam (India) and its relationship with maternal age, parity and infants survival. Anthropol Anz, 1986. 44(1): 13-8. 10. Sen J, Roy, Mondal. Association of maternal nutritional status, body composition and socioeconomic variables with low birth weight in India. J Trop Pediatr, 2010;56(4): 254-9 279 Int J Med Res Health Sci. 2015;4(2):274-280 11. Blanc AK, Wardlaw T. Monitoring low birth weight: an evaluation of international estimates and an updated estimation procedure. Bull World Health Organ, 2005; 83(3): 178-85. 12. MoHP NE. ICF International, Nepal Demographic Health Survey, MoHP, Editor. 2011: Kathmandu. 13. Daniel WW. Biostatistics: A Foundation for Analysis in the health Sciences. Seventh edition ed. 14. Eng J. Sample size estimation: how many individuals should be studied? Radiology, 2003; 227(2): 309-13. 15. Bonita R, Kjellstrom BR. Basic Epidemiology. Second Edition ed. 2006: WHO. 16. Glas AS. The diagnostic odds ratio: a single indicator of test performance. J Clin Epidemiol, 2003; 56(11): 1129-35. 17. Park K.. Park's Textbook of Preventive and Social Medicine, ed. 20th. 2009. 18. Kim H. Factors affecting the validity of selfreported data on health services from the community health survey in Korea. Yonsei Med J, 2013;54(4): 1040-8; 19. Yadav H., Lee N. Maternal Factors in Predicting Low Birth weight Babies. Med J Malaysia, 2013; 68(1): 44-47. 20. Karim E, CG Mascie-Taylor, The association between birthweight, sociodemographic variables and maternal anthropometry in an urban sample from Dhaka, Bangladesh. Ann Hum Biol, 1997;24(5): 387-401. 21. Osrin D. Cross sectional, community based study of care of newborn infants in Nepal. BMJ, 2002; 325(7372): 1063. 22. Mehata S, Chand, DR. Singh, P. Poudel, S. Barnett, Nepal Household Survey. 2012. 23. Mbuagbaw L, Gofin R. Can recall of birth size be used as a measure of birthweight in Cameroon? Paediatr Perinat Epidemiol, 2010;24(4): 383-9. 24. Sreeramareddy CT, Shidhaye RR, Sathiakumar N. Association between biomass fuel use and maternal report of child size at birth--an analysis of 2005-06 India Demographic Health Survey data. BMC Public Health, 2011; 11: 403. 25. Hirve SS, Ganatra BR. Determinants of low birth weight: a community based prospective cohort study. Indian Pediatr, 1994;31(10): 1221-5. 26. Golding J, Shenton T. Low birth-weight and preterm delivery in South-east Asia. The WHO International Collaborative Study of Hypertensive Disorders of Pregnancy. Soc Sci Med, 1990;30(4): 497-502. 27. Tomeo CA. Reproducibility and validity of maternal recall of pregnancy-related events. Epidemiology, 1999; 10(6): 774-7. 280 Shakya et al., Int J Med Res Health Sci. 2015;4(2):274-280 DOI: 10.5958/2319-5886.2015.00052.1 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 20 Nov 2014 Research article Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 10 Dec 2014 Accepted: 30th Jan 2015 WATER ADSORPTION CHARACTERISTICS OF NEW DENTAL COMPOSITES Rafed. M Al-Bader1,*Kareema M.Ziadan2, M. S Al-Ajely3 1 PhD. student, College of Dentistry, 2 Professor in polymer physic, Department of Physics, college of science, University of Basrah, Basrah, Iraq. 3 Professor in polymer, Department of Chemistry, college of Education, University of Mosul, Mosul, Iraq. *Corresponding author email:
[email protected] ABSTRACT Water sorption of dental composites affects dimensional stability, mechanical properties and bonding strength with tooth structures. The diffusion coefficient of water through the resin should be identified. Methods: Ten new composites fillings (M1-M10) were prepared from new Fluoroaluminosilicate powder composition and BisGMA/TEGDMA together with the related compounds such as tri ethylene glycol dimethacrylate, N,NDimethyl amino ethyl methacrylate and Camphorquinone. Five disk shapes were prepared for each composite using a stainless steel mold 15 mm in inner diameter and 1 mm in thickness, according to ISO 4049, the curing of each composite disk for 40 sec. Each disk was immersed separately in water for 90 day all at (37 ±1). Water sorption and solubility were calculated by using these measurements, Diffusion coefficients were also measured with the solution of Fick’s second law. Results: The water sorption (g/mm3) after 90 day immersion ranged from 14.98 g/mm3 (±0.90) for M10 to 36.81g/mm3 (±0.46) for M6. The solubility ranged from 3.3 g/mm3 (±0.90) for M6 to 8.55 g/mm3 (±0.31) for M7, the equilibration time for water sorption was reached at 20 day. M6 had the highest diffusion coefficient 6.25 ×10-9 cm2/s (±3.46). Conclusion: This investigation revealed that M6 composite filling was the best one due to the lowest water solubility while the other investigated fillings showed moderate to high solubility values but all are in accordance with the International Standard ISO 4049. Keywords: Water sorption, Solubility, Composites, Diffusion coefficient, Calcium Fluoroaluminosilicate. INTRODUCTION Materials left for long time in the oral environment will undergo an interaction with oral fluids. Visible light-curable polymeric composites are now routinely used as filling materials for dental restorations. These materials are based on polydimethacrylate matrix resins along with silane-coated inorganic fillers. They possess many advantages such as mechanical properties comparable to commercial dental amalgams and dental ceramics, excellent esthetic quality and the ability to bond to enamel surface. However, in aqueous environment they absorb water and release unreacted components. There are two different mechanisms that occur when the previously mentioned dental restorative materials Kareema et al., are exposed to or stored in water: the first is gaining weight from water uptake, and the second is losing weight from dissolution in water[1]. Water sorption has been studied in several glassy polymers used in dentistry. Composite resins[2,3], soft lining and poly(methyl methacrylate) denture bases[4] have all been shown to absorb water and, at the early stages, this sorption follows Fick’s law of diffusion. Studies have mostly been focused on determining the water sorption characteristics of epoxy-based polymers [5-7]. However, data are scanty on the resins that are employed as adhesives for bonding to hydrated dentin. The importance of composite-water interaction has been acknowledged in the ISO standard 4049 which 281 Int J Med Res Health Sci. 2015;4(2):281-286 states that the maximum values for water sorption and concurrent solubility for resin-based materials (composites and cements). In order to comply with this ISO standard, resin-based materials must have water sorption and solubility values equal or lower than 40 micrograms per cubic millimeter (sorption) and 7.5 micrograms per cubic millimeter (solubility) for specimens 15 mm in diameter and 1 mm thick[8]. Fluoride (F-) releasing restoratives are frequently studied because the F- ions could increase the dissolution resistance of the tooth structure, enhance remineralization and hinder demineralization[9,10]. Efforts have been made to develop a composite consist of an aluminosilicate glass matrix modified with other elements, and they contain large quantities of fluorine. Calcium Fluoroaluminosilicate glass powder is treated with a fluoride in an amount of from 0.01 to 5 parts by weight based on 100 parts by weight of the glass powder, The Calcium Fluoroaluminosilicate glass powder of the investigation is improved in not only physical properties such as crushing strength but also mixing workability without impairing the inherent characteristics thereof for the dental use[11]. So Calcium Fluoroaluminosilicate glass will be suitable as filler for resin-based dental composites because it is interact with the bone structure makes them useful materials for bone replacement in implants, naturally radiopaque and highly resistant to moisture. The aim of the present study is to determine the water sorption characteristics of light-cured resins made from new composites of Calcium Fluoro aluminosilicate glasses filler with various weight ratios. MARERIAL AND METHODS The compositions of the 10 composite resins tested, The ethoxylated bisphenol A glycol dimethacrylate Bis_GMA was purchased from Sigma Aldrich (UK) and TEGDMA (triethylene glycol dimethacrylate) manufactured from Sigma Aldrich (UK), N,NDimethyl aminoethyl methacrylate (DMAEMA) and camphor Quinone (CQ) were purchased from Aldrich (UK), Those materials were used to prepare the monomer phase. Calcium fluoroaluminosilicate glass was synthesized and sintered in our laboratory [12]. It was ball-milled and sieved to powder with a particle size < 25 μm. The particle size distribution was measured using a BET analysis (CHEMBET 3000 QUANTA CHROME). The average particle size was 2.64 μm. This Calcium fluoroaluminosilicate glasses was treated with γ -methacryloxypropyltrimethoxy-silane (γ-MPS) known as A-174 which was supplied by Sigma Aldrich (UK). Preparation of composite: Ten types composites formulations,containing the resins BisGMA/TEGD MA in a w/w ratio of 70/30 as the base resins. Resins were activated for visible light polymerization by CQ (0.5 wt %) and DMPT (0.5 wt %). Matrix resins were loaded (76 wt% ~ 60% Vol) and were then silanized. This Calcium Fluoroaluminosilicate glasses hand mixing. The compositions of the studied dental composites are shown in Table 1. Water absorption was determined on disc specimens, 15 mm diameter and 1 mm thick, for up to 90 days using the method outlined in ISO 4049. The discs were prepared between glass plates and were cured by exposure to dental curing lamp for 40sec on each side. Samples were measured, weighed and placed in individual sealed containers of water at 37ºC. The specimens were removed from the storage water at regular intervals, blotted dry and re-weighed. After 90 days specimens were placed in a desiccator containing dry silica gel and re-weighed at regular intervals over a period of 2 weeks. Table1: Composition (W%) of Calcium Fluoroaluminosilicate Glass Glass SiO2 Al2O3 M1 22 18 M2 22 19 M3 29 M4 CaF2 Al2PO4 AlF3 NaF 22 15 23 10 39 13 7 16.6 34.2 9.9 5.3 5 35 25 20 8 6 6 M5 39.52 23.6 13.65 3.62 9.7 9.91 M6 24.3 27.5 14.0 19.1 15.1 M7 33.9 17.5 8 15 10 M8 56.5 33.5 M9 48.9 29.1 15 M10 36.3 22 12 15.6 10 7 9 14.3 6.4 Preparation of specimens: Water sorption and solubility tests were determined according to the specification standard for composite (ISO 4049: 2000). Specimen discs approximately 15±0.2 mm in diameter and 1±0.1 mm in thickness were fabricated 282 Kareema et al., Int J Med Res Health Sci. 2015;4(2):281-286 in an aluminum mold between two glass slides they were irradiated for 40sec on each side using a quartz– tungsten–halogen light-curing unit (Optilux 500, Demetron Research Corporation, Danbury, CT, USA). The light-curing unit had an exit-window diameter of 8 mm and was operated at 400 mW/cm2 with the curing tip placed 1 mm from the glass plate. Four specimen discs were prepared for each for the ten experimental resin formulations. The thickness of the samples was measured accurately at three points using a micrometer. Also their diameters were measured, and their volumes were then calculated in mm3. water sorption and solubility: All the specimens were placed in a desiccator and transferred in a preconditioning oven at 37ºC. After 24 hrs they were removed, stored in the desiccator for 1 hr and weighted to an accuracy of 0.0001 g using a KERN 770 Germany. This cycle was repeated until a constant mass (m0) was obtained. Following, the discs were immersed in distilled water at 37ºC. At fixed time intervals they were removed, blotted dry to remove excess water, weighted and then back to the water. The time intervals were more during the first four day, preceding daily as the uptake slowed at more extended intervals. The uptake of water was recorded until there was no significant change in weight, i.e. equilibrium was attained. This took about 30-40 days. Sorption, desorption, and material net loss percentages were calculated as follows: = = − − (1) (2) Where M1 is the weight of the sample after immersion and M2 is the original weight of the sample before immersion. Diffusion coefficients: According to the Fick’s Law, the equation for diffusion in three dimension, when the diffusion coefficient D is constant, is expressed as = + + Here, x (m), y (m), z (m) is the coordinates, c (%) is the concentration where of the diffusing species at time t (s) is the time, and D (m/s) is the diffusion coefficient. For the one-dimensional model of linear flow of mass in the solid bounded by two parallel planes, the differential equation is expressed as follows: = (3) The differential equation is solved for the region h<x<h with zero initial concentration of water and with surfaces x=±h kept at constant concentration c0 for t > 0: It should be noted here that the solution to the Fick’s second law (Eq. (3)) might alternatively be expressed as = 4 ( ) ⁄ ⁄ + 2 =2 (−1) , ( 2( ) ⁄ ) (4) where Mt was the mass uptake (g) at time t (s), Me was the mass uptake (g) at equilibrium, l was the specimen thickness (cm) such that D is the diffusion coefficient (cm2s-1) calculated from the gradient of Mt/Me against t1/2. If the uptake Mt is measured at convenient intervals of time until equilibrium is reached, then a plot of M ⁄M∞ against t1/2 should provide a straight line for the earlier stages with the slope, S For which RESULTS =2 = , /4 (4) All of the studied composite resins increased in weight during immersion in water. The means of the percentage values for sorption, solubility and diffusion coefficient of the ten different types of Calcium Fluoroaluminosilicate materials were illustrated in Figure 1. During sorption, M9 and M10 showed significantly lower and no significant differences among them respectively, While M6, M5, M2 and M1 showed the highest sorption, which is lower than those required by ISO 4049 standard, 40µ g/mm3. Water solubility also showed differences within the studied groups. Four main groups of fillings can be classified: M9, M10, showed moderate solubility while M4 showed less than the above two 283 Kareema et al., Int J Med Res Health Sci. 2015;4(2):281-286 M1, M3, M8 were the filling materials with the highest mean water solubility value .Finally M6 was found the best filling. For all studied composites, the equilibration time for water uptake was of the order of 15-20 days depending on material and the volume of specimens. The rate of change in weight over the selected time intervals is presented in Figure 2 for all studied composites. Figure 3 the plots of Mt/Me versus square root of time, it can be seen that the plots are almost linear for M10 composites. The plots had linear increase in earlier stage and became balanced at the end of the process when the composites were completely saturated, that mean no more water can be absorbed or desorbed by the studied composites. The diffusion coefficients controlled process was confirmed by the linear part. Figure 4 shows the diffusion coefficients of the studied resins ranged between 0.87 and 6.2 ×10-10cm2/sec for M10 and M6 respectively. Fig. 3: Mt/M∞ against t1/2 (sorption) for M10 composites after immersion in water. Fig.4:Mean diffusion coefficients composite materials tested. values for DISCUSSION Fig. 1: Mean water sorption (μg/mm3) and water solubility obtained for composite materials (teeth filling) tested. Fig. 2: Changes in weight over 90 days for composite materials. The water sorption and solubility of dental restorative materials are of considerable clinical importance and cannot be neglected. Several data for water sorption and solubility for composite materials have been published, but it is difficult to correlate them as the results are often for different time periods and are expressed in different units. Moreover comparisons are difficult to make due to differences in reported specimen size, since different sizes of specimen will take different periods of time for water to completely infiltrate throughout the polymer matrix. Water molecules are able to diffuse through the inter-chain spaces of the resin matrix because of their smaller size of radius, which is less than 0.158 nm and smaller than the inter-chain spaces [13]. According to ISO 4049:2000 standard for dental restorative resins, a resin in order to be suitable for use as dental material must show water sorption lower than 40 µg/mm3 and solubility lower than 7.5 μg/mm3. The 284 Kareema et al., Int J Med Res Health Sci. 2015;4(2):281-286 values of water sorption for all studied composites, except that M6, are within the range of the ISO’s standard. On the contrary, the values of solubility are within the range of the ISO’s standard only for resin M7. Several factors, such as the polymeric matrix composition, filler particle type, mean particle sizes, and the degree of curing reached after the polymerization reaction can influence the solubility and sorption behavior of dental resin composites [14,15]. The studied resins used in this study have a great similarity in the filler particle content approximately 60% by volume. The Low water sorption values of resin are due to the method of preparation of Calcium Fluoroaluminosilicate glass, Filler particle size which was within 1 to 2 µm[12]. While the water solubility range was found between 2.9– 8.1 µg/mm3 .These results were similar to those obtained by Oysaed and Ruyter (1.4– 9.0 µg/mm3) [16] . Plots of Mt/M∞ against t1/2 Figure 3 for M10 filling (similarly for all studied resin) were linear in the initial stages of absorption and desorption cycles, which shows that the uptake process for these composites is diffusion controlled. The diffusion coefficients which have been determined in this study is within the range of 0.7–6.2 × 10-10 cm2/sec figure 4, in good agreement with other works and comparable to those reported for composite resins soaked in water, despite the difference in the form of the water and hence in the driving force for sorption [3,17]. CONCLUSIONS In this work, we conclude that the sorption and solubility values are in accordance with the ISO 4049:2000. The studied dental material (teeth filling) has shown that they have optimal physico-chemical properties for an adequate behavior in the oral aqueous environment, making it suitable for indirect composite restorations. ACKNOWLEDGMENT Rafed M. extend his appreciation to Dr M. Atai for his assistance and consultation in this work, thanks to university of Basrah Dentistry College for their help. Conflict of Interest: Nil REFERENCES 1. Toledano M, Osorio R, Osorio E, Fuentes V, Prati C, Garcı́a-Godoy F. Sorption and solubility of resin-based restorative dental materials. Journal of Dentistry. 2003;31(1):43-50. 2. Braden M, Causton E, Clarke R. Diffusion of water in composite filling materials. Journal of Dental Research.1976;55(5):730-2. 3. Asaoka K, Hirano S. Diffusion coefficient of water through dental composite resin. Bio materials. 2003;24(6):975-9. 4. Pfeiffer P, Rosenbauer E-U. Residual methyl methacrylate monomer, water sorption, and water solubility of hypoallergenic denture base materials. The Journal of Prosthetic Dentistry. 2004;92(1):72-8. 5. Vanlandingham M, Eduljee R, Gillespie J. Moisture diffusion in epoxy systems. Journal of applied polymer science. 1999;71(5):787-98. 6. Adamson MJ. Thermal expansion and swelling of cured epoxy resin used in graphite/epoxy composite materials. Journal of materials science. 1980;15(7):1736-45. 7. Li L, Yu Y, Wu Q, Zhan G, Li S. Effect of chemical structure on the water sorption of amine-cured epoxy resins. Corrosion Science. 2009;51(12):3000-6. 8. ISO4049. Dentistry-resin-based filling materials: 7.9 water sorption and solubility. 2000. 9. Kielbassa A, Schulte-Monting J, Garcia-Godoy F, Meyer-Lueckel H. Initial in situ secondary caries formation: effect of various fluoridecontaining restorative materials. Operative dentistry. 2002;28(6):765-72. 10. Ling L, Xu X, Choi G-Y, Billodeaux D, Guo G, Diwan R. Novel F-releasing composite with improved mechanical properties. Journal of Dental Research. 2009;88(1):83-8. 11. Akahane S, Hirota K, Tomioka K. Fluoroaluminosilicate glass powder for dental glass ionomer cement. Google Patents; 1988. 12. Al-Bader RM, M.Ziadan K, Al-Ajely MS. New Glass Compositions Based on CalciumFluoroaluminosilicate for dental composite. Journal of Advances in Chemistry. 2014;10 (5):2743-52. 13. Tamai Y, Tanaka H, Nakanishi K. Molecular simulation of permeation of small penetrants 285 Kareema et al., Int J Med Res Health Sci. 2015;4(2):281-286 14. 15. 16. 17. through membranes 2. Solubilities. Macro molecules. 1995;28(7):2544-54. Sideridou I, Tserki V, Papanastasiou G. Study of water sorption, solubility and modulus of elasticity of light-cured dimethacrylate-based dental resins. Biomaterials. 2003;24(4):655-65. Mortier e, jager s, alain d. influence of filler amount on water sorption and solubility of three experimental flowable composite resins. Journal of Materials Science and Engineering with Advanced Technology 2013;7(1):35-48. Øysæd H, Ruyter I. Water sorption and filler characteristics of composites for use in posterior teeth. Journal of Dental Research. 1986;65(11):1315-8. da Silva EM, Gonçalves L, Guimarães JGA, Poskus LT, Fellows CE. The diffusion kinetics of a nanofilled and a midifilled resin composite immersed in distilled water, artificial saliva, and lactic acid. Clinical oral investigations. 2011;15(3):393-01. 286 Kareema et al., Int J Med Res Health Sci. 2015;4(2):281-286 DOI: 10.5958/2319-5886.2015.00053.3 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 st Received: 21 Nov 2014 Research article Coden: IJMRHS Revised: 20th Dec 2014 Copyright @2014 ISSN: 2319-5886 Accepted: 27th Jan 2015 CARCINOMA CERVIX SCREENING – A CLINICOPATHOLOGICAL STUDY *Vissa Shanthi1, Bhavana Grandhi2, Nandam Mohan Rao3, Byna Shyam Sundara Rao4, Vangala Chidananda Reddy5, Swathi Sreesailam6 1,3,4 Associate professor, 2,5,6Assistant Professor, Department of pathology, Narayana Medical college and Hospital, Nellore, Andhrapradesh, India *Corresponding author email:
[email protected] ABSTRACT Background: Cervical carcinoma, the pathogenesis of which includes multiple factors was the leading cause of death 50 years ago and the mortality rate has been reduced to two thirds due to the effective screening by Pap smears which detected the cancers and precancerous conditions. Objective: The study was undertaken to analyze the routine cervical cancer screening on an age specific basis and to study the various predisposing factors of cervical carcinoma. Methods: We conducted an observation study on 1000 patients. The cervical smears collected were examined and predisposing factors were studied in these patients. Results: 1000 women above 20 years of age group were screened. There were 242 cases(24.2%) of dysplasia of which 133 cases (13.3%) were of mild dysplasia, 59 cases (5.9%) were of moderate dysplasia and 50 cases (5%) were of severe dysplasia. 29 cases (2.9%) showed invasive carcinoma. There were 564 (56.4%) inflammatory smears and 168 (16.8%) normal smears. Maximum number of dysplasia’s and carcinomas were found in the age group above 40 years. These patients were from low income group, had no formal education, attained menarche at the age of 13-14 years, married at the age of 15-17 years, had three or more children and had marital life for more than 30years. Conclusion: Cervical cytology has been main stay of prevention and early diagnosis of cervical carcinomas. Due to its simplicity and low cost, pap smears can be used for mass screening. Cervical carcinoma has multiple etiological factors which play role in its pathogenesis. Key words: Pap smear, Cervical carcinoma, Cytology INTRODUCTION Cervical carcinoma is the sixth most common visceral cancer in women and contributes to 5% of all cancer deaths in women worldwide. It accounts for approximately 15% of all cancers diagnosed in women world wide1. In the developing world 1.7 million cases of carcinoma cervix and 5-13 million cases of precancerous lesions were recorded 2,3. The highest crude mortality rate is recorded in Southern Africa. In North America, Western Europe and Australia, the incidence of cervical cancer is low 4. China has the least mortality rate 1. Death rate due to the cervical cancer has declined in the recent years Shanthi et al., due to early detection of cancers and precancerous conditions. Cervical cancer screening by pap smears has reduced the morbidity due to cervical cancer by 53%. Susceptibility of cervical cancer for prevention by screening programme is determined by its high prevalence, a long detectable preclinical phase and benefit from early treatment. The Pap smear screening test if carried out properly is sufficiently sensitive and has high specificity, is of low cost and low risk to the patient 5. Mass cytological screening has shifted the presentation of cervical carcinoma from the clinical 287 Int J Med Res Health Sci. 2015;4(2):287-293 to the preclinical stage. Though the incidence of cervical cancer has decreased significantly since 1960, age specific rates; however show an increase in young women, particularly those aged 25-29 years. It is not due to less effective screening of the younger population but the rise in incidence would be due to predisposition to risk factors 6. In this study we tried to analyze the predisposing factors for carcinoma cervix and the age related incidence of cervical cancer in around Tirupathi. MATERIAL AND METHODS This cross sectional study includes 1000 patients who attended the gynecologic outpatient department in our hospital during the period of two years. Institutional ethical committee approved the study protocol. Informed consent was obtained from all the study participants. Pap smear from 1000 patients who were in the age group above 20 years was collected. The etiological and risk factors like age, parity, age at menarche, age at marriage, use of oral contraceptive pills, socio economic status and educational status of patients whose smears showed dysplastic changes were studied. The patients whose smears showed only inflammatory changes without dysplasia were excluded. Smears were obtained from the patients with the help of Aylesbury spatula7. These smears were stained with Papanicolaou stain. Patient was placed in dorsal lithotomy or left lateral position. Nonlubricated (self-retaining) speculum was introduced into the introitus to visualize the cervix. Aylesbury spatula is placed in position and rotated in 3600 clock wise direction, so that sample from the ectocervix and endocervix including squamocolumnar junction are obtained. Specimen is spread evenly on glass slides. The smears collected were fixed in 95% of isopropyl alcohol for 15-30 minutes. These smears are stained with Papanicolaou stain. Smears of the patients which revealed dysplastic cells on microscopic examination were studied in detail. Patients which revealed dysplastic cells on microscopic examination were studied in detail. OBSERVATION AND RESULTS Shanthi et al., Cervical smears from 1000 women aged above 20 years who attended gynaecology out patient department were studied .A detailed history was recorded which included age, age of menarche, married life, number of pregnancies, age of last child, duration of menopause, use of oral contraceptive pills (OCP’s), tobacco chewing or cigarette smoking, socio-economic status and educational status of women. The gynecological symptoms and clinical status of cervix was also studied. The women were grouped in 9 groups depending upon the age and various cytological features were studied (Table 1). There were 242 cases (24.2%) of dysplasias, of which 133 cases (13.3%) were of mild dysplasia, 59 cases (5.9%) were of moderate dysplasia and 50 cases (5%) were of sever dysplasia. 29 cases (2.9%) showed invasive carcinomas. There were 564 (56.4%) inflammatory smears and 168 (16.8%) normal smears (Table 1). Highest incidences of mild and moderate dysplasia were seen in the age group of 40-50 years. Severe dysplasia and carcinomas were seen in the age group of 50-60 years. One case of invasive carcinoma was noted in the age group of 20 -30 years (Table 1). Maximum cases of invasive carcinoma, mild dysplasia, moderate dysplasia and severe dysplasia were noted in the menopausal age group when compared to reproductive age group (Table 2). Epithelial changes in relation to age at menarche were studied and the highest incidence of dysplasia was noted in patients who attended menarche at the age of 13 years and invasive carcinoma in the patients who attained menarche at the age of 14 years (Table 3). When the incidence of dysplasia in relation to the age at marriage was studied, it showed highest incidence of moderate, severe dysplasia and carcinoma in the patients who were married at the age of 15-17 years (Table 4). The incidence of carcinomas was found to be high in patients who had marital life of 31years and above (Table 5). The study on parity of these patients showed that highest incidence of invasive carcinoma, moderate and severe dysplasias were noted in women who had three or more children. In nulliparous women only three cases were found to have mild dysplasia but there were no cases of moderate, severe dysplasia and invasive carcinoma (Table 6). Epithelial abnormalities in relation to economic status were also studied, which showed that incidence of dysplasia and invasive carcinomas was 288 Int J Med Res Health Sci. 2015;4(2):287-293 maximum in the lower income group (Table 7) and these patients did not have formal education (Table 8). Most of the patients with dysplasias presented with irregular vaginal bleeding and invasive carcinomas presented as post menopausal bleeding (Table 9). On clinical examination, mild and moderate dysplasia cases presented as cervical erosion where as the cases with severe dysplasia and carcinoma presented as either growth on cervix or bleeding on touch (Table 10).Though the cigarette smoking, tobacco chewing and use of immunosuppressive drugs are considered as risk factors, in our study it did not reveal significant correlation (Table 11). Table 1: Epithelial abnormalities in relation to age Age in years Total Normal smears Inflammatory smears LSIL Mild dysplasia 20-30 203 (20.3%) 31-40 24 (2.4%) 150 (15%) 25 (2.5%) 2 (0.2%) 2 (0.2%) - 304 (30.4%) 53 (5.3%) 187 (18.7%) 36 (3.6%) 14 (1.4%) 11 (1.1%) 3 (0.3%) 41-50 287 (28.7%) 51 (5.1%) 148 (14.8%) 44 (4.4%) 22 (2.2%) 13 (1.3%) 8 (0.8%) 51-60 61 and above 128 (12.8%) 22 (2.2%) 17 (1.7%) 11 (1.1%) 14 (1.4%) 9 (0.9%) 78 (7.8%) 15 (1.5%) 11 (1.1%) 10 (1%) 10 (1.0%) 9 (0.9%) 56 (5.6%) 23 (2.3%) HSIL Moderate severe dysplasia Invasive carcinoma P<0.001. Table 2: Epithelial abnormalities in menopausal and reproductive age group women Age groups Total Normal smears Inflammatory smears LSIL mild dysplasia HSIL Moderate Severe dysplasia Invasive carcinoma Menopausal 449 (44.9%) 90 (9%) 192 (19.2%) 73 (7.3%) 37(3.7%) 33 (3.3%) 24 (2.4%) Reproductive 551 (55.1%) 75 (7.5%) 372 (37.2%) 60 (6%) 22(2.2%) 17 (1.7%) 5 (0.5%) P<0.001 Table 3: Epithelial abnormalities in relation to age at menarche Normal Inflammatory LSIL mild HSIL Moderate Invasive smears smears dysplasia severe dysplasia carcinoma Total Age at menarche in years 10-11 Years 40 (4%) 4 (0.4%) 24 (2.4%) 2 (0.2%) 5 (0.5%) - 5 (0.5%) 12 years 276 (27.6%) 38 (3.8%) 153 (15.3%) 43 (4.3%) 17 (1.7%) 21 (2.1%) 4 (0.4%) 13 years 418 (41.8%) 69 (6.9%) 230 (23%) 64 (6.4%) 25 (2.5%) 23 (2.3%) 7 (0.7%) 14 years 185 (18.5%) 39 (3.9%) 114 (11.4%) 13 (1.3%) 7 (0.7%) 3 (0.3%) 9 (0.9%) 15 years and above 81 (8.1%) 15 (1.5%) 43 (4.3%) 11 (1.1%) 5 (0.5%) 3 (0.3%) 4 (0.4%) P<0.005 Table 4: Epithelial abnormalities in relation to age at marriage Age at marriage 10-14 yrs 15- 17 yrs 18yrs and above Total 151 (15.1%) 406 (40.6%) 443 (44.3%) Normal smears 31 (3.1%) Inflammatory smears 69 (6.9%) LSIL Mild dysplasia 21 (2.1%) HSIL Moderate severe dysplasia 16 (1.6%) 8 (0.8%) Invasive carcinoma 6 (0.6%) 50 (5.0%) 210 (21 %) 55 (5.5%) 33 (3.3%) 39 (3.9%) 19 (1.9%) 84 (8.4%) 285 (28.5%) 57 (5.7%) 10 (1 %) 3 (0.3%) 4 (0.4%) P<0.001 Table 5: Epithelial abnormalities in relation to marital life 289 Shanthi et al., Int J Med Res Health Sci. 2015;4(2):287-293 Married life Total Normal smears Inflammatory smears LSIL mild dysplasia HSIL Moderate severe dysplasia Invasive carcinoma 0-5 years 41 (4.1%) 7 (0.7%) 30 (3%) 4 (0.4%) - - - 6-10 years 93 (9.3%) 18 (1.8%) 58 (5.8%) 15 (1.5%) 2 (0.2%) - - 11-20 years 267 (26.7%) 31 (3.1%) 187 (18.7%) 32 (3.2%) 5 (0.5 %) 10 (1%) 2 (0.2%) 21-30 years 285 (28.5%) 48 (4.8%) 165 (16.5%) 37 (3.7%) 19 (1.9%) 13 (1.3%) 3 (0.3%) 31 years and above 314 (31.4%) 61 (6.1%) 124 (12.4%) 45 (4.5%) 33 (3.3%) 27 (2.7%) 24 (2.4%) P<0.001 Table 6 Epithelial abnormalities in relation to parity Parity Total Normal smears Inflammatory smears LSIL mild dysplasia HSIL Moderate severe dysplasia Invasive carcinoma 0 56 (5.6%) 22 (2.2%) 31 (3.1%) 3 (0.3%) - - - 1 83 (8.3%) 17 (1.7%) 51 (5.1%) 11 (1.1%) 1 (0.1%) 3 (0.3%) - 2 3and above 368 (36.8%) 53 (5.3%) 240 (24%) 53 (5.3%) 11 (1.1%) 8 (0.8%) 3 (0.3%) 493 (49.3%) 73 (7.3%) 242 (24.2%) 66 (6.6%) 47 (4.7%) 39 (3.9%) 26 (2.6%) P<0.001 Table 7: Epithelial abnormalities in relation to economic status Economic status Lower income group Middle income group Upper group Normal smears Inflammatory smears LSIL mild dysplasia HSIL Moderate severe dysplasia Invasive carcinoma 701 (70.1%) 119 (11.9%) 374 (37.4 %) 83 (8.3%) 50 (5%) 47(4.7%) 28 (2.8%) 289 (28.9%) 42 (4.2%) 185 (18.5%) 49 (4.9%) 9 (0.9%) 3 (0.3%) 1 (0.1%) 10 (1%) 4 (0.4%) 5 (0.5%) 1 (0.1%) - - - Total income P<0.001 Table 8: Epithelial abnormalities in relation to education status Education status No Formal education Primary education Higher education Total Normal smears Inflammatory smears LSIL mild dysplasia 665 (66.5%) HSIL Moderate severe dysplasia Invasive carcinoma 103 (10.3%) 345 (34.5%) 88 (8.8%) 52(5.2%) 50 (5%) 27 (2.7%) 279 (27.9%) 51 (5.1%) 180 (18%) 39 (3.9%) 7 (0.7%) - 2 (0.2%) 56 (5.6%) 11 (1.1%) 39 (3.9%) 6 (0.6%) - - - P<0.001 Table 9: Epithelial abnormalities and gynecological symptoms 290 Shanthi et al., Int J Med Res Health Sci. 2015;4(2):287-293 Clinical symptoms Total Normal smears Leucorrhoea 307 (30.7%) Dysuria Irregular vaginal bleeding Post menopausal bleeding Pain in Lower abdomen Mass per vagina Routine check up Inflammatory smears LSIL Mild dysplasia HSIL Moderate severe dysplasia Invasive carcinoma 16 (1.6%) 219 (21.9%) 56 (5.6%) 13(1.3%) 2 (0.2%) 1 (0.1%) 35 (3.5%) 8 (0.8%) 24 (2.4%) 3 (0.3%) - - - 192 (19.2%) 15 (1.5%) 90 (9%) 31 (3.1%) 25(2.5%) 24(2.4%) 7 (0.7%) 71 (7.1%) 1 (0.1%) 13 (1.3%) 8 (0.8%) 8 (0.8%) 22(2.2%) 19 (1.9%) 194 (19.4%) 41 (4.1%) 121 (12.1%) 23 (2.3%) 8(0.8%) 1 (0.1%) - 78 (7.8%) 25 (2.5%) 39 (3.9%) 7 (0.7%) 5(0.5%) - 2 (0.2%) 123 (12.3%) 59 (5.9%) 58(5.8%) 5 (0.5%) - 1 (0.1%) - P<0.001 Table 10: Epithelial abnormalities in relation to clinical lesions Clinical lesions Erosion cervix Hypertrophied cervix Suspicious cervix (growth/ bleeding on touch) Total Normal smears 230 (23%) Inflammatory smears 6 (0.6%) LSIL mild dysplasia 137 (13.7%) HSIL Moderate severe dysplasia 55 (5.5%) 19 (1.9%) Invasive carcinoma 13 (1.3%) - 63 (6.3%) 10 (1%) 34 (3.4%) 12 (1.2%) 5 (0.5%) 1 (0.1%) 1 (0.1%) 82 (8.2%) - 3(0.3%) 10(1%) 10 (1%) 32 (3.2%) 27 (2.7%) Senile vaginitis 41 (4.1%) 9 (0.9%) 22 (2.2%) 4 (0.4%) 4 (0.4%) 2 (0.2%) - Polyp 4 (0.4%) 1 (0.1%) 2 (0.2%) 1 (0.1%) - - - 155 (15.5%) 5 (0.5%) 123 (12.3%) 18 (1.8%) 8 (0.8%) 1 (0.1%) - 87(8.7%) 29(2.9%) 40 (4%) 12(1.2%) 5(.5%) - 1 (0.1%) 338 (33.8%) 105(10.5%) 203 (20.3%) 21 (2.1%) 8 (0.8%) 1 (0.1%) - Endocervicitis Prolapsed Normal Table 11: Epithelial abnormalities in relation to risk factors Risk factors Total Normal smears Inflammatory smears LSIL mild dysplasia HSIL Moderate severe dysplasia Invasive carcinoma Cigarette smoking - - - - - - - Tobacco chewing 105(10.5%) 16 (1.6%) 41 (4.1%) 18 (1.8%) 12 (1.2%) 10 (1%) 8 (0.8%) Immunosuppressive drugs 1 (0.1%) 1 (0.1%) - - - - - DISCUSSION The etiology of cervical neoplasia, which is considered to be the third most common cancer in women, has been studied epidemiologically for over 150 years 8. Epidemiologically cervical cancer behaves like a sexually transmitted disease and is more common in women who have multiple sexual partners 9, or whose partners are promiscuous 10 and is absent in virgins. Epidemiological data has shown that cervical carcinoma is caused by sexually transmitted agent, Human Papilloma virus (HPV) which plays an important role in oncogenesis. Though HPV is considered to be an important etiological factor, the presence of other risk factors along with HPV infection are important in deciding the outcome of the disease i.e. whether HPV infection will regress or progress to cervical cancers 11 . 291 Shanthi et al., Int J Med Res Health Sci. 2015;4(2):287-293 The U.S. Preventive Services Task Force (USPSTF) has recommended that women aged 21 to 65 years should undergo cytological screening for every 3 years. If the women (30 to 65 years) want to lengthen the interval for Pap smear screening, then the combination of Pap smear test and HPV testing for every 5 years is recommended. The UPSTF does not recommend the cervical cancer screening in women younger than 21 years, for women elder than 65 years whose previous cytology smears were normal, women who had undergone hysterectomy with removal of the cervix without any previous precancerous lesion or cancers and testing for HPV alone or along with cytology in women who are younger than 30 years 12. Most of the patients who attended the Government Maternity Hospital, Tirupathi were of low socio economic group. Low, moderate and high income groups differ in various aspects like nutritional and vitamin deficiencies, parity, married life, age at marriage. Hence socioeconomic group is the index of all the above factors which share their contribution in the genesis of cancer cervix. The incidence of invasive cancer in our study was 2.9% which coincided with the results of JS Misra (2001) 13. In our study, severe dysplasia and invasive carcinomas were common after 50 years because of altered hormonal balance that are usually seen in the female genital tract. The role of hormonal factors in the etiology of cervical cancer had been underscored by recent studies which identified several independent risk factors like multiple births, early age at marriage and marital life. In our study, highest incidence of invasive carcinomas and dysplasias were found in women who had more than 30 years of married life. This shows that there is intimate relationship between married life and incidence of cancer cervix. Parazzini et al (1989) suggested that with every pregnancy, women would have double the risk compared to women without children and the risk was ten times more than unmarried women14. Other studies have shown that the incidence was high in women who marry early and tend to conceive more number of times as they are exposed to longer duration in sexual activity. The cigarette smoking /tobacco chewing was attributed as one of the risk factors of cervical neoplasia. In our study out of 29 cases of invasive carcinoma, cases were found to be associated with Shanthi et al., tobacco chewing and also few cases of dysplasias had association with tobacco chewing. Cigarette smoking has been associated with increased risk of cervical cancer, especially among long term or high intensity smokers 15. Smoking constituents have been found in cervical mucous, but the biologic mechanisms underlying the smoking-cervical cancer relationship have not been identified. The use of oral contraceptive pills (OCPs) is also another risk factor. But because most of the patients attending outpatient department are low socioeconomic group without formal education, the number of patients, using OCP’s were very few. After elaborate study it is clearly evident that no single factor can be named as the cause of cancer cervix. Many factors may play part and contribute to the causation of cancer like prolonged sexual life, multiple sexual partners, parity, low socio-economic status, the virus infections and genetics. Immunosuppression has been found to be associated with dysplastic changes in the cervix. HPV DNA is detected more often in pregnant women who have transient depression of cell mediated immunity. More recently, an increased risk of cervical neoplasia has been noted in patients infected with HIV 16. Immunosuppression is considered to inhibit clearance of papilloma virus and promote their reactivation 17. Most of the frank invasive carcinomas presented as growth on cervix or cervix which bleeds on touch which has also been found to be the same in study by JS Misra. Many cases of dysplasias presented as erosion cervix. Other symptoms are leucorrhoea, dysuria, irregular vaginal bleeding, pain in lower abdomen and mass per vagina. For the prevention of cervical carcinoma and precursor lesions American Cancer Society (ACS) recommends Human Papilloma virus vaccines for females aged 11 to 12 years. It also suggests that females as young as 9 years may receive HPV. For the females aged 13 to 18 years, HPV vaccination should be given to catch up missed vaccination or complete the vaccination series. Vaccination is not recommended for women over age of 26 years because ideally the vaccination should be done prior to genital HPV exposure as the benefit is likely to diminish with increasing number of lifetime sexual partners. Even after the vaccination, screening for the cervical intraepithelial neoplasia and cancer should continue. Two prophylactic HPV vaccine are 292 Int J Med Res Health Sci. 2015;4(2):287-293 available i,e. Gardasil which protects against HPV types 6, 11, 16 and 18 (quadrivalent) and Cervarix which protects against types 16 and 18 (bivalent) 18. 8. CONCLUSION Cervical carcinoma is caused not due to single etiological factor but multiple independent risk factors like age, age at menarche, age at marriage, parity, educational and economic status, use of oral contraceptives, cigarette smoking play role in the pathogenesis. Due to simplicity, low cost and validity of the Pap smear screening, it becomes apparent that this test could be effectively used to detect early cancer and premalignant changes in cervix uteri. ACKNOWLEDGEMENT 9. 10. 11. We are thankful to Dr.Sarela Jothi Bai, professor of pathology and Dr.Bharathi, professor of Gynecology for their assistance in completing the project. 12. Conflict of Interest: Nil. 13. REFERENCES 1. Pisani P, Parkin DM, Bray F, Ferlay J. Estimates of the world wide mortality from 25 cancer in 1990.Int J Cancer.1999;83:870-73. 2. Rajendra A Kalkar, Yogesh Kulkarini. Screening for cervical cancer: an over view. Obstet Gynecol India.2006; 56: 2. 3. Mohammed Shaoaib Khan, Fohadiya Yasin Raja et al. Pap smear screening for precancerous conditions of the cervical cancers. Pak J Med Res.2005; 44(3):111-3. 4. Parkin DM, Laara E, Muir CS. Estimates of the world wide frequency of sixteen major cancers in 1980. Int J Cancer.1988; 184-97. 5. Smith PA and Gray W. Cervical intraepithelial neoplasia and squamous cell carcinoma of the cervix: In Diagnostic cytopathology by Winifred Gray and Grace T Mckee. Chapter 30,2nd edition 2003;721-53. 6. Parkin DM, Nguyen-Dinh X, Day NE. The impact of screening on the incidence of cervical cancer in England and Wales. Br J Obstet Gynaecol.1985;92:150-57. 7. Paola Dey, Stuart Collins, Minaxi Desai, Cjaran Woodman. Adequacy of cervical cytology sampling with the cervex brush and the Ayles 14. 15. 16. 17. 18. bury spatula: a population based randomized controlled trial. BMJ 1996;313:721. Simon Herrington. The pathogenesis of cervical neoplasia. In: Winfred Gray and Mckee GT editors . Diagnostic Cytopathology .2nd edition 2003:707-18. Wyndder EL, Cornfield J, Schroff PD, Doraiswami KR. A study of environmental factors in carcinoma cervix. Am J Ostet Gynaecol.1954;63:1016-52. Buckley JD, Doll R, Harris RWC et al. Case control study of the husbands of women with dysplasia or carcinoma of the cervix uteri. Lancet.1981ii;1010-15. Schiffman M et al. Human Papilloma virus and cervical cancer. Lancet 370.2007;890. Virginia A. Moyer. Screening for cervical cancer: U.S Preventive Services Task Force Recommendation Statement. Ann Intern Med 2012; 156(12):880-91. Misra JS, Tandon P, Das K, Chandrawath. Cytological detection of carcinoma cervix and sexually transmitted diseases in urban and rural community of Lucknow. J Obstet Gynecol Ind.2001; 51(5):175-79. Parazzini F, La Vecchia C, Negri E, et al. Reproductive factors and the risk of invasive and intraepithelial cervical neoplasia. Br J Cancer.1989; 59:805-09. Mandelblatt JS, Fahs M, Garibaldi K et al. Association between HIV infection and cervical neoplasia. Implication for clinical care of female at risk for both the conditions.AIDS 1992;6: 17378. Winkelstein W Jr. Smoking and cervical cancercurrent status: a review. Am J Epidemol. 1990; 131:945-57. Burk RD.Human Papilloma virus and the risk of cervical cancer. Asian Journal of Obstet and Gynaec Practice.2003; 17(2).24-29. Debbie Saslow, Philip E.Castle, J.Thomas Cox, Diane D. Davey, Mark H.Einstein et al. American Cancer Society Guideline for Human Papilloma Virus (HPV) vaccine use to prevent cervical cancer and its precursor.CA Cancer J Clin 2007;57:7-28. 293 Shanthi et al., Int J Med Res Health Sci. 2015;4(2):287-293 DOI: 10.5958/2319-5886.2015.00054.5 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 28 Nov 2014 Research article Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 25 Jan 2015 Accepted: 16th Feb 2015 REPARATIVE OSTEOGENESIS DURING TREATMENT OF FRACTURE UNDER TRANSOSSEOUS OSTEOSYNTHESIS AND INTRAMEDULLARY INSERTION OF WIRES WITH HYDROXYAPATITE COATING Iurii M. Irianov1, Arnold V. Popkov1, Nikolay A. Kiryanov2 *, Tatiana Iu. Karaseva1, Evgenii A. Karasev1 1 Russian Ilizarov Scientific Center Restorative Traumatology and Orthopaedics (RISC RTO), Ul'ianova Street, 6. Kurgan, 640014. Russia, 2 Izhevsk state medical academy, Kommunarov str., 281, Izhevsk, Russia. *Corresponding author email:
[email protected] ABSTRACT Background: The problem of improving medical care for patients with the locomotor system injuries is very important especially last time. Material and Methods: Canine open comminuted tibial fractures modelled experimentally, wires with hydroxyapatite coating inserted intramedullary, osteosynthesis performed with the Ilizarov fixator. Regenerated bones investigated 14-360 days after surgery using the techniques of light microscopy, scanning and transmission electron microscopy, and X-ray electron probe microanalysis for histologic sections . Results: It has been found that a zone of active reparative osteo- and angiogenesis forms around the wires, as well as a bone sheath with the properties of osteogenesis conductor and inductor. Fracture consolidation occurs early according to the primary type without cartilaginous and connective tissue formation in bone adhesion. Presented morphological characteristics endovasal angiogenesis. Conclusion: The results of the study evidence of the positive effect of intramedullary wires with hydroxyapatite coating on the course and intensity of reparative osteogenesis during fracture healing Key words: Transosseous osteosynthesis, Intramedullary wires, Hydroxyapatite coating, Fracture healing, Reparative osteogenesis, Angiogenesis. INTRODUCTION The problem of improving medical care for patients with the locomotor system injuries every year is becoming increasingly important due to the increase of injured persons in number, to that of disability and mortality from injuries not having downward tendency. However, osteosynthesis real terms remain to be significant. The technique of directed stimulation of bone tissue regeneration process is practiced by using intramedullary wires with calcium phosphate coating in order to optimize the conditions for regenerated bone formation, as well as for treatment period reduction, and complication prevention [1, 2]. At the same time, the process of reparative osteogenesis using those or other implants inserted into the regenerated bone is poorly understood, as well as both their effectiveness characterization and mechanism of action are absent. The purpose of the present work consists in studying the morphological features of osteogenesis process for consolidation of long tubular bone fractures under transosseous osteosynthesis and intramedullary insertion of wires with hydroxyapatite bioactive calcium phosphate coating. Irianov et al., Int J Med Res Health Sci. 2015;4(2):294-298 MATERIAL AND METHODS 16 mongrel dogs, males and females, at the age from one to five years with the body weight of 20±2.9 kg were used for experiments. The keeping, surgical 294 interventions, and euthanasia of the animals were made in compliance with European Convention for the Protection of Vertebrate Animals (Strasbourg, 1986); they were approved by the Ethics Committee of RISC RTO. Procedures: The animals underwent intramedullary reinforcement of right tibia with two wires under general anesthesia. Wires of titanium alloy were used with bioactive coating of hydroxyapatite of 20-40-µm thickness and 2-8% porosity; the alloy was obtained by the technique of anodic oxidation in the arc mode. The coating presented a multilevel ultraporous system consisting of macro- and micropores of the diameter from 50-100 nm to 1-2 µm. Osteosynthesis was performed with the Ilizarov fixator, and an open comminuted fracture of leg bones was modeled in the shaft middle third. The Ilizarov fixator dismounting made after 28 or 35 days of fixation. Radiography performed in the course of the experiment. The animals were divided into four groups: 14, 21; 28, 35; 42, 90; 180, 360 days after surgery, four animals in each group and two ones – for each time point. Clinical observation of the animals carried out throughout the experiment. Radiography was made using «Premium Vet» X-ray machine (Sedecal, Spain) in direct and lateral views immediately after surgery and during the experiment. Tibias of three intact adult dogs were investigated for comparison. After euthanasia of the animals the shaft portions of the operated bones were sawed lengthwise, fixed in 2% solution of paraformaldehyde and glutaraldehyde, embedded in celloidin (after decalcification) and Araldite (without decalcification). Histotopographic sections were prepared using Reichert microtome (Germany) and stained with hematoxylin-eosin, and with picrofuchsin by Van Gieson. Research and photomicrography of histological sections were performed using «Stemi 2000-C» stereomicroscope and «AxioCam ERc 5s» digital camera completed with «Zen blue» software (Carl Zeiss MicroImaging GmbH, Germany). Araldite blocks were smoothed and investigated with INCA-200 Energy X-ray electron probe microanalyser (Oxford instruments, England). Facture zone image was obtained in characteristic X-ray radiati characterizing the degree bone tissue maturity was calculated. The index of compactness was calculated as well (bone tissue/nonmineralized structure content ratio).The blocks are then sawed ultra thin sections were prepared prepared on an ultra microtome LKB-8800 (Sweden), contrasted and examined using a transmission electron microscope JEM-2010 (Jeol, Japan). Then Araldite blocks were treated in sodium ethyolate 2% solution in order to remove the embedding medium, and they were investigated with scanning electron microscope JSM-840 (Jeol, Japan). The results of quantitative studies were processed using standard methods of variation statistics. The significance of differences between the values was estimated using nonparametric Mann-Whitney U-test. Differences were considered statistically significant for р ≤ 0.05. Irianov et al., Int J Med Res Health Sci. 2015;4(2):294-298 RESULTS Transverse fractures have been produced in tibial shaft middle third of all the animals after surgery (Figure 1, a). The height of diastasis between the fragments is 0.5-1.0 mm. The signs of periosteal reaction as cloud-like shadows appear in close proximity to the fracture line by 8-10 days after surgery. The formation of new bone cortex is determined by X-rays 35 days after surgery (Figure 1, b). Fig: 1a Fig: 1b 295 Fig 1: X-rays of canine tibia after fracture modeling and intramedullary osteosynthesis: a – shaft middle third fracture, immediately after surgery; b – newly formed cortex at the fracture site 35 days after surgery other from the periosteal and endosteal surfaces in the intermediary zone, and they form strata on the ends of fragments. Primary endosteal-periosteal and intermediary union is formed. The content of calcium and phosphorus in the intermediary zone of regenerated bone is 19 % and 20 %, respectively, and that of bone tissue – 26 % of the values of the shaft cortex in normal intact dogs (Table1) The regenerated bone is located all over the bone diameter. Numerous anastomosing trabeculae of reticulofibrous bone tissue in grow towards each Table1: Content of calcium, phosphorus, and bone tissue in the intermediary zone of regenerated bone, and in the cortex of intact shaft (M±m,%) Measures Calcium Phosphorus Bone tissue Са/Р Index of compactness Period of experiment, days 14, 21 28, 35 4.96±0.31 11.02±0.65 42, 90 17.27±1.08 180, 360 23.30±1.31 25.82±1.10 2.95±0.181 5.74±1.531 1.68±0.131 6.44±0.36 53.43±2.89 1.72±0.14 9.06±0.56 80.07±4.90 1.91±0.18 11.07±0.69 94.13±5.49 2.10±0.14 11.75±0.53 96.15±4.44 2.20±0.13 0.35±0.02 1.15±0.07 4.02±0.26 16.04±0.67 Significant changes comparing with the measures of intact animal shaft cortex. By 28, 35 days after surgery the ends of fragments lose clear boundaries due to massive deposits in the intermediary space of mature lamellar bone tissue. Periosteal strata of 2.5-3-mm height become compacted, and they combine the ends of fragments in fracture zone by the flattened fusiform “sleeve”. Ribbon-like spreads are formed in the periosteal area near fragmental ends as small-looped network of lamellar-structured bone trabeculae bridging fracture line. The regenerated bone in the intermediary zone is represented by spongy and compact bone tissue closely adhered with cortex of bone fragments. The phase of organogenesis and remodeling is observed evidenced by reorganization of primary trabeculae into organotypical osteon structures forming cortex (Figure 2, a, b). Gradual reorganization of the trabecular structures of coarse-fibered bone tissue into more mineralized and mature lamellar ones is also observed in the bone sheath round the wires. The content of calcium and phosphorus in the intermediary zone of regenerated bone in this period increases up to 43-55 %, and that of bone tissue – up to 56-57 % of the measures of the shaft cortex in normal intact dogs (Table 1). Cortical layer 24.97±1.28 Fig: 2b Fig 2: The newly formed cortex at fracture site 35 days after surgery: a – staining according to Van Gieson. Lens 2.5, eyepiece 10; b – the map of electron probe microanalysis, the image in characteristic X-ray radiation of calcium, magnification x15. 296 Irianov et al., Int J Med Res Health Sci. 2015;4(2):294-298 By 42, 90 days after surgery the ends of fragments in the intermediary space are connected by narrowlooped network of bone trabeculae, as well as by osteons of different maturity with compaction signs all over cortex width, and practically complete periosteal, intermediary, and endosteal bone union is revealed. The fracture healing occurs by the type of primary consolidation due to the fact that osteogenic cells of Haversian canals forming bone trabecular and osteons across the fracture line grow into the diastasis from the ends of fragments along blood vessels. The bone sheath around the wires is formed by compact bone of lamellar structure with forming osteons and spongy bone tissue which spreads not only into the diastasis but it also fills the medullary cavity of fragments thereby binding them like a pin. Both osteogenesis intense process and bone tissue remodeling is also seen in the periosteal parts of regenerated bone where numerous osteoblasts and functionally active osteoclasts are located, reorganization of the cortex of the fragmental ends is observed with vascular channel expansion and extensive stratification on the fragmental ends of the bone trabeculae surrounded by some layers of large osteoblasts. Secondary osteons of lamellar bone tissue are formed in the new cortex at fracture site, however, the intermediary zone of regenerated bone still differs significantly from the cortical layer of animals’ intact shaft by mineralization degree and organospecificity (Table 1). The content of calcium in the intermediary zone of regenerated bone during this period is 66-67 %, that of phosphorus – 76-77 %, and that of bone tissue – 83-84 % of the values of intact shaft cortex. By 180, 360 days after surgery the endosteal part of regenerated bone is rather small being represented by web-like network of thin lamellar-structured bone trabeculae in the expanded intertrabecular spaces of which vascular channels with wide lumens are located, as well as hematopoietic-and-fatty bone marrow. The bone sheath around the wires sharply becomes thinner, and it is fragmented, multiple functionally active hypertrophied osteoclasts and resorption lacunae are located on its outer surface. The content of calcium, phosphorus, and bone tissue in newly formed cortex at this stage of the experiment approximates to the measures of the shaft cortex in intact animals (Table 1). The investigations of the content of bone tissue and of the main mineral components in the intermediary zone of regenerated bone evidence of the fact that as far as the experiment duration increases, calcium and phosphorus content in the newly formed bone increases steadily as well thereby reflecting gradual prolonged mineralization of the regenerated bone throughout the experiment. The rise of Ca/P coefficient with increasing the experiment duration indicates qualitative changes in the mineral phase of regenerated bone tissue which are characterized by gradual decreasing the proportion of soluble calcium phosphate, as well as by increasing the proportion of hydroxyapatite and bone tissue maturity degree thereby approximating for these measures to the shaft cortex of intact animals. The index of bone tissue compactness in the newly formed part of regenerated bone cortex increased gradually as well, reflecting the rise in its organospecificity degree. At the same time, the index of bone tissue compactness in the regenerated bone intermediary zone amounted to 64.24±3.73 % of the values of intact shaft cortex even by the end of the experiment thereby evidencing of incompleteness of remodeling processes. Irianov et al., Int J Med Res Health Sci. 2015;4(2):294-298 DISCUSSION Intramedullary osteosynthesis is known to provide little-damage fixation of fractures, to allow earlier weight-bearing of the operated limb, and to be one of the main standard techniques for treating femoral and tibial shaft fractures in most countries [3,4]. The main disadvantage of intramedullary osteosynthesis is considered the risk of damaging vessels and circulation system of medullary canal which weakens the osteogenic and osteoinductive potential of bone marrow stromal pluripotent cells [5]. Experimental studies have demonstrated that insertion of even thin implant into the medullary cavity results in significant blood supply disorders of the medullary canal and cortex inside [6]. The possible mechanism of the stimulating effect of intramedullary wire insertion is connected with prolonged formation of the local foci of granulation tissue in the medullary cavity. The characteristic feature of the granulation tissue is the expression of endotheliocyte migration phenotype, and as a consequence – angiogenesis activation evidenced by intense formation of numerous endothelial sprouts which generate capillary buds and 297 endovasal spreads localizing in vascular lumens (endovasal angiogenesis). The creation of such foci provides the increase of osteoproducing cell population in fracture zone both endocrinally and paracrinally, as well as it stimulate regeneration angiogenesis, and thereby contribute to osteoreparation process activation. The additional coating of titanium implant surface with hydroxyapatite nanostructured high-porosity layer provides high biocompatibility with the tissue structures of regenerated bone, increases osteointegration rate, decreases the output of metal ions, and prevents the formation of fibrillary connective tissue and cartilage in the regenerated bone [6,7]. The zone of active appositional osteogenesis and angiogenesis is formed around the wires, as well as the bone sheath with osteogenesis conductor and inductor properties, which provide directed growth of bone tissue, prolonged stimulation of angiogenesis and reparative osteogenesis. Fracture consolidation occurs by the primary type early without cartilaginous and connective tissue formation in bone adhesion. CONCLUSION Thus, the results of the study evidence of the positive effect of intramedullary wires with hydroxyapatite coating on the course and intensity of reparative osteogenesis during fracture healing. The data obtained allow recommending this relatively little-invasive method of osteoreparation optimization to be used in combination with other methods of conservative and surgical treatment of bone fractures, especially for sluggish reparative processes in children, elderly and senile persons, as well as in debilitated patients. 2. 3. 4. 5. 6. 7. complications. A review of the prospective literature. Can J Surg. 2000; 43(4): 256-62. Griffith LE, Cook DJ, Frulke JP. Intramedullary reaming of long bones. Practice of intramedullary locked nails. Springer Verlag, 2006: 43-57. John VZ, Alagappan M, Devadoss S, Devadoss A. A completely shattered tibia. J Bone Joint Surg. Br. 2005 Nov; 87(11): 1556-59. Lin CM, Yen SK. Biomimetic growth of apatite on electrolytic TiO2 coatings in simulated body fluid.Materials Science Engineering. 2006; 26: 54-64. Joseph В, Rebello G. B CK. The choice of intramedullary devices for the femur and the tibia in osteogenesis imperfecta. J Pediatr Orthop. 2005 Sep; 14(5): 311-19. Schemitsch EH, Kowalski MJ, Swiontkowski MF. Cortical bone blood flow in reamed and undreamed locked intramedullary nailing: a fractured tibia model in sheep. J Orthop Trauma. 1994; 8(5): 373-82. Liu X, Chu PK, Ding C. Surface modification of titanium, titanium alloys, and related materials for biomedical applications. Materials Science Engineering. 2004; 47: 4921. ACKNOWLEDGEMENT We thank the staff of our institutions for their help in carrying out experiments and supervision over animals during all stages of work. Conflict of Interest: Nil REFERENCES 1. Coles CP, Gross M. Closed tibial shaft fractures: management and treatment 298 Irianov et al., Int J Med Res Health Sci. 2015;4(2):294-298 DOI: 10.5958/2319-5886.2015.00055.7 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS Received: 2nd Dec 2014 Revised: 6th Jan 2015 Research article Copyright @2014 ISSN: 2319-5886 Accepted: 16th Jan 2015 INFARCTION IN NORMAL AND INTRAUTERINE GROWTH RETARDATION [IUGR] PLACENTA *Pooja Dhabhai1, Ghanshyam Gupta2 1,2 Department of Anatomy, R.N.T. Medical College, Udaipur, Rajasthan, India *Corresponding author email:
[email protected] ABSTRACT Background and Purpose: The purpose of the study is to compare the presence of Infarction in normal placentas and IUGR placentas. Study design and setting: Research study, Department of Anatomy, R.N.T. Medical College, Udaipur. Study Sample: 100 control and 100 IUGR Placentas Inclusion criteria: 100 Placentas from normal control Pregnancies and 100 Placentas from mother who Delivered Intra Uterine Growth Retarded (IUGR) babies Exclusion Criteria: we refer only uncomplicated Pregnancies without any previous diseases Results: Chi Square test was used for statistical analysis. Conclusion: Increased incidence of extensive infarction associated with low fetal weight Keywords: Infarction, Placenta, Intrauterine Growth Retardation INTRODUCTION Fetal growth depends on the proper development and function of the placenta, which serves to maintain mater no fetal interference for the exchange of blood gases, nutrients, and waste [1]. The architecture of the placenta is altered in many maternal diseases such as diabetes mellitus[2], hypertension[3], preeclampsia [PE] [4], and eclampsia[5]., Although the placenta is a vital organ, its systemic study has been neglected; however, in recent times, it has evoked great interest, and much work is being conducted to understand the unique biological status of this complex organ[6]. Placental examination has clinical value in cases of PE and intrauterine growth retardation (IUGR), both of which are associated with high perinatal morbidity and mortality accompanied with gross pathological changes in the placenta. Placental infarcts are usually wedge shaped and always have a point of contact with the basal plate, when fresh they are well demarcated, dark red and moderately firm [7]. Placental infarctions are zone of ischaemic necrosis of group villi due to complete interference with their blood supply in the deciduas or in the local state by thrombosis of a spiral arteriole or a retroplacental haemorrhage[8]. Small areas of infarction, involving less than 5% of the parenchyma, were found in almost a quarter of placentas from normal pregnancies and are of no clinical significance. Extensive infarction, that is involving more than 10% of villous substance is associated with a high incidence of fetal hypoxia, low birth weight and fetal death and is virtually confined to placentas from patients suffering from the hypertensive complications of pregnancy. Extensive infarction is [7] due to occlusion of multiple maternal arterioles . It was found that extensive infarction in cases of toxaemia were associated with low birth weight, [7] placental weight and increased foetal death MATERIAL AND METHODS 299 Pooja et al., Int J Med Res Heath Sci. 2015;4(2):299 -301 The study of placenta in normal and IUGR cases was carried out at R.N.T. Medical College & Hospital, Udaipur. The cases were studied from 1-713 to 1-5-14. The study plan was approved by institution Ethical Board and consent form was filled by patients. The placenta were collected from 200 women admitted to the labour Rooms of the hospital (either directly or through the antenatal wards). All the cases were within the age group of 18-40 years, of average height and weight. Group 1normal pregnancy 100 patients included in this group, normal Hb and urine analysis, not associated with any disease. Group 2-IUGR cases 100 cases of IUGR were included. After the delivery placenta were collected for gross studies, washed and surface dried between blotting papers. Presence of Infarction noted as Mild(less than 5% of total placental area) Moderate(more than5% less than 10% of total placental area) Severe(more than 10% of total placental area) [7] Area of infarction on the maternal surface varied from no Infarcted area to 5-10 % of the total surface (as calculated from combined area of the infarcts as seen on the maternal surface.) [7] Mild(less than 5% of total placental area) Mod(more than5% less than 10% of total placental area) Severe(more than 10% of total placental area) 9 51 4 20 0 24 *Highly significant p<0.0001 Table2.Statistical comparison of present in control and research group Author Place No. of case s GangaR Singal (2013)9 Kotgirwar (2011)10 PradeepS Londhe11 Figen Barut12 Gediminas Meèëjus13 Nayereh Ghomian14 Günyeli 15 Present Study Bhavnagar 100 Bhopal 55 nil 1.8 <0.01 Andhra Pradesh Turkey Lithuania 374 5.4 10.6 <0.01 110 120 nil 4.2 92.7 49.2 <0.01 <0.01 Iran 46 8.7 39.1 <0.0001 Turkey IndiaUdaipur 52 200 4 13 58 96 <0.05 <0.0001 *Highly significant p<0.01,p<0.05 RESULTS Infarction Infarction Result present in % of cases Contro Resea l rch 5 10 <0.01 p<0.0001,*Significant DISCUSSION Area of Infarction Fig.1 Photograph of maternal surface of placenta showing area of Infarction Table 1 Analysis for Infarction Infarction type Normal pregnancies group (n = 100) IUGR pregnancies group (n = 100) 87 4 Nil p value <0.0001 * Present study shows that infarction is present in higher % of cases in IUGR group and the difference is highly significant in our study. The p value (<0.0001) is highly significant. The present study is consistent with Nayereh Ghomian et al 14 also shows Highly significant values of infarction in research group. Among Indian studies the present study is consistent with study of Ganga R Singal[9], Kotgirwar[10]. Pradeep S Londhe[11] also studied higher percentage of infarction in research group. The p value (<0.01) is significant and thus favours the present study. Among western studies the present study is consistent with Figen Barut[12], Gediminas Meèëju[13] ,Günyeli et al[15] as they also showed higher occurrence of infarction in IUGR group. In present study infarction was seen in 13 cases of normal terms pregnancy but 300 Pooja et al., Int J Med Res Heath Sci. 2015;4(2):299 -301 extent of infarction was less than 10% of placental tissue. It was seen in 96% cases of IUGR , in 24% of these extent of infarction was more than 10% of placental tissue on gross examination. 6. CONCLUSION Increased incidence of extensive infarction was seen in cases of IUGR. These cases were associated with low foetal weight. Every placenta shows many degenerative features. Presumably these are to an extent, physiologic sequence of evolution. However, when they occur in excess, they must be considered as pathological, particularly when they affect foetal growth deleteriously. 7. 8. 9. ACKNOWLEDGEMENT Conflict of Interest-NIL 10. REFERENCES 1. Vogel P. The current molecular phylogeny of Eutherian mammals challenges previous interpretations of placental evolution. Placenta. 2005; 26:591–96. 2. Pardo F, Arroyo P, Salomón C, Westermeier F, Guzmán-Gutiérrez E, Leiva A, Sobrevia L. Gestational diabetes mellitus and the role of adenosine in the human placental endothelium and central nervous system. J Diabetes Metab. 2012; 2:10-11. 3. Barker DJ, Bagby SP, Hanson MA. Mechanisms of disease: in utero programming in the pathogenesis of hypertension. Nat Clin Pract Nephrol. 2006;2:700–07. 4. Sankar KD, Bhanu PS, Kiran S, Ramakrishna BA, Shanthi V. Vasculosyncytial membrane in relation to syncytial knots complicates the placenta in preeclampsia: a histomorphometrical study. Anat Cell Biol. 2012; 45:86–91. 5. Akhlaq M, Nagi AH, Yousaf AW. Placental morphology in pre-eclampsia and eclampsia and 11. 12. 13. 14. 15. the likely role of NK cells. Indian J Pathol Microbiol. 2012; 55: 17–21. Murphy VE, Smith R, Giles WB, Clifton VL. Endocrine regulation of human fetal growth: the role of the mother, placenta, and fetus. Endocr Rev. 2006; 27: 141–69. Fox,H.in Post graduate obstetrical and Gynecological Pathology by Fox,H and Langley,F.a.1stEd. 1973;409-37, Zeek PM,Assali NS Vascular changes in the deciduas associated with eclamptogenic toxaemia of pregnancy.American Journal of clinical Pathology,1950;20:1099-09. Dr.Ganaga R Singal et al ,Placental Morphometry in Relation to Birth Weight of Full Term Newborn ; SEAJCRR 2013; 2(5) 334-42 S kotgirwar, M ambiye, S athavale,V gupta, S trivedi, Study of Gross and Histological features of placenta in intrauterine growth retardation ;J. Anat. Soc. India 2011 60(1) 37-40 Londhe, pradeep s.et al Placental morphometry in relation to birth weight of full term newborn babies. ,National journal of integrated research in medicine . 2012; 3( 1): 67-72. Figen Barut et al;Intrauterine growth restriction and placental angiogenesis; Diagnostic Pathology 2010,5:24 Gediminas meèëjus, Influence of placental size and gross abnormalities on intrauterine growth retardation in high-risk pregnancies, Acta medica lituanica. 2005;12 (2)14–19 Ghomian, Nayereh et al 2014 Iranian Journal of Pathology;Winter2014; 9 (1): 9 Günyeli et al. Placental examination in IUGR and Stillbirth ; J Turkish-German Gynecol Assoc 2011; 12: 75-9 301 Pooja et al., Int J Med Res Heath Sci. 2015;4(2):299 -301 DOI: 10.5958/2319-5886.2015.00056.9 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 7 Dec 2014 Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 4 Feb 2015 Accepted: 20th Feb 2015 Research article COMPARISON OF ENDOSCOPIC SINUS SURGERY AND ANTRAL WASH OUT IN THE MANAGEMENT OF SUBACUTE AND CHRONIC MAXILLARY SINUSITIS *MuthuBabuK, Srinivasan MK., Sakthivel M, Kiran kumar C, Arvindh kumar G Department of ENT, Meenakshi Medical College and Research Institute, Kanchipuram, Tamil Nadu, India *Corresponding author: MuthuBabu. K ; Email:
[email protected] ABSTRACT Introduction: Sub acute and chronic maxillary sinusitis is commonly encountered in day to day ENT practice. Here we compare the management options available in the treatment of these two conditions. Methodology: Endoscopic sinus surgery and antral wash out are two well known and authentic procedures used in the management of maxillary sinusitis. Here we evaluate the effectiveness and advantages of both the procedures in the management of sub acute and chronic maxillary sinusitis. 40 patients were evaluated. 20 patients underwent antral lavage and the remaining 20 underwent Endoscopic sinus surgery. Equal number of patients with sub acute and chronic maxillary sinusits underwent both the procedures. Result: Evaluation was done based on the symptoms, anterior rhinoscopy finding and radiological finding. Conclusion: Endoscopic sinus surgery is an ideal management tool for chronic maxillary sinusitis. But sub acute maxillary sinusits can be treated as a day care procedure by antral washout. Keywords: Antral wash out, Endoscopic sinus surgery, Maxillary sinusitis. INTRODUCTION Sinusitis is classified as acute sinusitis – 7days to 4 weeks duration, sub acute sinusitis – 4 weeks to 12 weeks duration and chronic sinusitis – more than 12 weeks duration, acute exacerbation of chronic maxillary sinusitis and recurrent sinusitis – more than 4 episodes per year [1]. Here we limit our study to sub acute and chronic maxillary sinusitis. The differential diagnosis is based upon the duration of symptoms and sinus endoscpic finding [2]. We compare the effectiveness of two authentic procedures, antral washout and endoscopic sinus surgery. Sub acute maxillary sinusitis usually clears up by repeated sinus washout [3]. MATERIAL AND METHODS Patients from the outpatient and inpatient Department of ENT and head and neck surgery, Meenakshi Medical College and Research Institute were taken up for the study after getting the approval. Patients in the age group of 20 to 45 years of both sexes were taken up for the study. Only patients who were suffering from exclusive maxillary sinusitis were evaluated. Exclusions: Involvement of other paranasal sinuse, Presence of nasal polyps, Allergic rhinitis, Acute exacerbations of chronic diseases, Fungal sinusitis, Presence of any tumours in the nose. Randomized separation study was done after getting the written consent from the patients. 40 patients with symptomatic maxillary sinusitis were evaluated. 20 patients underwent antral wash out.10 patients were suffering from sub acute maxillary sinusitis and the rest 10 patients were suffering from the chronic form of the disease. Similarly 20 patients underwent endoscopic middle meatal antrostomy out of which 10 were suffering from sub acute maxillary sinusitis and the other 10 patients with chronic 302 Muthu Babu et al., Int J Med Res Health Sci. 2015;4(2):302-304 Disease Percentage of patients improved following antral wash Chronic maxillary sinusitis Subacute maxillary sinusitis Percentage of patients improved following endoscopic sinus surgery 20% 90% 90% 90% RESULTS 9 out of 10 patients who underwent antral wash out for sub acute maxillary sinusitis were relieved of the symptoms that they complained off. Anterior rhinoscopy and nasal endoscopic evaluation also revealed complete normalcy after the procedure. Radiological appearance of sinuses also showed improvement with decrease in the opacification. Similarly 9 out of 10 patients who underwent endoscopic surgery with sub acute symptoms showed similar improvement. On the other hand 9 out of 10 patients who were suffering from chronic maxillary sinusits and who underwent endoscopic sinus surgery showed improvement based on the symptoms, signs and radiologic comparisons. But only 2 out of 10 patients with chronic maxillary sinusits showed symptomatic improvement following antral wash out (Fig 1). improved 10 No. of patients maxillary sinusitis. Evaluation was then done based on the symptoms like nasal discharge, headache, anterior rhinoscopic examination, endoscopic examination of the nose, X-ray of the paranasal sinuses, CT scan of the paranasal sinuses. The evaluation of all these parameters was done before the procedure and after the procedure. In few patients who had purulent secretions the pus was sent for culture and sensitivity. Antral lavage: Under local anaesthesia, 4% xylocaine was used to anaesthetize the nasal cavity through the inferior meatus[4]. A Lichtwitz trocar and canula was inserted into the maxillary antrum through the inferior meatus and the antrum washed with normal saline. By doing so the antrum was washed out and the patency of the natural maxillary sinus ostium was established thus helping in the treatment of the disease. Endoscopic sinus surgery: Using 0 degree nasal endoscope, under local or general anaesthesia the procedure was performed depending on the ability of the patient to withstand the procedure [5]. A middle meatal antrostomy and complete toileting of the maxillary antrum was done. Pus if present was sent for culture and sensitivity. Patients were followed up every week for six weeks and the patient’s response to treatment was evaluated depending on the symptoms like headache, nasal discharge, and nasal obstruction and from the anterior rhinoscopy and nasal endoscopic findings. Preoperative and post operative X-ray and CT scan of the patients were compared to come to a conclusion regarding the results of both the procedures. Table1: Showing percentage of patients improved following antral wash and endoscopic sinus surgery. 8 6 Subacute 4 Chronic 2 0 Antral wash FESS Fig 1: Comparison of antral wash-out with FESS for sub acute and chronic diseases. DISCUSSION It was Messerklinger who made us understand about the physiology of the nose and sinuses and also in recognizing the mucociliary transport mechanism in the nose and sinus mucosa. The mucociliary transport of mucous occurs in a definite genetically predetermined system. The transport is always towards the natural ostium. In sinusitis the pathology is not in the major sinuses but secondary to impaired drainage caused by disease in the ethmoidal infundibulum blocking the natural ostium in the middle meatus. This leads to stagnation and impaired ventilation causing damage to the respiratory epithelium with consequent inflammation and further occlusion of the ostium. Functional endoscopic surgery is aimed in tackling the pathology in the natural ostium. Antral wash out aims at washing out the stagnated contents in the antrum through a trochar and canula inserted through the inferior meatus and is washed out through the natural ostium. So any minimal pathology in the ostium may be cleared of in 303 Muthu Babu et al., Int J Med Res Health Sci. 2015;4(2):302-304 this procedure itself. Hence we were induced to make such a comparative study. The predisposing factors for sinusitis are Upper respiratory tract infections, anatomic variations, allergic rhinitis, immuno deficiency diseases, inhalation of irritants etc[2].Dental infections are also a common cause for maxillary sinusitis. Here two of our patients had dental infection. Typical organisms in an odentogenic sinusitis include anaerobic streptococci, streptococci sanguis, streptococcus salivarius, streptococcus mutans, bacteroides, proteus and coliform bacilli [3]. In sub acute cases antral wash out is frequently carried out as a first line of management. Antral washouts are also done in some centres at the time of polypectomy [4].local anesthesia is usually preferred. We use 4% xylocaine surface anesthesia. In some centres Propandid as the sole anaesthetic agent for antral wash out in adult day case is described [5,6]. One of the main benefits of antral wash out in sub acute cases is that the tap provides material for culture and sensitivity to guide antibiotic selection especially in immunocompromised patients in the intensive care units. The commonest organism being gram positive organisms responding to amoxicillin and clavalunic acid [7]. If penicillin group is to be avoided due to hypersensitivity then cefpodoxime and cefuroxime can be used [8-11]. In our study no such limitations were present. CONCLUSION From the above study we came to a conclusion that in the management of sub acute maxillary sinusitis both antral was out and endoscopic sinus surgery provides equal relief. Since Antral wash out is a simpler procedure and doesn’t require hospital stay and can be done as a day case, antral wash out still holds good in the treatment of sub acute maxillary sinusitis. But functional endoscopic sinus surgery still remains the gold standard in the treatment of chronic maxillary sinusitis. ACKNOWLEDGMENT Conflict of interest: Nil REFERENCES 1. Ian S Mackkay , Valerie J Lund classification and differential diagnosis of rhinosinusitis,ScottBrowns otorhinolaryngology and head and neck surgery.7th edition 2008; 1380. 2. A.Masood, Loannis Moumoulidis,Joan Panesar Predisposing factors for sinusitis. Postgraduate Medical journal 2007 83(980) 402 – 08. 3. Legret.KG, Zimmerman,Stierna P Sinusitis of odontogenic origin. Pathophysiological impli cations of early treatment. Acta otolaryngol. 2004.124(655) 662 -63. 4. Dowel.M,Pahor AL Antral wash out in nasal polypectomy The journal of laryngology and otology 1992,106(8) 695-96. 5. D.L.Scott Propandid as the sole anaesthetic agent for antral wash out in adult. British journal of anaesthesia 1970 .42 (10):889 – 90. 6. Pang YJ,WillatDJ, Do antral wash out have a place in the current management of chronic sinusitis.J of Laryngol and otoln 1996:110:92628. 7. Garau .J, DaganR, Accurate diagnosis and appropriate treatment of acute bacterial rhino sinusitis: Minimising bacterial resistance Clin Ther 2003:25 (7):1936-51. 8. Melen I, Lindal L, Andreasson.L, Rundcrantz H chronic maxillary sinusitis. Definition, diagnosis and relation to dental infections and nasal polyposis: Acta otolaryngo 1986. 101(3-4): 3207. 9. G.E.Archer The treatment of subacute maxillary sinusitis especially in children: Proc.R.Soc.Med. 1947 40(4); 854-58. 10. Mochloulis G, HernJD, Hollis LJ, Tolley NS, Maxillary antral lavage using inferior meatus anaesthesia J laryngol otal 1996 110(8) : 763-4. 11. Young JJ, Liw Y, Jil Q, Wang ZY, Sun J, Wang QP, Liz Q, Xu JG local aneasthesia for functional endoscopic sinus surgery employing small volumes of epinephrine containing solutions of lidocaine produces profound hypertension: Acta Anaesthesiol Scan 2005: 49(10): 1471-6. I would like to thank Dr. K.Nithyananthan, M.S., DEAN Meenakshi Medical College and Hospital Research Institute for giving us this opportunity to conduct this study. I would also like to thank the medical and paramedical staff of the Dept of ENT for their assistance. 304 Muthu Babu et al., Int J Med Res Health Sci. 2015;4(2):302-304 DOI: 10.5958/2319-5886.2015.00057.0 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 nd Received: 22 Dec 2014 Research article Coden: IJMRHS Revised: 5th Jan 2015 Copyright @2014 ISSN: 2319-5886 Accepted: 1stMar 2015 COMPARISON OF THE KNOWLEDGE, ATTITUDE AND PRACTICES OF ESSENTIAL MEDICINES AMONG MEDICAL PRACTITIONERS OF A MEDICAL COLLEGE VERSUS PRIVATE MEDICAL GENERAL PRACTITIONERS OF AN URBAN PLACE OF SOUTH INDIA *Vidyarthi SurendraK1, Nayak RoopaP2, Gupta Sandeep K3, Dandekar Rahul H4 1 Associate Professor, 2Professor and Head, 3Assistant Professor, Department of Pharmacology, Dhanalakshmi Srinivasan Medical College and Hospital, Siruvachur, Perambalur, Tamil Nadu 4 Assistant Professor, Department of Community Medicine, Dhanalakshmi Srinivasan Medical College and Hospital, Siruvachur, Perambalur, Tamil Nadu *Corresponding author email:
[email protected] ABSTRACT Background: India is the third largest producer and exporter of medicines to most of the countries. The World Medicine Situation Report 2011 states that 65% persons in India do not have access to essential medicines. While, huge unethical prescribing ofdrugs for monetary gains has been a second major cause of rural indebtedness. Aims and Objectives: The primary objective of the study was to compare the Knowledge, Attitude and Practices of Essential Medicines among Medical Practitioners of a Medical College and Private Medical General Practitioners of an urban place, e.g. Perambalur District of South India. Materials and Methods: After ethical approval, the study was started, in Dhanalakshmi Srinivasan Medical College and Hospital (DSMCH), Siruvachur-621113, Perambalur, Tamil Nadu. It was a questionnaire based study. The faculties of the DSMCH and Medical Private Practitioner of Perambalur district included as participants in the study. We distributed knowledge, attitude and practice (KAP) based 15multiple choice questions on National Essential Medicine List, 2011 (NEML) to each healthcare professionals (HCPs) to attempt within 15 minutes. Results: Overall, Knowledge, attitude and practices regarding NEML 2011 were 57.06%, 38.36%; 51.16%, 51.82%; 21.73%, 28.7% to HCP from DSMCH and HCP from Perambalur district, respectively. Whereas, 42.2 % HCPs from DSMCH and 44.7 % HCPs from Perambalur district were prescribed branded and generic drugs both. Conclusion: The result’s data shows that regular awareness programmes should be conducted to update knowledge, change attitude and practices regarding essential medicines to serve the society as best as possible. Key words: Essential Medicine List (EML), National Essential Medicine List (NEML), Knowledge, Attitude, Practice, (KAP), Essential medicine. INTRODUCTION Access to essential medicines is a fundamental human right. India is the third largest producer and exporters of medicines to most of the countries.[1]Whereas, huge unethical prescribing of unnecessary drugs for monetary gains by health service providers has been a second major cause of rural indebtedness.[1] While, the World Medicine Situation Report 2011 states that 65% persons in India do not have access to essential medicines.[2]Therefore, an earlier attempt of establishing low cost quality generic medicines, motivating providers to prescribe generic medicines and follow standard treatment protocols partially succeeded and Provision of free medicines to all patients seeking care in government hospitals has improved access to health care many folds. The 305 Surendra et al., Int J Med Res Health Sci. 2015;4(2):305-310 WHO has defined “Essential medicines (drugs) those that satisfy the priority healthcare needs of the population. They are selected with due regard to public health relevance, evidence on efficacy and safety, comparative cost effectiveness and it should be available at all time, in adequate amounts, in appropriate dosages forms, with assured quality and adequate informations”[3]Though, healthcare professionals play an important role to prescribing essential medicines, so question arises what about their awareness on essential medicines. Thus, the present survey conducted to compare the Knowledge, Attitude and Practices regarding Essential medicines among Medical practitioners of a Medical College and Private Medical General Practitioners of an urban place, e.g. Perambalur District of South India. Aims and objectives: The primary objective of the study was to compare the Knowledge, Attitude and Practices of Essential medicines among Medical practitioners of a Medical College and Private Medical General Practitioners of an urban place, e.g. Perambalur District of South India. MATERIAL and METHODS After getting approval from the ethics committee, the present study was conducted in the month of February 2014, in Dhanalakshmi Srinivasan Medical College and Hospital (DSMCH), Siruvachur-621113, Perambalur, Tamil Nadu. The study was questionnaire based comparison among two groups of the healthcare professionals. The Professors, Associate Professor, Assistant Professor, senior and junior resident (SR, JR), pharmacist, dentist and casualty medical officer (CMO) of DSMCH included in group ‘A’ and they are abbreviated as “A_DSMCH_HCP” and Medical General Practitioner of Perambalur district included in group ‘B’ and they are abbreviated as “B_Perambalur_GP”. We distributed 5-knowledge, 5-attitude and 5-practice (KAP) based, i.e. 15 multiple choice questions which was based on National Essential Medicine List, 2011 (NEML) to each healthcare professionals (HCPs) to attempt within 15 minutes. Statistics: After evaluation of each paper, we analyzed the data by using Epi Info Free available online/offline software and statistical calculations done; like percentage, chi-square test, p-values. RESULTS We formed two groups, 61 healthcare professionals from DSMCH in group ‘A’ (A_DSMCH_HCP) and in group ‘B’ (B_Perambalur_GP) 61 general practitioners from Perambalur District. The demography of the participated HCPs were the 11professor, 4-associate professor, 22-assistant professor, 4-senior resident (SR), 9-junior resident (JR), 1-casualty medical officer (CMO), 7-pharmacist and 3-dentist were participated in group “A”, out of 61 HCPs. While all 61 HCPs of group “B” were General practitioners from various medical subjects. Average age of the included HCPs was 39 years and45 male, 16 female HCPs were from DSMCH, while 49 male, 12 female HCPs were from Perambalur District. We analyzed knowledge, Attitude and Practices (KAP) about essential medicines of 61 HCPs of A_DSMCH_HCP and 61 HCP of B_Perambalur_GP; Perambalur District. Obtained responses data shown in table1, 2 and 3 respectively. Statistics: We used Epi. Info free available online/offline software to calculate the obtained responses in percent and applied Chi- square test and calculated p-value of each questions’ response. Knowledge on National Essential Medicine & its List2011: Overall, 57.06% HCP from DSMCH and 38.36% HCP from Perambalur district were aware about EML 2011, while 21.98%, 28.86% HCP were do not know about EML2011 from DSMCH and Perambalur district respectively and even 20.98%, 32.82% HCP from DSMCH and Perambalur district were not sure about knowledge of EML2011 respectively(Table 1). Attitude about HCP for National Essential Medicine & its List2011: Overall, 51.16% HCPs from DSMCH attitude were strongly agree or strongly like to attend/refer NEML2011, while; 51.82% HCPs from Perambalur district attitude was strongly agree or strongly like to attend/refer NEML2011. One side, 44.94% HCPs from DSMCH were like to refer NEML, whereas 40.62% HCPs from Perambalur district were like to refer NEML(See details on Table 2). Practices about National Essential Medicine & its List2011 for HCPs:8.2 % HCPs from DSMCH always prescribed generic drugs, whereas, 14.8% 306 Surendra et al., Int J Med Res Health Sci. 2015;4(2):305-310 prescribed branded drugs, while 62.3% HCPs drugs, respectively, while; 20.9 % HCPs from prescribed branded as well as generic drugs both. DSMCH and20.9%HCPs from Perambalur district 6.6% HCPs from Perambalur district always were frequently prescribed old essential drugs, prescribed generic drugs, whereas, 36.1% prescribed respectively. Whereas, 42.2% HCPs from DSMCH branded drugs, while 55.7 % HCPs prescribed and 44.7% HCPs from Perambalur district were branded as well as generic drugs both. Overall, 21.73 prescribed branded and generic drugs both (See % HCPs from DSMCH and 28.7 %HCPs from details on Table 3) Perambalur district were always prescribed branded Table1: Knowledge Based Questions and obtained Responses of Both Group ‘A’ and ‘B’ HCPs Knowledge Based Questions Know Indian Essential Medicine list 2011 is the List of drugs by generic names and it is required to satisfy the priority healthcare needs of a population. Q.2 *NLEM2011 incorporated with twenty seven sections with 348 drugs. Q.3 Indian EML2011 formulary has Basic drug informations like Dose, Generic name, Clinical indications. Q.4 Essential medicines selection criteria are Pattern of prevalent diseases, Relative efficacy, cost and suitability of drugs and treatment facilities. Q.5 WHO revise and publish essential medicine list in every two years interval, while Govt. of India, θMOHFW published EML in 1996, 2003, 2011. Knowledge about NEML2011 (Total Percentage in Average): A-DSMCH_HCP Don’t Not Know Sure B-Perambalur_HCP Know Don’t Not Sure Know Q.1 39 (63.9%) 7 (11.5%) 15 (24.6%) 34 (55.7%) 30 (49.2%) 40 (65.6%) 20 (32.8%) 8 (13.1%) 11 (18%) 13 (21.3%) 6 (9.8%) 26 (42.6%) 46 (75.4%) 10 (16.4%) 5 (8.2%) 19 (31.2%) 22 (36.1%) 57.06% 21.98% 0 27 (44.3%) Chisquared PValue 10.8 0.005 38 17 (62.3%) (27.9%) 18 17(27.9%) (29.5%) 22.9 0 7.3 0.03 32 (52.5%) 12 (19.7%) 17 (27.9%) 9.2 0.01 20 (32.8%) 19 (31.2%) 20 (32.8%) 22 (36.1%) 0.2 0.9 20.98% 38.36% 28.86% 32.82% Abbreviations: *NLEM= National list of Essential Medicine, θMOHFW= Ministry of Health and Family Welfare. Table 2: Attitude Based Questions and obtained responses of both groups ‘A’ and ‘B’HCPs Attitude Based Questions Q.6 Q.7 Have you ever refer essential Strongly Like to Medicine list 2011 or your like to refer refer Hospital formulary in last three 19 (31.2%) 42(68.9%) years? Strongly Like to Have you ever read any article read/ regarding essential medicines or like to read/ attend attend attended any seminar, conferences, symposium, CME, workshop etc. on it? Q.8 A-DSMCH_HCP Do you think prescribing essential medicines should be made mandatory? Q.9 Do you think prescribing Generic drugs should be made mandatory? Q.10 I Strongly like, like, dislike, to select essential medicines as per its relative efficacy, cost and suitability for the treatment. Attitude for θEML2011 (Total Percentage ) B-Perambalur_GP Dislike to refer 0 Strongly like to refer 17 (27.9%) Like to refer Dislike to refer 41(67.2%) 3(4.9%) Dislike to read/ attend Strongly like to read/ attend Like to read/ Attend Dislike to read/ attend 42 (68.9%) 1 (1.6%) 37 (60.7%) 19 (31.1%) 5 (8.2%) Strongly agree Agree Disagree Strongly agree Agree Disagree 40(65.6%) 18(29%) 3(4.9%) 37(60.7%) 19(31%) 5(8.2%) Strongly agree Agree Disagree Strongly agree Agree Disagree 18 (29.5%) 35(57.4%) 19(31%) Strongly Like like 44 16 (72.1%) (26.2%) 51.16% 44.94% 7(11.5%) Dislike 1 (1.6%) 3.9% 25(40.9%) 29(47%) Strongly Like like 42 16 (68.9%) (26.2%) 51.82% 40.62% 7(11.5%) Chisquared 3.1 17.9 0.6 PValue 0.2 0.000 0.7 3.8 0.2 1.05 0.6 Dislike 3 (4.9%) 7.54% Abbreviations:*CME = Continue medical Education , θEML2011: Essential Medicine List2011 307 Surendra et al., Int J Med Res Health Sci. 2015;4(2):305-310 Table3: Practice Based Questions and obtained responses of both groups ‘A’ and ‘B’HCPs Practice Based Questions Q.11. Have you presented / not presented ……numbers of articles / posters on Essential Medicine in last three years? Q 12. I prescribe/ don’t prescribe Generic / branded / both drugs. Q 13. I always / frequently / occasionally prescribe / don’t prescribe essential drugs. Q 14. I prescribe/ don’t prescribe New drugs / Old drugs / both drugs. Q15. I prescribe/ don’t prescribe Zinc supplements always / frequently occasionally to acute diarrhoeal children. Practice about EML2011 (Total percentage) A-DSMCH_HCP B-Perambalur_GP Presented Not Presented Presented Not Presented 1 (1.6%) 60 (98.4%) 0 61 (100%) Branded drugs 9 (14.8%) Always 26 (42.6%) new drugs 6 (9.8%) Generic drugs Both (Branded & Generic drug) 5 38 (8.2%) (62.3%) Frequentl y Occasionally 30 (49.2%) old drugs 2 (3.3%) Don’t Both drugs Branded drugs Generic drugs 9 (14.8%) 22 (36.1%) 4 (6.6%) Don’t both drugs Always 3 (4.9%) Prescribe both drugs 43 (70.5%) 2 15 (3.3%) (24.6%) Don’t both new drugs drugs 10 0 (16.4%) Don’t Occasionally prescribe Always prescribe Both prescribe drugs Both (Branded & Generic drugs) 1 (1.6%) Frequently Prescribe Occasionally prescribe Don’t both drugs 29 (47.5%) 9 (14.8%) old drugs both drugs 8 (13.1%) Don’t both drugs 0 61 (100%) Frequently Prescribe Occasionally prescribe Don’t prescribe Both drugs 5 (8.2%) Freque ntly 12 (19.7%) 14 (22.9%) 19 (31.2%) 16 (26.2%) 33 (54.1%) 18 (29.5%) 5 (8.2%) 21.73 % 20.9 % 42.2% 15.2% 28.7 % 20.9 % 44.7% “An essential medicines list (EML) is a limited number of carefully selected medicines by the authorized committee. For many decades, such lists have been published as formularies and institutional lists of medicines that are made available to health facilities and health workers. These may not be called EMLs but they serve the same function. EMLs have been one of the cornerstones of public health delivery and the basis for efforts to ensure consistent medicine supply and management”.[4] The characteristic features of Essential medicines (drugs) those that satisfy the priority healthcare needs of the population, they are selected with due regard to public health relevance, evidence on efficacy and safety, comparative cost effectiveness and it should be available at all time, in adequate amounts, in appropriate dosages forms, with assured quality and adequate information. [5] Thus, EML is an important strategy in improving access to and use of medicines, especially for the vulnerable segment of a population. Furthermore, an EML can be used as an PValu e - - 12.2 0.007 9.6 0.02 21.1 0.0001 24.2 0 Don’t both drugs 34 (55.7%) Always DISCUSSION Chisqua red 0 5.7% advocacy tool to help countries spend their limited resources on the medicines that are most needed and offer the best value for money. [6] So, on this juncture, awareness programmes targeting various stakeholders like doctors, patients, consumer groups, and the media are needed.[7] The present study compares the knowledge, attitude and practices about Indian National essential medicines list 2011among HCPs of DSMCH as well as Perambalur district. We observed that, overall, 57.06% HCPs from DSMCH and 38.36% HCPs from Perambalur district had knowledge in EML 2011, while (55% Hettihewa LM, 2010), though 21.98% HCPs from DSMCH and 28.86% HCPs from Perambalur district were do not know about EML2011 and even 20.98% HCPs from DSMCH and 32.82% HCPs from Perambalur district were not sure about knowledge of EML2011. Whereas, (54% Hettihewa LM, 2010of his study group and 29% Hettihewa LM, 2010 MPs had fair knowledge in EDL and 17 % Hettihewa LM, 2010) were not aware about EDL in their own study). Thus, obtained data in the present study indicate that timely interval evaluation needed to check and update knowledge regarding EML of HCPs that will help to 308 Surendra et al., Int J Med Res Health Sci. 2015;4(2):305-310 improve patients’ safety and teaching curriculum of pharmacology. The similar suggestion was also given by Hettihewa LM, 2010 in his study. Overall, 51.16% HCPs from DSMCH attitude were strongly agree or strongly like to attend / refer NEML2011, while; 51.82% HCPs from Perambalur district attitude was strongly agree or strongly like to attend/refer NEML2011. Even, 44.94% HCPs from DSMCH were like to refer NEML, whereas 40.62% HCPs from Perambalur district were like to refer NEML. The 65.6%HCPs from DSMCH and 60.7% HCPs from Perambalur district attitude were prescribing essential medicines should be mandatory, respectively. Whereas, the 57.4 % HCPs from DSMCH and 40.9 % HCPs from Perambalur district attitude was prescribing generic drugs should be mandatory, respectively. The72.1%HCPs from DSMCH and 68.9% HCPs from Perambalur district attitude was strongly like to select essential medicines as per its relative efficacy, cost and suitability for the treatment, respectively. The 1.6%, i.e., only one out of 61 HCPs from DSMCH have presented an articles / posters related to Essential Medicine in last three years. While, no one HCPs from Perambalur district presented an article / poster which was related to essential medicine. The 14.8 %, 8.2 % and 62.3 % HCPs from DSMCH were prescribed branded drugs, generic drugs and branded as well as generic drugs both, respectively, whereas, 36.1 %, 6.6 % and 55.7 % HCPs from Perambalur district were prescribed branded drugs, generic drugs and branded as well as generic drugs both, respectively. While, Mahajan R, et al, 2010 reported in his study that only 15.1% clinicians wrote the generic drugs. [8] The 42.6%, 49.2% and 4.9% HCPs from DSMCH were prescribed essential drugs always, frequently and occasionally, respectively, while, 24.6%, 47.5% and 14.8% HCPs from Perambalur district were prescribed essential drugs always, frequently and occasionally, respectively. The 9.8%, 3.3% and 70.5% HCPs from DSMCH were prescribed new essential drugs, old essential drugs and new as well as old both essential drugs, respectively, while, all 61 HCPs from Perambalur district, i.e., 100% HCPs were prescribed new as well as old both essential drugs. The 19.7%, 22.9% and 31.2% HCPs from DSMCH were prescribed zinc supplements always, frequently and occasionally in acute diarrhoeal children, respectively, though, 54.1%, 29.5% and 8.2% HCPs from Perambalur district were prescribed zinc supplements always, frequently and occasionally in acute diarrhoeal children, respectively. CONCLUSION The primary responsibilities of the healthcare professionals, that many awareness programmes should be conducted to increase knowledge about essential drugs, and attitude of the healthcare professionals should be changed to promote use of essential medicines as well as generic medicines and this changed attitudes of healthcare professionals should be practiced in routine working environment, then it will be possible to provide medicines to almost all needy people. Even, it is well known information that, “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”. Limitations: The obtained data in the present study was based on the responses of the healthcare professionals from the given questionnaire on National Essential Medicine List 2011 only. ACKNOWLEDGEMENT We acknowledge with gratitude to Chhaya Pachuli; Mudit Mathur; Ritesh Laddha: “Prayas Centre for health equity”, including their entire team members(Prayas Centre), who allowed to use their few text lines in this present study. We also acknowledge heartily to Dr. Hettihewa LM, and Dr. Mahajan R. including his colleagues who allowedusing his few texts. Conflict of Interest: Nil REFERENCES 1. Samit Sharma; Indian Administrative Service, Chhaya Pachauli; Mudit Mathur; Ritesh Laddha; Prayas Centre for Health Equity, Avinash Kumar; Oxfam India, S. Srinivasan; All India Drug Action Network, Narendra Gupta; Prayas Centre for Health Equity, Prayas: Free Access to 309 Surendra et al., Int J Med Res Health Sci. 2015;4(2):305-310 2. 3. 4. 5. 6. 7. 8. Essential Medicines in Rajasthan. South Asia Institute.Harvard.edu/.../Prayas,%20Free%20Acc ess%20to%20E, Prayas is a Non Govt. Organization, working Since 1979 Medicines: essential medicines, Factsheet N°325 Revised June 2010, WHO Media Centre. K. D. Tripathi, “Essential of Medical Pharmacology”, 7th Edition, JAYPEE Brothers Medical Publisher (P) Ltd, 2013;4 Rianne van den Ham University of Utrecht, the Netherlands Lisa Bero University of California, San Francisco, USA Richard Laing. “The World Medicines Situation Selection of Essential Medicines”, Department of Essential Medicines and Pharmaceutical Policies, WHO/EMP/MIE/, Geneva, 3rd Edition, 2011. Kotwani A. BMC Health Services Research 2013, 13:285 http://www.biomedcentral.com/14726963/13/285. Hettihewa LM, “Comparison of the Knowledge in Core Policies of Essential Drug List among Medical Practitioners and Medical Students in Galle, Sri Lanka”.Online Journal of Health and Allied Sciences. Jul-Sep 2010;9( 3): 1-5. Mahajan R, Singh NR, Singh J, Dixit A, Jain A, Gupta AEncephale.J Pharm Bioallied Sci.2004;30 (5):437-46. Hans V Hogerzeil. Essential medicines and human rights: what can they learn from each other? Bulletin of the World Health Organization, 2006, 84 (5):371-75. 310 Surendra et al., Int J Med Res Health Sci. 2015;4(2):305-310 DOI: 10.5958/2319-5886.2015.00058.2 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 20 Dec 2014 Research article Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 rd Revised: 23 Jan 2015 Accepted: 7th Feb 2015 PHENOTYPIC DETECTION OF MBL, AMPC BETA-LACTAMASE AND CARBAPENEMASES IN MULTI DRUG RESISTANT ISOLATES OF ACINETOBACTER BAUMANNII Richa Hans1, *Dakshina Bisht2, Ritu Agarwal3, M.Irfan4 1 MD Student, 2Professor, 3Assistant Professor, 4PhD student, Department of Microbiology, Santosh Medical College, Ghaziabad, U.P, India *Corresponding author email:
[email protected] ABSTRACT Introduction: Acinetobacter baumannii is one of the major pathogens causing nosocomial infections due to emergence of resistance to various antimicrobial agents. Resistance due to antimicrobial degrading enzymes is now a worldwide problem and a major reason of concern for the treating physicians. Keeping this in mind, the present study was designed to isolate Acinetobacter baumannii and study various antimicrobial resistance mechanisms in them. Materials and methods: A total of 50 A.baumannii isolates from various clinical samples were screened for meropenem resistance for the detection of Carbapenemase and MBL production. Carbapenemase production was confirmed by Modified Hodge Test whereas MBL by Disk Potentiation Test. Cefoxitin resistance was used as a screening test for AmpC beta-lactamase production which was confirmed by AmpC disk test. Results: Maximum isolation of A.baumannii was found in patients admitted in the Intensive care unit with respiratory tract infection. Among the 50 A.baumannii strains, Carbapenemase production was observed in 26.4%, MBL production in 52.9% and AmpC beta lactamase production in 56%. Conclusion: Our study emphasizes on multi-drug resistant A.baumannii highlighting the antibiotic crisis as a result of emergence of various bacteria that show resistance to various antibiotics. Acinetobacter epitomises this trend, as it is an important nosocomial pathogen with a capability of cross-infection particularly in ICUs and a grave limitation of treatment options, thus, requiring an urgent need to control the spread of MDR strains in the hospitals. Keywords: Acinetobacter, Modified Hodge Test, Metallo-beta-lactamse, AmpC beta-lactamse INTRODUCTION For many years, Acinetobacter species were considered to be saprophytic in the environment, found as a major constituent of the flora of soil, water and sewage and within the hospital environment. However, due to a number of agents as well as host factors, they have now emerged as important nosocomial pathogens predominantly in ICU settings most commonly affecting immuno-compromised patients, although they have also been isolated as the etiological agent of pneumonia in healthy individuals [1]. Multi drug resistance in A.baumannii is not a new phenomenon. They are known to be intrinsically resistant to various antibiotics along with the ability to acquire genes that encode for resistance determinants.[2]Production of beta-lactamases, aminoglycoside-modifying enzymes, diminished expression of outer membrane proteins [OMP] and up-regulation of efflux pumps play a crucial role in antibiotic resistance. Newer beta lactamases causing antimicrobial resistance include Extended-spectrum beta-lactamases (ESBL), AmpC beta-lactamses and Metallo-beta-lactamases (MBL). [3] Beta-lactamases act on many penicillins, cephalosporins, carbapenems and monobactams. 311 Richa et al., Int J Med Res Health Sci. 2015;4(2):311-316 Metallo-beta-lactamases also referred as Class B beta-lactamases act on penicillins, cephalosporins and carbapenems but not on monobactams.[4] MBLs have zinc as metal ion which is linked to cysteine or histidine residue and it reacts with the carbonyl group of the amide bond of penicillins, cephalosporins and carbapenems.[5] AmpC beta-lactamases are known to bestow resistance to cephalosporins in the oxyimino group and are not affected by available available betalactamase inhibitors. [6] The presence of MBLs and AmpC beta lactamases in a single isolate confer resistance to carbapenems which are usually the drug of choice in Acinetobacter infections. A. baumannii also possess an intrinsic class D oxacillinase belonging to the OXA-51-like group of enzyme. OXA-51-like enzymes are able to hydrolyze penicillins (benzylpenicillin, ampicillin, ticarcillin and piperacillin) and carbapenems (imipenem and meropenem). Accumulation of multiple resistance mechanism leads to the development of pan-resistant strains limiting the therapeutic options. Many multidrug resistant bacteria including A.baumannii produce combinations of different enzymes responsible for drug resistance. With the increasing number of MBL, ESBL and AmpC producing bacteria along with porin loss and efflux mechanisms, an increase in carbapenem resistance has been observed. Carbapenems being the drug of choice for highly resistant Acinetobacter species, its increasing resistance pattern limits therapeutic options. Keeping this in mind, present study was undertaken to isolate Acinetobacter baumannii and study various antimicrobial resistance mechanisms prevalent amongst the isolates in one of the tertiary care hospitals in North India. method, as per the guidelines of the Clinical Laboratory Standards Institute (CLSI).[8] Susceptibility to the following antibiotics (disc concentration) were tested: Ofloxacin(5 µg); Erythro mycin(15µg);Gentamcin(10µg);Cotrimoxazole(1.25+ 23.75 µg); Doxycycline(30 µg); Cefoxitin(30 µg); Ceftazidime(30µg); Piperacillin/Tazobactam (100+10 µg):Colistin(10µg);Tigecycline(15µg); Aztreonam(30 µg); Imipenem(10 µg) and Meropenem(10 µg). Quality control strains used were Escherichia coli ATCC 25922 and Pseudomonas aeruginosa ATCC 27853. Meropenem resistance was used to screen for beta-lactamase production and Cefoxitin resistance for AmpC beta lactamase production. Detection of Carbapenemase Modified Hodge Test: It was used to detect carbapenemase production in meropenem resistant strains. A culture suspension of Escherichia coli ATCC 25922 adjusted to 0.5 McFarland’s standard was inoculated on the surface of Muller-Hinton Agar plate using a sterile cotton swab. After drying, 10μg meropenem disc was placed at the centre of the agar plate and test strains were streaked from the disc’s edge to the periphery of the plate in four different directions. The plate was then incubated overnight at 37°C. Presence of a clover leaf shaped zone of inhibition along the growth of test strain was considered as positive for carbapenemase production. [9] (Figure 1) Quality control strains used were, K. pneumoniae ATCC® BAA-1705—MHT positive, K. pneumoniae ATCC® BAA-1706—MHT negative. MATERIALS AND METHODS A total of 50 consecutive non-duplicate Acinetobacter baumannii isolates from various clinical samples and patients from all age groups and both sexes from March 2013 till Feb 2014 were included. The samples comprised of sputum, urine, wound swabs, tracheal aspirates, blood, pus, bronchial lavage and endotracheal tubes. A.baumannii strains isolated were identified by standard microbiological methods.[7]The anti-microbial susceptibility testing was performed using antibiotics obtained from HiMedia, Mumbai, by the Kirby Bauer disk diffusion Fig 1: Modified Hodge Test Detection of MBL Disc Potentiation Test: The test organism adjusted to 0.5 McFarland’s opacity standards was inoculated on Muller-Hinton agar plate. Two 10µg imipenem discs, 312 Richa et al., Int J Med Res Health Sci. 2015;4(2):311-316 100% 80% 60% 40% 20% 0% ANTIBIOTICS Cefepime Of the 50 isolates, 28 (56%) strains were isolated from the respiratory secretions (sputum, tracheal secretions, endotracheal tips and BAL), 12 (24%) from pus (including wound swabs) and 9 (18%) from blood samples and only 1 (2%) from urine. Intensive care unit (ICU) had the most isolation rate of 34 (74%) A.baumannii followed by medicine ward 5 (10%), surgery ward 4 (8%), paediatric ward 3 (6%) and ENT ward 1 (2%). In our study, all the strains were found to be resistant to gentamicin, erythromycin, trimethoprimsulphamethaxole,piperacillin/tazobactam,ceftazidime, cefoxitin and aztreonam. 40 (80%) of the isolates were resistant to ofloxacin while 34 (68%) to doxycycline. Colistin and tigecycline showed 50 (100%) sensitivity towards all the strains. Graph 1 depicts the antibiogram of A.baumannii.(Fig 4) Cefpodoxime alone was considered as a positive result.[10] (Fig 2) Fig 2: Disc potentiation test Detection of AmpC beta-lactamases The AmpC Disc Test: Cefoxitin resistant strains were subjected to AmpC disc test for the production of AmpC beta-lactamase production. A culture suspension of Escherichia coli ATCC 25922 adjusted to 0.5 McFarland’s standard was lawn cultured on Muller-Hinton Agar plate. A cefoxitin disc (30µg) was placed on the surface of the agar and a blank disc moistened with sterile saline and inoculated with few colonies of test strain was placed besides cefoxtin disc in such a way that it was almost touching it. The plate was incubated overnight at 37ºC. Flattening or indentation of zone of inhibition around cefoxitin disc in the vicinity of the disc with the test strain was considered as positive for the AmpC beta lactamase production. An undistorted zone was considered as negative. RESULTS Ofloxacin Imipenem Meropenem Gentamycin Erythromycin Piperacillin/tazob… Doxycycline Colistin Trimethoprim-… Tigecycline Cefoxitin one containing 750 µg EDTA, obtained from Himedia, Mumbai were placed on the inoculated plate and incubated for 24hrs at 37°C. The zones of inhibition around the imipenem disc alone and imipenem-EDTA disc were recorded. An increase in the zone of inhibition of at least 7mm around the imipenem-EDTA disc as compared to imipenem RESISTANT INTERMEDIATE SENSITIVE Fig 4: Antibiogram of A.baumannii Of the 50 isolates, 34 (68%) isolates expressed resistance to meropenem and only 26 (52%) to imipenem. Of these 34 meropenem resistant strains, 9 (26.4%) were positive for Carbapenemase production by Modified Hodge test and 16 (52.9%) were positive for MBL production by EDTA disc potentiation test (EDTA-DPT). Of the 50 cefoxitin resistant isolates, 28 (56%) were confirmed for AmpC beta lactamase production by AmpC disc test. Table 1 depicts the results for MHT, MBL and AmpC production in A.baumannii isolates. Fig 3: AmpC Disc test 313 Richa et al., Int J Med Res Health Sci. 2015;4(2):311-316 Table 1: Modified Hodge Test, Disc Potentiation Test and AmpC Disc Test MBL CARBAPENEMASE AMPC Screen Test (Meropenem resistance) Confirmatory Test (EDTA- disk potentiating test) Screen Test Confirmatory (Meropenem Test (MHT) resistance) Screen Test (Cefoxitin resistance) Confirmatory Test (AmpC disk test) 34 (68%) 16 (47.05%) 34 (68%) 50 (100%) 28 (56%) 9 (26.4%) Of the 50 A.baumannii isolates, co existence of Carbapenemase and MBL production was observed in 8 (16%) isolates. There were 2 isolates which expressed all three resistance mechanism whereas only 7 isolates expressed no resistance mechanism. Fig 5 depicts co-existence of various resistance mechanisms in MDR A.baumannii. 60.00% 47.05% 50.00% 26% 40.00% 16% 18% 30.00% 10% 20.00% 2% 2% 10.00% 0.00% 56% 26% RESISTANCE MECHANISMS Fig 5: Existence of Multi Resistance Mechanisms in MDR A.baumannii Of the 50 isolates, 47.05% were found to be MBL producers, out of which 16% also co-produced carbapenemase and 18% co-produced AmpC. However, there were 2% strains which only expressed MBL production. Carbapenemase production was found in 26% of the total strains, of which 10% also co-produced AmpC beta lactamase and 2% strains were positive only for carbapenemase production. However, 26% of the isolates were positive for only AmpC beta lactamase production, suggesting AmpC beta lactamase being a more expressed resistance mechanism in our study. DISCUSSION A.baumannii is an effective human colonizer in the hospital. Combination of its environmental flexibility and presence of multiple resistance determinants makes it a successful nosocomial pathogen. MDR A.baumannii infections tend to occur more frequently in immune-compromised individuals, patients on broad spectrum antibiotics and with underlying diseases and those subjected to invasive procedures.[12]According to Ambler Classification, Beta lactamases are grouped into 4 major molecular classes; A, B, C and D. A, C and D are referred as serine-beta-lactamases, whereas group B beta lactamases are called MBL. Newer beta lactamases that hydrolyse cephamycins, cephalosporins, monobactams and carbapenems are of increasing concern as they limit therapeutic options leading to treatment failures and poor prognosis. [13] We observed that 56% of the A.baumannii isolates were from the respiratory secretions which included sputum samples, endotracheal secretions, bronchioalveolar lavage and endotracheal tips, 24% from pus samples, 18% from blood and only 2% from urine. In a study by Muthusamy et al.[11] conducted in Coimbatore, South India isolation rate was found to be 73% from respiratory secretions. In yet another study by Jaggi et al. [14] in Gurgoan, Haryana, 57.4% of the A.baumannii isolates were from respiratory secretions, 23.8% from blood, 13.5% from pus and 2.5% from urine, an observation similar to ours, suggesting thereby that respiratory tract would be the most common site of isolation in our geographical area. It is a well documented fact that a lot of risk factors associated with Acinetobacter infections exist in the ICU like potential environment reservoirs, opportunities for cross transmission, sick, immunecompromised patients who are colonized, patients with multiple wounds and indwelling devices, heavy use of broad spectrum antibiotics and frequent contamination of the hands of health care workers employed in patient care. This fact was supported by our results, where 74% of the A.baumannii isolates were from the ICU followed by medicine ward (10%), 8% from surgery ward, 6% from paediatric and 2% from ENT ward. Sinha N et al. [15] also noted similar findings with maximum isolation from the ICU of 22.14% followed by 314 Richa et al., Int J Med Res Health Sci. 2015;4(2):311-316 paediatrics (20.71%), neurosurgery (15.71%) and general surgery wards (12.85%). In our study, high resistance of 68% was observed against meropenem, which was in contrast to a study conducted earlier by Sinha N et al.[15] where only 20% resistance was observed. Taneja et al,[16] observed 18.5% and Dheepa M et al [11] observed 35% resistance. However, in Brazil, the resistance to carbapenemase was found to be ranging from 71.4% to 100% in various hospitals of that region. [17] Thus, the aforementioned observations could only suggest that Carbapenemase-producing Acinetobacter spp might be on a rise worldwide which could be due to indiscriminate carbapenemase usage and selection pressure in hospitals. In our study, 26.4% organisms were carbapenemase producers as evidenced by the Modified Hodge Test. The prevalence of carbapenemases as reported by Noyal et al.[9] was 14.3% whereas another study by Kumar et al.[18] documented a very high prevalence of 71%. A very low prevalence of 2.96% was also reported by Patwardhan et al.[19] No established phenotypic methods are available for detection of specific serine carbapenemases. However, for zinc based carbapenemases (MBL) various methods like EDTA-disc potentiation test, MBL E-test and EDTA based microbiological assay are available. In our study, 47.05 % of meropenem resistant strains were confirmed to be MBL producers, whereas Dheepa Muthusamy et al [11] detected 10% of the strains to be MBL producers in her study conducted in South India and John S et al [20] detected 14.8%. Noyal MJC et al [9] did a similar study in Pondicherry, South India and identified 6.5% MBL producers. In a study done at AIIMS, New Delhi, 48.72% of A.baumannii strains were ascertained to be MBLenzyme producers by the same method, thus implying rapid spread of resistance amongst this pathogen. [21] Although there are no CLSI guidelines for the detection of AmpC beta lactamase production, but we followed AmpC disk test to detect AmpC production and observed 28 (56%) of 50 cefoxitin resistant isolates of A.baumannii showed production of AmpC beta-lactamase enzyme. Noyal et at [9] and Sinha et al[22] also reported 67.4% and 42.9% respectively, in their studies. Although carbapenems are the drugs of choice for A. baumannii infections, such resistance profile limits therapeutic options to polymyxins and tigecycline, which showed 100% sensitivity to A.baumannii in our study. These drugs have their own grave side effects, limiting their routine usage for patients in hospitals. Thus, it is recommended to perform these simple tests like Modified Hodge Test for carbapenemase, Disc Potentiation test for MBL and AmpC disk test for AmpC beta lactamase production in microbiology laboratories to determine resistance mechanisms and prevent indiscriminate use of antibiotics. CONCLUSION A.baumannii is becoming a global medical challenge due to the emergence of multi-drug resistance. Newer beta lactamase are a matter of concern as they are developing rapidly and lead to treatment failure. Carbapenems are known to be effective therapeutic agents for A.baumannii infections and its resistance limits the use to polymyxins and tigecycline. Disappointingly, there are limited antibiotics for the treatment of infections caused by MDR A.baumannii on the horizon. Several new medicines are still in research and combination of drug therapy is being currently used in the hospitals including ours to treat MDR A.baumannii infections. Thus, due to such high prevalence of resistance, antibiotics must be used judiciously by the clinicians and appropriate infection control measures need to be implemented to control the spread of infections in hospitals. ACKNOWLEDGMENT: None Conflict of Interest: Nil REFERENCES 1. Lyons,R.W. Acinetobacter calcoaceticus. Clin.microbiol. Newsletter1983; 5:87 2. Stephan C, Nathalie C, Eric E, Cecile G, Henri D, Alain R. AmpC cephalosporinase hyper production in clinical strains of Acinetobacter baumannii. J. Antimicrob. Chemother 2003; 52:629-35. 3. Gupta V; An update on newer b-lactamases; Indian J Med Res, 2007;126: 417-27. 4. Ambler RP. The structure of b-lactamases. Philos Trans R Soc Lond B Biol Sci 1980; 289 : 321-31 315 Richa et al., Int J Med Res Health Sci. 2015;4(2):311-316 5. Walsh TR, Mark AT, Laurent P, Patrice N. Metallo-betalactamases: the quiet before the storm? Clin Microbiol Rev 2005; 18 : 306-25. 6. Thomson KS. Controversies about extendedspectrum and AmpC beta-lactamases. Emerg Infect Dis 2001; 7: 333-6. 7. Collee JG, Miles RS, Watt B. Identification of bacteria. In: Collee JG, Fraser AG, Marmion BP, Simmons A, editors. Practical Medical Microbiology. 14 th ed., Singapore: Churchill Livingstone Publishers, Longman; 2003; 131-49 8. Clinical and Laboratory Standards Institute Supplemental tables. Performance standards for Antimicrobial Susceptibility testing. Twenty First Informational Supplement.2011;21:31 9. Noyal MJC, Menezes GA, Garish BN, Sujatha S, Parija SC. A simple screening test for the detection of carbapenemases in the clinical isolates of non fermentative, gram negative bacteria. Indian J Med Res 2009; 129: 707-71. 10. Krista L, Epp S, Vivika A, Piert M, Lulu K, Karin O, et al. The prevalence and the antibiotic susceptibility of Acinetobacter baumannii, Pseudomonas aeruginosa and Klebsiella pneumoniae in Estonian intensive care units in comparison with European data. Scand J Infect Dis 2006; 38: 1001 11. Muthusamy D, Appalaraju Boppe. Phenotypic methods for the detection of various beta lactamases in carbapenem resistant isolates of Acinetobacter baumanii at a tertiary care hospital in south India. Journal of Clinical and Diagnostic Research [serial online] 2012 ;6:970-73. 12. Peleg AY, Seifert H, Paterson DL. Acinetobacter baumannii: Emergence of a Successful Pathogen. Cli Microbiol Re. 2008;21(3):538-82. 13. Koneman EW, Allen SD, Jand WM, Schreckenberg PC. Colour Atlas and Text Book of Diagnostic Microbiology. 6 th ed. San Francisco: Lippincott; 2006. p. 955-6 14. Jaggi N. Acinetobacter baumannii isolates J Microbiol Infect Dis. 2012;2(2) June 15. Sinha N, Agarwal J, Srivastava S, Singh M. Analysis of carbapenem-resistant Acinetobacter 16. 17. 18. 19. 20. 21. 22. from a tertiary care setting in North India. Indian J Med Microbiol 2013;31:60-3 Taneja N, Maharwal S, Sharma M. Imipenem resistance in nonfermenters, which cause nosocomial urinary tract infections. Indian J Med Sci 2003;57: 294-99. Hanoch S. I. Martins 1, Maria Rosa Q. Bomfim 1,2, Rafaela O. França 1, Luiz M. Farias 1, Maria Auxiliadora R. Carvalho 1, José Carlos Serufo 3 and Simone G. Santos 1,; Resistance Markers and Genetic Diversity in Acinetobacter baumannii Strains Recovered from Nosocomial Bloodstream Infections ; Int. J. Environ. Res. Public Health 2014, 11, 1465-78 Kumar AV, Pillai VS,Kavitha R, Dinesh, Karim S .Thephenotypic detection of carbapenemases in meropenem resistant Acinetobacter calco aceticus-baumannii complex in a tertiary care hospital in South India. Journal of clinical and diagnostic research. 2011; 5(2):223-6. Patwardhan N Satish, Patwardhan S Shripad & Deore Santosh; Detection of ESBL, MBL, Amp C and Carbapenemases and their coexistence in clinical isolates of gram negative bacteria; JMRP 2013 ;2 (7):300 John S, Balraghunathan R .Metallo-betalactamase producing Pseudomonas aeruginosa and Acinetobacter baumannii. IJMM.2011; 29(3):302-4. Goel V, Hogade SA, Karadesai S G. Prevalence of extended-spectrum beta-lactamases, AmpC beta-lactamase, and metallo-beta-lactamase producing Pseudomonas aeruginosa and Acinetobacter baumannii in an intensive care unit in a tertiary care hospital. J Sci Soc 2013; 40:2831 Sinha M, Srinivasa H. Mechanisms of resistance to carbapenems in meropenem-resistant Acinetobacter isolates from clinical samples. Indian J Med Microbiol 2007;25:121-5. 316 Richa et al., Int J Med Res Health Sci. 2015;4(2):311-316 DOI: 10.5958/2319-5886.2015.00059.4 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 rd Received: 23 Dec 2014 Research article Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 27 Jan 2015 Accepted: 10th Feb 2015 PREVALENCE OF HEALTH CARE ASSOCIATED INFECTIONS IN A TERTIARY CARE HOSPITAL IN DAKSHINA KANNADA, KARNATAKA: A HOSPITAL BASED CROSS SECTIONAL STUDY *Animesh Gupta1, Divya C V1, Diwakar K Singh1, Krutarth B2, Maria N2, Srinivas R1 1 Postgraduate, 2Assistant Professor, Department of Community Medicine, A J Institute of Medical Sciences & Research Centre, Mangalore, Karnataka, India *Corresponding author email:
[email protected] ABSTRACT Background: Health Care-Associated Infections (HCAI) affect millions of people each year and raise a great risk for patients in health care settings, leading to high rates of morbidity and mortality. Objective: To estimate the prevalence of HCAI and to explore the association between certain socio-demographic factors, invasive procedures and mean duration of hospital stay with HCAI in a tertiary-care hospital. Materials and Methods: Data was obtained from the patients who were admitted for more than 48 hours in the general wards and their records in tertiary-care hospital for duration of 3 months (February 2014 to April 2014). Results: Among 290 patients, the prevalence of HCAI was estimated to be 11.7%. The prevalence of HCAI was proportionately less among men (10.2%) than in women (14.2%), was more (15.6%) among patients who underwent invasive procedures after admission and with mean duration of hospital stay of 12.47 days. Conclusion: Health CareAssociated Infections (HCAIs) were found to be significantly associated with increased duration of hospital stay and invasive procedures done after admission. Prevalence was higher in patients aged more than 40 years. Keywords: Health Care-Associated Infection, Prevalence INTRODUCTION Health Care-Associated Infections (HCAI) are the infections acquired during hospital care which are not present or incubating at admission. Infections occurring more than 48 hours after admission are usually considered hospital associated. [1] HCAIs are an important public health problem in developing as well as in developed countries. Hospital-wide prevalence of HCAI in low- and middle-income countries varied from 5.7% to 19.1% with a pooled prevalence of 10.1% and even as high as 15.5% in high quality studies.[2] Over 1.4 million people worldwide suffer from HCAI at any given time.1 The risk is 2 to 20 times higher in developing than in developed countries.2 Animesh et al., Some of the factors responsible for HCAI are prolonged and inappropriate use of invasive devices and antibiotics, high-risk and sophisticated procedure, immuno-suppression and other severe underlying patient conditions, insufficient application of standard and isolation precautions. [3] The fight against HCAI as a public health priority was promoted through the World Health Organization's 'Clean Care is Safer Care' campaign. HCAIs are multi-factorial, which are related to healthcare systems and procedures as well as behavioral practices. [4] At any given time, out of every 100 hospitalized patients, 7 in developed and 10 in developing countries will acquire at least one health care-associated infection. [2] 317 Int J Med Res Health Sci. 2015;4(2):317-321 The most common types of HCAIs are urinary tract infection, surgical tract infection, lower respiratory tract infection, blood stream infection, skin and soft tissue infection. Gastroenteritis is the most common HCAI in children[1]. HCAI is a great risk for patient safety and its impact can result in prolonged hospital stay, long-term disability, increased resistance of microorganisms, and additional financial burden for the health system, patients and their families, as well as excess deaths.2 It is estimated that 80% of all hospital deaths are directly or indirectly related to HCAIs[5]. Some of the common determinants of HCAI are inadequate environmental hygienic conditions, poor infrastructure, insufficient equipment, understaffing, overcrowding, inadequate infection control measures, unsafe injection practices, absence of local and national guidelines and policies[3]. The main modes of transmission of HCAI are contact, droplet, air-borne, common vehicle and vector-borne. The risk of contracting HCAI is universal and percolates every health-care facility and system worldwide, but the true burden remains unknown, particularly in developing countries [2]. HCAIs usually receive public attention only when there is epidemic [1]. Although often hidden from public attention, no institution or country can claim to have solved this very real ongoing endemic problem, despite many efforts[2]. Objectives 1. To estimate the prevalence of HCAI. 2. To estimate the association of HCAI with certain risk factors. MATERIALS AND METHODS Study setting: A Hospital based cross-sectional study was conducted in a tertiary-care hospital in Dakshina Kannada district of Karnataka, India for duration of 3 months from February 2014 to April 2014. All inpatients admitted in the wards of Medicine, Surgery, Orthopedics, OBG, and Pediatrics in a tertiary-care hospital for more than 48 hours were included in the study irrespective of their age & Sex. Patients who were critically ill and those admitted in ICUs were excluded from the study. Animesh et al., Sample size calculation: Taking the prevalence of 26% from a study done by Saleem M et al[6] and with 20% of allowable error, the sample size was calculated by using the formula n = 4pq/ L². The sample size was estimated was 290. Method of data collection Ethics clearance from the institution was obtained. A pretested structured proforma was used to collect the data after obtaining written informed consent from the patients by interview method. The proforma included name, age, gender, IP number, name of the ward, date of admission and discharge, diagnosis, treatment and procedures done. History and physical examination were conducted for each patient from the date of admission until discharge. All the patients in the study were visited at least once a day. Laboratory results and medical charts were reviewed. The study subjects were followed up from the day of admission till the day of discharge. Statistics: The data was entered in Microsoft excel 7.0 and analyzed in SPSS Trial Version 16. Descriptive statistics and tests of significance like Pearson Chi-square test were used and the statistical significance level was fixed at p<0.05. RESULTS The mean age of study population was found to be 41.8 years (SD-15.4, Range- 4 to 85 years) and the mean age of patients who developed HCAI was 42.2 years (SD-16.5, Range- 7 to 75 years). Table 1: Prevalence of HCAI in relation to age Age No. of Patients HCAI group Examined No. (%) (in years) 0-15 11 1 (9.1) 16-30 69 6 (8.7) 31-45 89 14 (15.7) 46-60 90 10 (11.1) >61 31 3 (9.7) 290 34 (11.7) Total Fisher’s exact test value = 1.986, p value = 0.742 (non significant) The maximum patients were 31% in the age group 46-60 years followed by 30.7% in the age group 3145 years as shown in Table 1. The prevalence rate of HCAI was 11.7%, of which thrombophlebitis, urinary tract infection (UTI) and fever were found to be 5.86%, 4.14% and 1.82%, respectively. Out of the 34 318 Int J Med Res Health Sci. 2015;4(2):317-321 patients who had developed HCAI, 41.2% and 29.4% corresponds to age groups 31-45 and 46-60 years, respectively. 200 150 n=177 159 (89.8%) 100 n=113 N 97 (85.8%) 50 0 18(10.2%) MALE HAI 16 (14.2%) FEMALE NO INFECTION Fig1: Prevalence of HCAI in relation to gender (n=290) In this study, 61.0% were males, but the prevalence of HCAI was found to be proportionately higher in females (14.2%) compared to males (10.2%) as shown in Figure 1. Table 2: Association of HCAI in relation to multiple variables (n=290) Health care- Chi P Variables associated infection square value value Present Absent Age < 40 14 112 0.081 0.776 (in (11.1%) (88.9%) years) > 40 20 144 (12.2%) (87.8%) Duration < 7 4 135 20.18 0.000* of stay days (2.9%) (97.1%) in >7 30 121 hospital days (19.9%) (80.1%) Invasive Yes 21 113 145.16 0.000* procedur (15.7%) (84.3%) es No 13 143 (8.3%) (91.7%) *significant Table 2 shows the association of HCAI in relation to age, duration of stay in hospital and invasive procedures done. In this study, it was found that the patients who were more than 40 years had higher prevalence of HCAI (12.2%) compared to those less than 40 years (11.1%), though it was not found to be statistically significant (p>0.05). This finding was probably due to the higher number of invasive procedures done among those above 40 years of age leading to longer duration of stay in the hospital. The Animesh et al., patients who had undergone invasive procedures had significantly high prevalence of HCAI with 21 (15.6%) compared to those who had not undergone invasive procedures with 13 (8.3%). The prevalence of HCAI was higher in patients who stayed in hospital for more than 7 days compared to less than or equal to 7 days, which is statistically significant. The mean duration of hospital stay for the patients with HCAI was found to be 12.47 days and for those without HCAI was 7.98 days. DISCUSSION Majority of patients in this study were males (61.0%). Similarly, in a study by Dileep Kumar S et al[7] and Rahim B et al[8], showed that 53.0% and 53.6% of the study subjects were males, respectively. The prevalence of HCAI in this study was 11.7%. Similar findings were observed in studies conducted by Malhotra S et al[9] and Razine R et al[10]. The mean age of patient was high among who developed HCAI which was similar to the study done by Satpathy et al [11]. Females had proportionately higher prevalence of HCAI than males in this study, which was also found in study done by Dileep Kumar S et al[7] and Saleem M et al. [6] Prevalence of HAI was insignificantly high among patients above 40 years of age which was similar to the findings from the study done by Dileep Kumar S et al[7]. In this study the prevalence of HCAI was significantly higher in patients who stayed for more than 7 days which showed, longer the duration of hospital stay, more the chances of developing HCAI. Similar facts were observed in multiple studies analyzed by World Health Organization were hospital stay more than 7 days was found to be a risk factor for the development of an HCAI[2]. The patients who developed HCAI had presented as thrombophlebitis (5.8%), UTI (4.1%) and fever (1.8%). Thrombophlebitis was the commonest HCAI. Askarian M et al12 showed the prevalence of blood stream infection as 2.5% and UTI as 1.4%, which concluded that blood stream infection was more compared to other HCAIs. These findings were similar to those in this study. The prevalence of HCAI was significantly higher in patients who underwent any invasive procedures like intravenous lines, urinary catheterization and any 319 Int J Med Res Health Sci. 2015;4(2):317-321 surgical procedures. Similar trend was observed in most of the studies analyzed by World Health Organization[2]. CONCLUSION The present study of Health Care-Associated Infections (HCAIs) in the tertiary care hospital showed a prevalence rate of 11.7%. HCAI were found to be significantly associated with increased duration of hospital stay and invasive procedures done after admission. The prevalence was higher among patients aged more than 40 years and proportionately more among female patients. HCAI was common in hospital patients in medical and surgical wards. Recommendations: In India, however, hospitals often do not follow infection control practices, and this leads to the spread of disease. In response to the growing burden of HCAIs in India, the Global Antibiotic Resistance Partnership (GARP) is issuing several key recommendations that aim at reducing the prevalence of HCAIs, including increased handwashing, use of isolation rooms for infected patients, increased availability and uptake of diagnostic tests, reminders to limit catheter use, and use of gloves and gowns. The Ministry of Health & Family Welfare Task Force also recommends that all hospitals create an infection control plan, committee and team. Surveillance of antibiotic resistance, combined with tracking physician prescribing patterns, can be the foundation of successful infection control programmes in hospitals. A large proportion of these hospital infections are easily preventable with increased hospital infection control, including stepping up hygiene practices, such as frequent hand-washing. Limitations: The study was conducted for duration of 3 months to estimate the prevalence of HCAI, since the number of study subjects was small, so it is possible that the prevalence rates may not be extremely precise. Acknowledgement: The authors are thankful to Dr. (Prof) Manohar Rao, Dr. (Prof) Jayaram S, Dr. (Prof.) P V Kurulkar, Dr. (Prof.) Prasanna K S and Dr. (Prof.) Hemant Kumar of the Community Medicine department for their valuable guidance and support. Animesh et al., Conflict of interest: The authors declare no conflict of interest & not funded by any agency. REFERENCES 1. Prevention of hospital-acquired infections; A Practical Guide; 2nd edition, World Health Organization.[Available at http://www.who.int/ csr/resources/publications/whocdscsreph200212. pdf] 2. World Alliance For Patient Safety. Global Patient Safety Challenge 2005 – 2006. Clean Care Is Safer Care.[Available at http://www.who.int/ patientsafety/events/05/GPSC_Launch_ENGLIS H_FINAL.pdf] 3. World Health Organization. Health careassociated infections Fact Sheet. [Available on http://www.who.int/gpsc/country_work/gpsc_ccis c_fact_sheet_en.pdf] 4. Gignon M, Farcy S, Schmit J L, Ganry O. Prevention of healthcare-associated infections in general practice: Current practice and drivers for change in a French study. Indian J Med Microbiol 2012;30:69-75 5. Hughes AJ, Ariffin N, Huat TL, Abdul Molok H, Hashim S etal., Prevalence of nosocomial infection and antibiotic use at a university medical center in Malaysia. Infect Control Hosp Epidemiol 2005; 26:100-4 6. Saleem M, Vaish AK, Idris MZ, Sonkar AA, Agarwal J, Singh M, etal., Pattern of Nosocomial Infection among patients admitted in Medical and Surgical wards of a secondary care hospital in north India: An epidemiological evaluation. Indian Journal of Community Medicine, 2012; 24(4): 285-90 7. Dileep Kumar Sharma, Yogendra Kumar Tiwari, Nitya Vyas and Rakesh Kumar Maheshwaril. An investigation of the incidence of nosocomial infections among the patients admitted in the intensive care unit of a tertiary care hospital in Rajasthan, India. International Journal of Current Microbiology and Applied Sciences, 2013; 2(10): 428-35 8. Rahim Baghaei, Peyman Mikaili,, Davood Nourani, Hamid Reza Khalkhali. An epidemiological study of nosocomial infections in the patients admitted in the intensive care unit of Urmia Imam Reza Hospital. An etiological 320 Int J Med Res Health Sci. 2015;4(2):317-321 9. 10. 11. 12. investigation. Annals of Biological Research, 2011; 2 (5) :172-78. Malhotra S, Sharma S, Hans C. Prevalence of Hospital Acquired Infections in a tertiary care hospital in India. Int. J. Med. Med. Sci., 2014; 1(7): 91-94 Razine R, Azzouzi A, Barkat A, et al. Prevalence of hospital-acquired infections in the university medical center of Rabat, Morocco. International Archives of Medicine 2012;5:26 Satpathy. P261: Study of hospital associated infections (HAI) at tertiary hospital in India; economic implication for developing countries. Antimicrobial Resistance and Infection Control 2013, 2 (Suppl 1):P261 Askarian M. Point prevalence and risk factors of hospital acquired infections in a cluster of university-affiliated hospitals in Shiraz, Iran. Journal of infection and public health, 2012; 5:169-16. Animesh et al., 321 Int J Med Res Health Sci. 2015;4(2):317-321 DOI: 10.5958/2319-5886.2015.00060.0 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 24 Dec 2014 Research article Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 20 Jan 2014 Accepted: 9th Feb 2015 STUDY OF THE BASELINE WIDAL TITRES AMONG HEALTHY INDIVIDUALS OF RURAL POPULATION IN PUDUCHERRY *Jeyakumari D1, Jaberlin Sneha AJ2, Gopal R2 1 Department of Microbiology, Tagore Medical College & Hospital, Chennai, Tamil Nadu, India Department of Microbiology, Sri Manakula Vinayagar Medical College & Hospital, Puducherry, India 2 *Corresponding author email:
[email protected] ABSTRACT Background: Enteric fever is endemic in developing countries like India. Widal test in a single serum sample is often the only test relied upon for laboratory diagnosis. The test is considered positive if the antibody titres are higher than the cut - off value in a single test or a rising titre in paired sera. But normal baseline titres in healthy population and cutoff values have not been established in our area. So the aim of our study was to determine the base line titres of antibodies among apparently healthy populations and to define the significant titres of widal test. Materials and Methods: Samples were initially screened by Widal slide agglutination test and further confirmed by the Quantitative tube agglutination test. Results: Among the 500 samples from apparently healthy individuals, 260 samples were positive for agglutinins. 141 were positive for ‘O’ agglutinin and 163 were positive for ‘H’ agglutinin of Salmonella typhi. Among 141 samples, 30 showed agglutination up to 1in 20 titre, 100 up to 1in 40 and 25 (4.8%) up to 1in 80. Among 163 samples, 18 showed a titre of 1 in 20, 120 showed a titre of 1 in 40 and 21(4.2%) up to 1 in 80. Conclusion: When a single widal titre is used for the diagnosis of enteric fever in our locality, it will be more appropriate to change the currently used cutoff levels against S.typhi to ≥ 1 in 160 for anti-O and ‘H’ agglutinins remains the same of ≥ 1 in 160. Keywords: Baseline titer, Widal test, Healthy population INTRODUCTION Enteric fever continues to be a global health problem, especially in tropics and subtropics [1] and enteric fever is a major endemic health problem in developing countries like India. The global estimation of typhoid fever was about 21.6 million in 2000 and 5412,744 illness were due to paratyphoid fever. These fevers are considered as a major cause of morbidity and mortality in developing countries with more than 90% of cases found in Asia only. [2, 3] Enteric fever is caused by Salmonella enterica subspecies enterica serotype Typhi and Salmonella enterica subspecies enteric serotype Paratyphi A and Paratyphi B. In contrast to other Salmonella serotypes, these enteric fever serotypes have no known hosts other than humans. The mode of transmission is by close contact with the patients or carriers. Since the clinical presentation of enteric fever is non-descript, laboratory tests are essential for diagnosis. The gold standard and definitive diagnosis is by isolation of Salmonella enterica serotype Typhi, ParatyphiA and Paratyphi B from blood, bone marrow, stool or urine etc. which is about 90% in the first week of illness and decreases to about 50% by the third week from blood sample. Culture facilities are not available in the rural set up where Widal agglutination test has a greater scope for diagnosis of enteric fever in developing countries. Widal test though in vogue for more than hundred years is still 322 Jeyakumari et al., Int J Med Res Health Sci. 2015;4(2):322-326 plagued with controversy about its usefulness in diagnosis of enteric fever. [4] The use of Widal test in the diagnosis of typhoid fever during the acute phase of the illness has largely been abandoned in developed countries. [5] Due to practical difficulties in the management of a patient the results of a single test performed at the end of the first week is often the only test relied upon for laboratory diagnosis. The significant titres of antibodies to ‘O’ and ‘H’ antigens varies from place to place and with time since antibodies that react with Salmonella ‘O’ and ‘H’ antigens appear in a variety of other conditions like malaria, dengue, other gram negative infections and in healthy persons in endemic areas. [6, 7] In endemic areas the use and interpretation of single Widal test depends on result of the baseline titres among the healthy population. It is therefore necessary to establish the baseline titres periodically in each region to define the significant titres of ‘O’ and ‘H’ antibodies for proper interpretation of the results. Objectives 1. The objective of the present study is to determine the base line titres of antibodies for each of the ‘O’ and ‘H’ antigens of Salmonella enterica serotype Typhi, Paratyphi ‘A’ & Paratyphi‘B’ among apparently healthy blood donors and patients attending the Microbiology laboratory for various investigations other than for enteric fever. 2. To define the significant titres of widal test for diagnosis of enteric fever in a single serum sample. MATERIAL AND METHODS Type of study: Cross sectional Subjects: Total samples (n = 500) were collected in which, Serum samples of Healthy blood donors (n = 300) who voluntarily donated blood to our hospital blood bank during the study period. Inclusion criteria: Donors who had no history of any illness suggestive of enteric fever in the preceding six months. Negative for all screening tests routinely done in donors includes Malaria parasite antigen, HBsAg, and antibodies to HIV 1 and 2, HCV and Treponema pallidum. No history of typhoid vaccination in the preceding three years was included. Serum samples (n=200) received in the Microbiology laboratory for various serological tests accept widal. These samples were from the seemingly healthy individuals who came for Medical checkup and Antenatal visits. Only samples of serum with negative results for the requested serological tests were included in the study. Patients without fever or gastroenteritis or any illness suggestive of enteric fever in the preceding six months and not vaccinated for typhoid in the preceding three years were included in the study. Exclusion criteria: Subjects who did not meet the above criteria were excluded. Methods: Informed consent was obtained from all the donors and patients and approval of the institutional ethics committee was obtained. Questionnaires were given to evaluate the present and past clinical conditions. About 5ml of blood was collected in a clean dry test tube from each of the subjects and allowed to clot. Serum was separated and stored in the refrigerator at 2-8º C for no more than seven days. All samples were initially screened by rapid slide agglutination test using the standard colored Salmonella antigen supplied by ‘SPAN DIAGNOSTICS’, Surat, India. Samples showing agglutination with undiluted serum were retested by the standard tube agglutination test of Widal for antibodies against all the four antigens of Salmonella typhi ‘O’ and ‘H’, Salmonella paratyphi ‘AH’and ‘BH’ as per the standard procedure. Serial dilutions of serum were done starting from 1/20 to 1/640 and one drop of the appropriate antigen suspension was added. Incubate ‘H’ agglutinations for 4 hours at 37ºC in a water bath and read after standing on the bench for half an hour and ‘O’ agglutinations for 4 hours at 37ºC and read after overnight refrigeration at 4C. The highest dilution of serum showing visible agglutination was taken as the endpoint and titre expressed as reciprocal of the dilution.[8] For quality control a known positive and negative control sera was also included with each run. The results were analyzed for age, sex and base line titre taken was the highest titre shown by any of the study samples. Statistical analysis by using SPSS – version 20 was also carried out. In which one sample T-test was done to compare the current titre value with the observed titre values. All samples of blood donors (n=300) were screened by Immunochromatography strip for Malaria parasite, HBsAg, antibodies to HIV (Tri dot ELISA), HCV (Dot ELISA), and Treponema pallidum (RPR). Samples of donors negative for all the above cited infections alone were included in the 323 Jeyakumari et al., Int J Med Res Health Sci. 2015;4(2):322-326 study. In the patients group all serum samples (n=200) other than those requested for Widal test and which were negative for the respective tests were included in the study. RESULTS 41-50 years 25 5 Samples were analyzed by using SPSS. Among the 500 samples, 260 samples were positive and 240 were negative for agglutinins to Salmonella serotypes typhi and paratyphi A & B. In these positive samples, 143 (28.7%) were positive for ‘O’ agglutinin and 157 (31.5%) were found positive for ‘H’ agglutinin of Salmonella typhi. Only 14 (2.8%) and 11 (2.2%) samples were positive for agglutinins to paratyphi AH & BH respectively. Amongst 143 samples positive for ‘O’ agglutinins, 30 (6%) showed agglutination up to 1in 20 titre, 93 (18.7%) up to 1in 40 and 18 (3.6%) up to 1in 80 and in 157 samples positive for ‘H’ agglutinins, 18 (3.6%) showed a titre of 1 in 20, 120 (24.1%) showed a titre of 1 in 40 and 15 (3.0%) up to 1 in 80. Among 14 samples (2.8%) were positive for anti ‘AH’ in the titre of 1in 20 and 7 (1.4%) were in 1 in 40 whereas among 11 samples positive for anti ‘BH’, 8 (1.6%) were in the titre of 1 in 20 and 3 (0.6%) were in 1 in 40. (Table 2) Among the total of 500 blood samples, 300 samples were collected from healthy blood donors who donated blood to our hospital blood bank and 200 samples from patients who reported to the Microbiology laboratory for various serological tests except for Widal. Demographic distribution of individuals according to age group and sex is given in the [Table 1] Table: 1. Demographic distribution of individuals according to age group and sex. Total Participants Frequency % 500 100 Sex Male 380 76 Female 120 24 Age 16- 20 years 55 11 groups 21- 30years 270 54 31- 40years 150 30 Table: 2. Number and percentage of samples positive for agglutinins with end titres against different serotypes of Salmonella enterica. Serotype Antibody type No and % of positive samples Dilution (1 in 20) Dilution (1 in 40) Dilution (1 in 80) Dilution (1 in 160) Dilution (1 in 320) S. typhi Anti- TO 143 (28.7) 30 (6) 93 (18.7) 18 (3.6) 2 (0.4) NIL S. typhi Anti-TH 157 (31.5) 18 (3.6) 120 (24.1) 15 (3.0) 3 (0.6) 1 (0.2) S. paratyphi A Anti-AH 14 (2.8) 7 (1.4) 6 (1.2) NIL NIL NIL S. paratyphi B Anti-BH 11 (2.2) 7 (1.4) 4 (0.8) NIL NIL NIL The one sample T test showed that the observed value is different from the present recommended value and it is statistically significant (P value < 0.01). (Table 3) Table: 3. one sample T – test Name of the agglutinins Salmonella ‘O’ab Salmonella ‘H’ab Salmonella ‘AH’ab Salmonella ‘BH’ab N Mean Std. Deviation Sig - ( 2 tailed) ‘P’ value 500 500 500 500 11.66 12.72 .76 .60 22.300 20.722 4.926 4.252 < 0.01 < 0.01 < 0.01 < 0.01 DISCUSSION Bacterial culture remains the gold standard for definitive diagnosis of enteric fever but lack of the facility and cost limits its use in the developing countries. [2] The widal test which detects agglutinating antibodies to Salmonella enterica subspecies enteric serotype Typhi ‘O’ and ‘H’ antigens and ‘H’ antigens of Salmonella enterica subspecies enteric serotype Paratyphi A and B is widely used in the developing countries due to the ease of performing the test, low cost and relatively rapid results. Widal test is also useful for diagnosis of 324 Jeyakumari et al., Int J Med Res Health Sci. 2015;4(2):322-326 patients already on antibiotics which may inhibit the growth in culture. The present study showed that frequency of agglutinins to Salmonella typhi ‘O’ and ‘H’ is more than that of Salmonella paratyphi AH and BH. This indicates that exposure to Salmonella paratyphi A & B is less than Salmonella typhi among the population in Puducherry which is similar to that of other regions in our country. [9, 10] In the present study the highest dilution of agglutination against ‘O’ antigen of S. typhi was 1:160 in two out of 500 samples (0.4%) tested ie) less than 1% while it was 3.6% at a titre of 1 in 80 which hitherto has been assumed as the significant titre for ‘O’ in this region. The highest titre for Salmonella typhi ‘H’ was 1in 320 in 1 out of 500 (0.2%) of the study population and 3 out of 500 (0.6%) showed a titre of 1in 160 which is the presumed significant titre in this region. The study shows that a titre of ≥ 1 in 160 for ‘O’ and ‘H’antibodies of Salmonella typhi holds good as the percentage of positivity of these titres is significantly less (<1%) among the population screened. Nevertheless the majority of the screened population were having a titre of 1 in 40 (18 – 24%) for both ‘O’ and ‘H’ antibodies of Salmonella typhi, the titre ≥ 1 in 80 should also be considered as a significant titre with clinical correlations. Also the highest dilution against ‘AH’ antigen was 1in 40 in 6 out of 500 samples (1.2%) and 1in 20 in 7 out of 500 samples (1.4%) against BH antigen. Recent study done by Aruni et al and Sreenath etal [11,12 ] showed the significant titres should be greater than 1: 80 for anti – O and greater 1: 160 for anti – H for a presumptive diagnosis of typhoid fever. In the study done by Senewiratne B etal [13] a titre of ≥ 1 in 160 against ‘H’ and ‘O’ antigens of Salmonella typhi was seen in only 1% of patient with non typhoidal fever. In the study by ‘ Frimporg and others at Ghana [14] the anti ‘O’ titre was ≥ 1 in 160 in 1% of the 307 healthy food handlers while anti ‘H’ titre of ≥ 1 in 320 for S. typhi was 2.6%. In a study at Jordan by Shehabi AA,[15] during an outbreak of typhoid fever, 92% of patients with positive blood culture developed agglutinins against TO and TH in titres of 1 in 80 or more indicating the utility of a single widal test in the acute stage of the disease. In the study by Zailani SB etal, [16] the base line titre for Salmonella typhi and paratyphi for both ‘O’ and ‘H’ antibodies was 1 in 80 among the healthy individuals of the community at Ile - Ife, Nigeria. In the study by El-Shafie S [17] 10.5% of healthy individuals in Sudan showed a titre of 1 in 320 against S. typhi ‘O’ and 4.3% and 5.3% showed a titre of 1in 160 for S.paratyphi ‘A’ and ‘B’ respectively. In the study by Ibadin MO [18] at Benin City, Nigeria 1.1% of the healthy school children tested showed a titre of 1 in 160 for either antigens of S.typhi. Studies conducted in various regions of the world at different periods of time and even within the same region showed a variable baseline titre. It is therefore imperative to estimate the baseline titres among the healthy population in every region at regular intervals and interpretation of single Widal test result must take into account of the baseline titres in their respective areas. In the present study the baseline titres in the majority was less than 1 in 160 for Salmonella typhi‘O’ (99.6%) and ‘H’ (99.4%) antibodies. The significant titre for ‘O’ and ‘H’ antigens of S.typhi could therefore be assumed to be ≥ 1 in 160 in this part of the country. None of them had the baseline titre of ≥ 1in 80 (100%) for S. paratyphi ‘AH’ and paratyphi ‘BH’. The baseline titre for anti ‘AH’ was found to be 1 in 40 (1.4%) and for anti ‘BH’ was 1in 20(1.6%). Hence the significant titre could be presumed to be ≥ 1in 80 for ‘AH’ and ≥ 1in 40 for ‘BH’ antibodies of our region. CONCLUSION More than fifty percent of healthy participants (52%) were positive to agglutinins for serotypes of Salmonella. This indicates that enteric fever is strongly endemic in our region which would be the sanitation index of a country. Our study disclosed that periodic evaluation of baseline titres of Salmonella serotypes agglutinins, particularly in endemic areas is necessary to avoid false positive results. Based on the results of our study it is recommended to change the currently used cut - off value, that is ≥ 1 in 80 for ‘O’ agglutinins of Salmonella typhi to ≥ 1 in 160. The significant titre for ‘H’ agglutinins of Salmonella typhi remains the same, which is ≥ 1 in 160. The significant titre for ‘AH’ of Salmonella paratyphi A is considered to be of ≥ 1in 80 and for Paratyphi B is ≥ 1in 40. The baseline titre for ‘TO’ is same in most of the regions while the titres against ‘TH’ is variable in the different studies. 325 Jeyakumari et al., Int J Med Res Health Sci. 2015;4(2):322-326 ACKNOWLEDGEMENT We would like to acknowledge and thank the Indian council of Medical Research for sanctioning this project (ICMR – STS project – 2012) to MS. Jaberlin Sneha JA. 10. 11. Conflict of Interest: Nil REFERENCES 1. Abdul Razak SH, Abbas Abood AD, Adawia Fadil A. The distribution of anti – salmonella antibodies in the sera of healthy blood donors in baquba city. irqui j comm. med 2011; 24: 241-44. 2. Deepak P, Komal Raj R, Bimala S, Suresh Raj K, Bishnu Raj T. baseline titre and diagnostic cut off value for widal test: A comparative study in healthy blood donors and clinically suspected of enteric fever. JHAS 2012; 2:22-26. 3. Crump JA, Luby Sp, Minz ED. The global burden of typhoid fever. Bulletin world health organization 2004; 82:346-53. 4. Lateef AO, Aprileona LK. Widal agglutination test-100 years later: Still plagued by controversy. Postgrad Med J 2000; 76: 80-84. 5. Cammie F, Lesser SI Miller. Salmonellosis. In: Dennis LK, Eugene B, Anthony SF, Stephen LH, Dan LL etal., eds, Harrison’s Principles of Internal Medicine. 16th edn. Newyork: McGraw – Hill, Medical Publishing division, 2006; 897-02. 6. Bharat M P, Rajendra K, Shyam KM, Janak K. Distribution of antibody titer against Salmonella enterica among healthy individuals in Nepal. Annals of Clinical Microbiology and Antimicrobials 2009; 8: 1-7. 7. Collee JG, Fraser AG, Marmion BP, Simmons A. Mackie and Mc Cartney Practical Medical Microboiology. 1996; 14th ed, New York, Churchill Livingston; 38. 8. Kok TW, Worswick D, Gowans E. Some serological techniques for microbial and viral infections: In: Collee JG, Fraser AG, Marmion BP, Simmons A, eds, Mackie & McCartney Practical Medical Microbiology. 14th edn. Delhi: Elsevier, a division of Reed Elsevier India Pvt Ltd, 2007. 179-83. 9. Punia JN, Joshi RM, Gupta V, Arora RK. Determination of Baseline widal titres from 12. 13. 14. 15. 16. 17. 18. Chandigarh. Indian J Med Microbiol 2003; 21:144. Patil AM, Kulkarni ML, Kulkarni AM. Baseline Widal titres in healthy children. Indian J Paediatrics 2007; 74: 1081-83. Aruni I.S, Prabakaran P, Kumaran J. Study of baseline widal titre against Salmonella species amongst healthy individuals in Thiruvananthapuram district of Kerala, South India. The Experiment 2014; 20:1380-83. Sreenath K, Sujeesh S, Deepa R. Detection of baseline widal titres among the blood donors: A population based study. Int. J. Curr. Microbiol. App.Sci 2014; 3:428-31. Senewiratne B, Senewirante K. Reassessment of the Widal test in the diagnosis of typhoid. Gastroenterology 1977; 73: 233- 36. Frimpong EH, Feglo P, Essel - Ahum M, Addy PA. Determination of diagnostic Widal titres in Kumasi, Ghana. West Afr J Med 2000; 19:34-38. Shehabi AA. The value of a single Widal test in the diagnosis of acute typhoid fever. Trop Geogr Med 1981; 33: 113- 16. Zailani SB, Oylelese AO, Aboderin AO. Determination of baseline antibody titre to S. typhi/ paratyphi in Ile- Ife, Nigeria. Afr J Med Med Sci 2003; 32: 307-10. El- Shafie S. The Widal test in a normal healthy population in the Sudan. East Afr Med J 1991; 68:266- 69. Ibadin MO, Ogbimi AO. Anti- typhoid agglutinins in school aged African children. East Afr Med J 2002; 79: 92-95. 326 Jeyakumari et al., Int J Med Res Health Sci. 2015;4(2):322-326 DOI: 10.5958/2319-5886.2015.00061.2 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS Copyright @2015 th th Received: 9 Jan 2015 Revised: 6 Feb 2015 Research article ISSN: 2319-5886 Accepted: 12th Feb 2015 COMPARISON OF POTENCY OF ANTIFUNGAL ACTION OF DANDRUFF SHAMPOOS AND DIFFERENT PLANT EXTRACTS *Naga Padma P, Anuradha K, Divya K Dept of Microbiology, BVB, Bhavan’s Vivekananda College, Secunderabad, Telangana, India *Corresponding author: Naga Padma; Email:
[email protected] ABSTRACT Context: Dandruff a very common scalp disorder with high prevalence in population is caused by numerous host factors in conjunction with Malassezia furfur. Most of the commercially available anti-dandruff hair shampoos contain some form of antifungal agent(s) that appear to reduce the incidence of the disease. There are no good scientific studies done to prove the antifungal activity of commercially available hair shampoos. Aim: In this study commercially available shampoos were assessed for antifungal activity against a human dandruff isolate of M. furfur. The shampoos were Head & Shoulders, Clinic All Clear, and Pantene etc. The results demonstrated that all six of the assayed hair shampoos have some antifungal effect on growth of M. furfur. These products have poor efficacies, more side effects and give scope for recurrence of symptoms. Methods and Materials: Therefore different plant extracts that possess various active compounds which have antifungal activity could help to overcome the incidence of the disease and also avoid the emergence of resistance in the pathogen. The plant extracts were tested in different concentrations like 1:5, 1:10, 1:20 and they were hibiscus, neem, soap nut, etc. The inhibitory action was studied using agar well assay and disc diffusion method and the results indicated in percentage of inhibition. Conclusion: The study was significant as not only efficient known plant products with anti-dandruff activity could be compared with commercially available shampoos but also their better efficacies at minimum concentrations could be identified. This can help make a polyherbal mixture that could be incorporated in hair oil or shampoos for better anti-dandruff activity. Keywords: Malassezia furfur, Dandruff, plant extracts, anti-dandruff hair shampoos INTRODUCTION Malassezia species formerly known as Pityrosporum is a lipophilic, dimorphic opportunistic yeast causing skin and hair infections like Pityriasis versicolar, seborrheic dermatitis and dandruff, etc[1][2] . Dandruff medically described as Pityriasis capitis is caused by Malassezia species like M.furfur, M.globosa, M.restricta [3]. It is a common scalp disorder and also a major cosmetic problem as it causes hair fall [4]. It has been investigated and reported that there was no complete cure for this disease. This disease is of global prevalence and needs effective therapeutic remedy. There are natural effective remedies to control dandruff in Ayurveda [5] but presently people are depending on commercial shampoos containing some antifungal compounds like miconazole, ketoconazole, selenium sulphide etc. Plant products contain various compounds like alkaloids, flavanoids, tannins, terpenoids etc which have efficient antifungal activity [6] [7]. These compounds can be used in combination as polyherbal mixtures for controlling dandruff. The present work was a comparative study of the effect of commercial anti 327 Naga Padma et al., Int J Med Res Health Sci. 2015;4(2):327-331 dandruff shampoos and natural plant products to evaluate their anti fungal efficacy. There are no reports of such comparative study and this study gives significant information about the higher antifungal efficiency of natural products at low concentration which can be exploited for commercial poly herbal preparations. Aim: The present study was undertaken to find the comparison of efficacy of different types of plant extracts verses chemical shampoos. by using gelatin hydrolysis test, litmus milk reaction, fermentation of carbohydrates like dextrose, xylose, rhamnose, raffinose and mannitol and the results were recorded [11]. Inoculum preparation: The inoculum of Malassezia furfur was prepared by inoculating in 5ml of Sabouraud’s broth and incubated at 300C such that there are 106 cell/ ml[12]. Dilution of shampoos: The commercially available shampoos as mentioned in (Table 1) along with their active ingredient were diluted with sterile distilled MATERIALS AND METHODS water to get 10 fold, 20 fold dilution. These were used for antifungal assays. Isolation of culture: In the clinical study the Table 1: Active ingredients in different organism was isolated from scalp of person suffering commercially available shampoos from Dandruff and maintained on Sabouraud’s [8] Active antidandruff Shampoos media (which is a defined selective media for ingredients medically significant fungi and inhibits growth of Zinc Pyrithione Head and shoulders, normal flora) slants and stored in refrigerator at 40C Pantene, Garnier, Loreal for one month. Selinium sulphide Head and Shoulders, Growth and Identification: The isolate was Nuetrogena screened by plating the scalp swab on Sabouraud’s Ketoconazole Nizoral , Vivel Ultra Pro media enriched with 2 % lipid source like olive oil. Preparation of plant extracts: The different plant The organism was identified based on cultural, sources tested are mentioned in (Table 2) along with microscopic and biochemical methods. their generic names, appropriate plant part used and Cultural: Growth pattern and colony morphology [7] was observed on Sabouraud’s media enriched with a dosage . The plant part was collected from the plant [9] source washed thoroughly, cut into smaller pieces and lipid source like olive oil/ butter . ground into fine paste. The fine paste was made into a Microscopic: Gram stained smear of the culture was [10] solution with sterile distilled water, centrifuged at observed under microscope for cell morphology .. 5000 rpm and the supernatant was used as sample for Biochemical: The organism was biochemically tested anti fungal assays. Table 2: Different plant extracts used and their common names[7] Scientific name Plant part used for extraction of active compound Part used Extracted i.e. Alcohol/ aqua Dose used for antifungal activity Azadirachta indica Piper betle Ocimum tenuiflorum Murraya koenigii Hibiscus rosasinensis Aloe vera Coriandrum sativum Mentha asiatica Phyllanthus emblica Citrus limon Sapindus mukorossi Alpinia galangal Lawsonia inermis Hibiscus rosasinensis Neem Betel leaf Tulsi Curry leaf Hibiscus flowers Aloevera Coriander Mint Amla Lemon Soapnut Dumparashtram Henna Hibiscus leaves Leaf Leaf Leaf Leaf Flower Leaf Leaf Leaf Fruit Fruit Fruit Root Leaf Leaf Water Water Water Water Water Water Water Water Water Water Water Water Water Water 1:10 1:5 1:5 1:5 1:5 1:20 1:5 1:5 1:20 1:20 1:20 1:5 1:10 1:5 328 Naga Padma et al., Int J Med Res Health Sci. 2015;4(2):327-331 zone of inhibition. The highest was for Vivel followed by Head and Shoulders and Dove (Fig3). Zone of Inhibition Using Different Shampoos Fig 1: Microscopic observation of Malssezia furfur Effect of lipid source on the growth of M. furfur: Among the fatty substances tested, M. furfur grew well in Sabouraud's dextrose broth and agar medium containing olive oil followed by butter, coconut oil etc (Fig 2 A and B) . Fig 2 A and B: Growth of Malassezia furfur on Olive oil (A) and butter (B) Antifungal Assay: Among the Antidandruff shampoos tested every shampoo showed a very good 10 Dove Zone of inhibition (1:40) Nizoral 0 Vivel Zone of inhibition (1:20) Pantene 5 Head… Malassezia furfur grew as white to tan cream colored colony with smooth pasty consistency on Sabouraud’s media and the cells appeared bottling shaped when observed microscopically (Fig 1). The Biochemical studies indicated that fermentation of dextrose and xylose produced acid but no gas. Maltose, lactose, rhamnose, raffinose and mannitol were not fermented by M. furfur. Liquefaction of gelatin was observed and there was acidification of litmus milk. Inhibition zones in cm RESULTS Clear Antifungal Assays: The antifungal activity of antifungal shampoos and plant extracts was tested by [13] disc diffusion method and agar well assay . Shampoo Fig 3: Anti fungal activity of different shampoos, represented by zone of inhibition (in cm) The zones of inhibition of different plant extracts indicated significant antifungal activity on Malassezia furfur (Fig 4). Fig 4: Plates showing zone of inhibition for different plant extracts Fig 5: Anti fungal activity of different plant extracts, represented by zone of inhibition (in cm) on Malassezia furfur 329 Naga Padma et al., Int J Med Res Health Sci. 2015;4(2):327-331 Among the plant extracts tested Lemon showed the highest zone followed by Soap nut, Henna, Aloevera and Neem (Fig 5). Comparatively the plant extracts shampoos showed a high zone of inhibition than the shampoos. The inhibition zones of antidandruff shampoos at low concentrations almost matched with those of plant extracts. DISCUSSION Dandruff is a common disease caused by Malassezia species especially Malassezia furfur. The lipolytic activity of these organisms induces hydrolysis of human sebum tri-glycerides in to free fatty acids that cause both hair loss and scalp [14]. Medically significant fungi are known to grow on Sabouraud’s agar medium. The present isolate being lipolytic grew well on olive oil and Butter enriched medium this is in accordance with other reports on growth of Malassezia [15]. All the antidandruff shampoos had good antifungal activity but there is considerable variation in the potency of their antifungal activity depending on the active compound and its concentration. In the present study the best antidandruff shampoo was Vivel Ultra Pro as it contains Ketokanozole which is reported to be anti-malassezial agent [16]. This was followed by Dove and Head and Shoulders as they contain antifungal compounds like Zinc Pyrithione. Most of the plant extracts were showing good antifungal activity almost equivalent to that of commercially available shampoos. Lemon, Henna, Soap nut, Amla had more antifungal activity and this could be because of their active compounds like Citric acid in Lemon and Amla and Saponins in Soap nut [17]. As there are no reports of such comparative aspect the present study gives significant information about the higher antifungal activity of natural products at low concentration which can be exploited for commercial poly herbal preparations. Use of natural plant products is not only cost effective but also negligible side effects. [18] [19]. CONCLUSION The present study was significant as not only efficient known plant products with anti-dandruff activity could be compared with commercially available shampoos but also their better efficacies at minimum concentrations could be identified. Further this research work can help make a polyherbal mixture that could be incorporated in hair oil or shampoos for better anti-dandruff activity. ACKNOWLEDGMENTS The authors (P. Naga Padma , K.Divya and K.Anuradha) are grateful to the management of BVB Bhavan’s Vivekananda College for encouraging to carry out this work. REFERENCES 1. Gupta AK, Batra R, Bluhm R, Boekhout T, Dawson TL. Skin diseases associated with Malassezia species. J Am Acad Dermatol. 2004; 51 (5): 785-98. 2. Vijayakumar R, Muthukumar C, Kumar T, Saravanamuthu R. Characterization of Malassezia Furfur and its control by using plant extracts. Indian J Dermatol. 2006; 51:145-8. 3. Shuster S. The aetiology of dandruff and the mode of action of therapeutic agents. Br J Dermatol. 1984; 111: 235-42 4. Ravichandran G, Shivaram,Kolhapur SA. Evaluation of the clinical efficacy and safety of “Antidandruff Shampoo” in treatment of Dandruff. The Antiseptic.2004; 201(1): 5-8 5. Sonica Krishnan. Effective home remedies for fungal infections, Available from: http://completewellbeing.com/article/naturecures/andhttp://www.herboveda.co.in/2011/7/14/ ayurveda-cure-for-fungal- infections-combat-thefungus-naturally/. 2011. 6. Agrawal DP. Medicinal properties of Neem: New Findings, Available from: http://www.infinity foundation.com/mandala/t_es/t_es_agraw_neem. htm. 2001. 7. Saneesh Kumar. Analysis on the Natural Remedies to Cure Dandruff/Skin Disease-causing Fungus - Malassezia furfur. Adv Bio Tech. 2013;12 (07) : 01-05 8. Sabouraud R. Contribution a l'etude de la trichophytie humaine. Etude clinique, microscopique et bacterioloqique sur la pluralite des trichophytons de l'homme (French). Ann. Dermatol. Syphil. 3:1061-1087. 330 Naga Padma et al., Int J Med Res Health Sci. 2015;4(2):327-331 9. Kaw Bing Chau, I-Ly Chau, I-Ee Chau, Kwai Hoe Chong and Kerk Hsiang Chau. A modified mycological medium for isolation and culture of Malassezia furfur. Malaysian J Pathol 2005. 27(2) : 99 – 105. 10. Kindo A.J, Sophia S.K.C, Kalyani J and Anandan S. A identification of Malassezia species. Ind J. Medical Microbiol. 2004;22(3):179-181. 11. Nakabayashi A, Sei Y, and Guillot J. Identification of Malassezia species isolated from patients with seborrhoeic dermatitis, atopic dermatitis, pityriasis versicolor and normal subjects. Med. Mycol. 2000; 38: 337-41 12. Nakamura Y, Kano R, Murai T, Watanabe S, and Hasegawa A. Susceptibility Testing of Malassezia Species Using the Urea Broth Microdilution Method. Antimicrob. Agents Chemother. 2000; 44 (8):2185-86 13. Finn RK. Theory of agar diffusion methods 19. Krishnamoorthy J, Ranganathan S. Gokul Shankar S and Ranjith M.S. Dano: –A herbal solution for dandruff. Afr J Biotechnol. 2006.5(10):960-62. for bioassay. Anal Chem1959: 31: 975-7 14. Yvonne M, De Angelis, Christina M. Gemmer, Joseph R. Kaczvinsky, Dianna C. Kenneally, James R. etal., Three Etiologic Facets of Dandruff and Seborrheic Dermatitis: Malassezia Fungi, Sebaceous Lipids, and Individual Sensitivity. J Investig Dermatol Symp Proc. 2005; 10: 295 –297. 15. Vijayakumar R, Muthukumar V, Kumar T, and Saravanamuthu R. Characterization of Malassezia furfur and its Control by Using Plant Extracts. Indian J Dermatol. 2006:51(2):145-8. 16. Nikam SR, Khanvilkar VV, Jagdale DM, Jadhav AP, More SH and Kadam VJ. Evaluation of antibacterial and antifungal activities of marketed anti-dandruff shampoos. Indo Am J Pharm Res 2013:3(10):8097-100. 17. Prabha Manju M, Gokul Shankar S, Navin Kumar Sharma, Babu K and Chiranjeevi A. Antifungal activity of selected plant extracts against Malassezia globosa. Int. J of Scientific and technical research. 2012:5(2): 162-168. 18. Krishnamoorthy J, Ranganathan S. Anti – Pityrosporum ovale activity of a herbal drug combination of Wrightia tinctoria and Hibiscus rosasinensis. Indian J. Dermatol .2000:45 (3): 2128. 331 Naga Padma et al., Int J Med Res Health Sci. 2015;4(2):327-331 DOI: 10.5958/2319-5886.2015.00062.4 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 25 Dec 2014 Research article Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 27 Jan 2015 Accepted: 22nd Feb 2015 ASSESSMENT OF AWARENESS AND BELIEFS REGARDING INTRA UTERINE DEVICE AMONGST ITS FORMER USERS ATTENDING TERTIARY CARE CENTRE IN GUJARAT *Jogiya Priyanka D1, Lodhiya Kaushik K2, Chavada Paras3 Department of Obstetrics & Gynaecology, Pandit Deendayal Upadhyay Govt. Medical College, Rajkot, Gujarat *Corresponding author email:
[email protected] ABSTRACT Background: Only 1.8% of married women of reproductive age in India use IUDs despite its advantages over Hormonal pills or permanent methods. The present study was done to study the awareness of the mothers about IUD which affects its utilisation. Method: This was a descriptive cross sectional analytical study was carried out at obstetrics and gynecology department of PDU Government medical college and civil hospital, Rajkot, Gujarat, from January 2014 to June 2014. Post natal mothers who had delivered in the hospital, who had previously used intrauterine contraceptive device (IUCD) for a period of more than one month & who agreed to be a part of the study were included in the study. Results: A total of 110 women who agreed to be a part of the study, were interviewed. The mean age of study participants was 29.2±3.3 years & over half of them resided in urban areas (56.36%) & were housewives (74.54%). Over 90% of the participants were aware of barrier or hormonal methods of contraception & 25 to 50 % of them had also used them in the past. Mean duration of IUD use amongst the study participants was 36.9 ± 18.9 months. While over three fourth of the participants reported to have been provided some sort of counselling before IUD insertion only 64% of them agreed that their pelvic examination was done simultaneously. Awareness about IUD was significantly higher among graduate & working women while there was no significant association of knowledge with other independent variables. Conclusion: There was lack of knowledge amongst participants regarding IUDs as well as many myths which needs to be addressed in order to improve its utilisation by the community. Key words: Adverse events, Attitude, Awareness, Beliefs, Intra Uterine device, Knowledge INTRODUCTION According to the Population Reference Bureau1, about 17% (100 million) of all married women in less developed countries (LDCS) would prefer to avoid a pregnancy but are not using a contraceptive method. In Africa, 22 countries have levels of unmet need of 20 percent or higher, and in Latin America and Asia, most countries have levels of unmet need of 10 percent of women or higher.[1] Worldwide, 61% of women aged 15–49 years who were married or in a consensual union (635 million women) used some form of contraception in 2003. In Priyanka et al., developed countries, women relied mostly on oral contraceptives (16%), female or male sterilization (15%) and condoms (13%); only 9% of women used long-acting reversible contraceptive (LARC) methods. The respective percentages in developing countries were 6, 25, 3 and 18% (United Nations, 2003).[2] India’s population, which crossed one billion in 2000, is projected to reach 1.53 billion by 2050, making it the most populous country in the world. Women of reproductive age group (15-49 years) make up 332 Int J Med Res Health Sci. 2015;4(2):332-338 approximately 248 million. As per NFHS –3, the contraceptive prevalence rate in India is 56.3 %, which varies widely among different states and the unmet need for family planning is high at 13% (6% for spacing).[3] Although oral contraceptives can be very effective in preventing unintended pregnancies, they have been associated with poor compliance which often results in contraceptive failure. In contrast, female sterilization does not depend on users’ adherence, is highly effective, but it has a permanent contraceptive effect. Notably, LARC methods combine reversibility with particularly high effectiveness, which does not rely (or relies at a small degree only) on users’ compliance or correct use.[2, 4-7] Intrauterine contraception is the most widely used amongst the long-acting reversible contraceptives (LARC) in the world today, especially in developing countries. The majority of devices used are copper intrauterine devices (Cu-IUDs) with 1 150 million women users.[8] The evolution of the intrauterine device (IUD) has led to a safe and effective contraceptive choice for many women. The efficacy in pregnancy prevention far surpasses other daily and scheduled methods such as pills, patches, and contraceptive rings.[9,10] Satisfaction rates rank high among IUD users in the United States (US) compared to other methods, and complication rates have been shown to be low.[11] Since the mechanism of action of IUDs is localized to the uterus and cervix, with little if any systemic effect,[12] they are an optimal method for women with multiple medications or medical co-morbidities. In addition to its high efficacy over other contraceptives, additional advantage of its use in women with contraindications to other systemic contraceptives[13] makes IUDs a standout among contraceptive choices. IUCD services are offered free of cost by the government in India. Yet despite this favourable profile, only 1.8% of married women of reproductive age in India use IUDs.[3] So the present study was carried out with the objective to assess the knowledge & beliefs of post – natal mothers about IUD & their attitude towards the use of the same. MATERIAL AND METHODS Type of study: This was a descriptive cross sectional analytical Priyanka et al., Place of research: Study was carried out at obstetrics and gynecology department of PDU Government medical college and civil hospital, Rajkot, Gujarat. Inclusion criteria: Post natal mothers who had delivered in the hospital, who had previously used intrauterine contraceptive device (IUCD) for a period of more than one month & who agreed to be a part of the study were included in the study. The present study was conducted over a period of 6 months from January 2014 to June 2014. Sampling Method: The subjects were selected by convenient sampling method based on availability of mothers (N=110). The consent of all the subjects was taken prior to the study. Permission from the ethical committee of the institution was sought before the starting of the study. Method: Data on socio-demographic profile, awareness & use of different contraceptives, their preference for IUCD, their attitude & beliefs regarding IUCD was collected using a pretested, semi-structured questionnaire. Independent variables were Age, education, occupation & obstetric profile of the woman. Dependent variables were awareness & beliefs of women regarding IUCD use. For each of the ten knowledge based questions about IUD asked to participants, each correct response was given a score of one. Their performance was classified as Good, average or poor if their score was 8-10, 5-7 & 0-4 respectively. Statistics: Data entry and analysis was done using MS-Excel 2007. Chi-square test was used to find the association between knowledge scores & demographic variables for an alpha error of 5%. RESULTS Depending on the inclusion criteria & consent given by mothers, interview of a total of 110 post-natal mothers was taken. The mean age of study participants was 29.2±3.3 years & over half of them resided in urban areas (56.36%) & belonged to joint families (54.64%). Majority of the participants belonged to Hindu religion (76.36%) & were housewives by occupation (74.54%). Although none of the participants were illiterate only 20% of the participants had graduated. The mean parity of the participants was 2.4±0.6. Over 90% of the participants were aware of barrier or hormonal methods of contraception & 25 to 50 % of 333 Int J Med Res Health Sci. 2015;4(2):332-338 them had also used them in the past. Mean duration of IUD use amongst the study participants was 36.9±18.9 months. While over three fourth of the participants reported to have been provided some sort of counselling before IUD insertion only 64% of them agreed that their pelvic examination was done simultaneously. This highlights the laps in duty on the part of service providers & could lead to flare up of cervical infection have it been present at the time of insertion of IUD. (Table 1) The proportion of mothers giving correct responses to each of the ten knowledge based questions about IUD is shown in table 2. Majority (93.6) of the participants were aware of at least other methods of contraception. Over three fourth of them knew the type of IUD used & its duration of effectiveness. Around one third of the mothers were aware of at least two of the adverse events as well as changes in menstrual bleeding pattern following its insertion. Nearly half of the participants did not know the importance of regularly feeling the thread of IUD or its follow up criteria following IUD insertion. Very few of the mothers knew of newer IUDs available or that IUD can also be used in a nulligravida. These findings highlight serious gaps in the knowledge of the participants about IUDs. (Table 2) In the present study, the major reasons for preference of IUD over other methods as per the participants were minimum user interference (46%) & its long lasting contraceptive efficacy (40%). Other reasons were its ability to be discontinued at any time when needed, less cost, easily controlled by women, no consuming drugs & fewer side effects. (Table 3) The main side effect reported by participants was abdominal pain/cramps after insertion in around 40% cases. The other were Leucorrhea (25%), Dysmenorrhea (21%), changes in bleeding pattern during menstruation (14%), expulsion of IUD (8%), infection (3%). About 17% of the participants reported no occurrence of any adverse events. (Table 4) The mothers who were interviewed also had many myths & beliefs about IUD as can be seen in table 5. Participants above thirty years of age had higher levels of knowledge than those under thirty. However this difference was not statistically significant. Residents from urban areas had significantly higher knowledge scores than their counterparts in rural areas. Participants belonging to Hindu religion had higher scores which showed borderline significance as compared to other religions. This difference could be attributed to the difference in level of education of the participants belonging to other religions. The knowledge scores of participants who had used IUD for more than three years did not differ significantly than those who had used IUD for less than three years. Participants who were educated up to secondary level or higher & those who were employed had higher level of knowledge about IUD than those who were educated up to primary standards or those who were unemployed. This difference was highly significant. There was no significant association between increasing parity of participants or participants with past history of abortion & their level of knowledge about IUCD. (Table 6) Table 1: Profile of IUD use amongst study subjects Response N= 110 Variable % Main source of information about IUCD* Mass media (TV, Newspaper) Friend, Relative Health care personnel 15 99 73 13.6 90 66.36 65 13 16 15 59.0 11.8 14.5 13.6 104 108 20 52 94.5 98.1 18.1 47.2 27 49 00 24.5 44.5 0 84 76.3 60 64.5 Decision making for IUD use Couple Husband Herself Mother-in-Law Method IUCD* aware other than Condom OCP Injectable method Permanent methods Utilisation of other methods in past* OC Pills Barrier method Others Counselling provided before IUD insertion Pelvic examination done before IUD insertion Mean duration of IUD use 36.95 ± months 18.89 *multiple answers 334 Priyanka et al., Int J Med Res Health Sci. 2015;4(2):332-338 Table 2: The knowledge of participants about various aspects of IUCD Knowledge regarding Total N = 110 % At least two other methods of temporary contraception Type of IUCD used 103 93.64 83 75.45 Duration of effectiveness of IUCD Side effects of IUCD (at least 2) 85 77.27 76 69.09 Changes in menstrual bleeding pattern At least two advantages of IUD over other methods of temporary contraception Necessity to feel thread Ideal follow-up criteria 68 61.82 64 58.18 55 52 50.00 47.27 Knows about newer IUCD Use of IUD for family planning of a newly married childless couple 25 10 22.73 9.09 Minimum user interference Long lasting Can be stopped any time when pregnancy is wanted Less cost Controlled by women Others (less side effects, no taking regular drugs) *multiple responses Adverse events* Encountered by participants % Abdominal pain/cramp after insertion Leucorrhea Dysmenorrhea Bleeding pattern changes during MC Expulsion Fever with infection No side effect 43 39.09 28 24 16 25.54 21.81 14.54 09 03 19 8.18 2.72 17.2 *Participants may have more than one adverse event Table 3: Preference for IUCD over other methods amongst the participants Advantages of IUCD Table 4: Frequency distribution of adverse events due to IUD use amongst the participants (multiple responses) Yes N=110* 51 44 36 % 28 28 24 25.54 25.54 21.81 46.36 40 32.72 Table 5: Beliefs regarding IUCD amongst users (multiple responses) Belief (N=110) Yes % Rest period needed after prolonged use Perforate uterus Discomfort during sex Causes infection in uterus Decrease capacity to do physical work Causes cancer Acts by causing abortion Birth defect Ectopic pregnancy Infertility Moves to heart /brain Infection to foetus Weight gain Cause preterm labour in case of accidental pregnancy 88 80 60 55 36 33 54.5 50 32.7 30 31 23 17 17 15 13 05 07 03 28.1 20.9 15.4 15.4 13.6 11.8 4.5 6.3 2.7 *multiple responses Table 6: Association of knowledge scores of the participants to various demographic variables Demographic variables Good Average Poor Chi-square test (8-10) (5-7) (1-4) Age in Years <30, N=77 16 37 24 Chi = 2.913, p = 0.233 >30, N=33 11 16 6 Residence Rural, N=48 5 27 16 Chi = 7.491 p = 0.023 Urban, N=62 20 28 14 Religion Hindu N=84 24 36 24 Chi = 5.772 p = 0.055 Others N=26 2 17 7 Education Up to primary N=37 1 17 19 Chi = 21.478 p = 0.00002 Secondary & above N=73 26 35 12 Occupation House-wife N=81 9 48 24 Chi = 24.135 p = 0.000005 Employed N=29 16 7 6 Parity Two para N=74 20 36 18 Chi = 1.298 p = 0.522 More than two para N=36 7 17 12 Abortion No abortion N= 60 12 29 19 Chi = 1.308 p = 0.519 Past history of abortion N= 50 14 24 12 Duration of use < 3 years N = 73 17 36 20 Chi = 0.052 p =0.974 >3 years N = 37 8 19 10 335 Priyanka et al., Int J Med Res Health Sci. 2015;4(2):332-338 Table 7: Attitude of subjects regarding IUCD Attitude of subjects about Yes % IUCD use (N= 110) Feels satisfied with IUCD 84 76.36 use Will encourage a friend to 101 91.81 use IUCD Willing to use it again if 54 49.09 needed Willing to check the thread 69 62.72 of inserted IUD regularly after every menstruation DISCUSSION The major source of information about IUCD was a friend or a relative in 90% of the participants with secondary role of health care personnel & minimal information through mass media. (Table 1) This highlights the failure of mass media in creating awareness about IUDs. Reddy et al in 2003[14] stated that the major source of knowledge among men about Family Planning methods was magazines (64%) followed by personal relations i.e. spouse, friends and relatives (62%), mass media (54%) and health personnel (34%). The role of health care providers in providing contraception knowledge should be prioritised as it’s a two way communication process & will provide correct & complete information as compared to friends or mass media. Although in 60% of cases the decision for IUD use was by the couple themselves, in about 25% of the cases the decision for IUD use was dominated by husband or mother-in-law hampering the decision making ability of the women. (Table 1) Prachi R et al in 2008[15] mentioned that in 41.6% of the women the choice of contraceptive methods used was decided by their husband which is higher than that in present study. The difference was due to difference in the literacy rate of women & settings in which the study was done. In a comparative study on attitude of contraceptive methods users by Ehsanpour et al (2010), desirable attitude amongst users towards IUD in comparison with other methods was due to high efficacy, ease of use, lack of interference with sexual relationship and no need for daily remembrance.[16] This finding was very similar to the present study. (Table 7) Patients must also be counselled regarding expected adverse events after IUD insertion & tips to manage them. Thorough counselling about expected changes in bleeding patterns before IUD insertion correlates with satisfaction rates and continuation rates.[17,18] It must be stressed upon that the occurrence of side effects experienced by the mothers will decrease over a period of few months.[18] This will ensure greater compliance among the mothers towards use of IUD.(Table 4) In the present study, 80% of the participants mentioned that a break from continuous usage of IUD is needed, while there is no such literature supporting this view point, discontinuation of IUD would also increase the risk of unintended pregnancy. Table 5 highlights many myths & beliefs about IUD amongst its former users. Around half of the mothers believed that IUD will perforate the uterus & over one third of them believed that it would lead to infection. Infection following IUCD insertion is less than 1%. This minimal risk is highest during the first 20 days after IUCD insertion, especially if aseptic precautions have not been taken, rather than due to IUCD itself.[3] World Health Organization found that the risk of development of pelvic inflammatory disease (PID) in women with IUD is same as or less than the risk of PID in women without IUDs.[19, 20, 21] The attitude of a woman about the use of IUD is based on her existing knowledge, her beliefs about IUD & counselling provided by the service provider. Although over three fourth of the participants were satisfied about IUD use still there remained a quarter of them who for various reasons were not satisfied with IUD. Only half of the participants were willing to use IUD again for contraception which is a matter of concern. As many as 40% of the participants were not motivated to check the thread of IUD after menstruation. These findings pose a serious threat to the continuation of use of IUD in future. The concerns of these women need to be immediately attended to prevent discontinuation of IUD use in them. (Table 7) CONCLUSION The mothers in the present study were unaware about the basic knowledge regarding IUD. Age of the participants, Religion, parity status, history of abortion or duration of use of IUDs did not significantly affect the knowledge scores of the participants regarding IUD. However there was 336 Priyanka et al., Int J Med Res Health Sci. 2015;4(2):332-338 strong association between education & working status of participants to their awareness about IUD. The findings of the present study showed that many former users of IUDs still have false beliefs, concerns & unfavourable attitudes about IUDs. This may result in discontinuing their IUD use as well as propagate false beliefs amongst their peer groups. IUDs are safe and effective in women of any reproductive age. They offer superior contraceptive efficacy, plus noncontraceptive benefits that can improve quality of life in many women. Patient lack of knowledge about IUDs coupled with practitioner apathy for sufficient counselling, all continue to be barriers to IUD use. Recommendation: The dispersion of accurate information addressing their beliefs & concerns is crucial to the continued use and growing acceptance of this beneficial method. 7. 8. 9. 10. Conflict of Interest: Nil REFERENCES 1. Ashford, Lori. Unmet need for family 2. 3. 4. 5. 6. planning: recent trends and their implications for programs. Policy Brief. Measure Communications, Population Reference Bureau, Washington D.C., 2003; 170 1-8. Mavranezouli I. The cost-effectiveness of long-acting reversible contraceptive methods in the UK: analysis based on a decisionanalytic model developed for a National Institute for Health and Clinical Excellence (NICE) clinical practice guideline.Hum Reprod 2008;23:1338-45. IUCD Reference Manual for Medical Officers. Available at http:// nrhm. gujarat. gov.in/manuals.htm accessed on 2nd feb 2015. Rosenberg MJ, Waugh MS. Oral contraceptive discontinuation: a prospective evaluation of frequency and reasons. Am J Obstet Gynecol 1998;179: 577–82. Ingelhammar E, Moller A, Svanberg B, Tornbom M, Lilja H, Hamberger L. The use of contraceptive methods among women seeking a legal abortion. Contraception 1994;50:143–52. Bianchi-Demicheli F, Perrin E, Bianchi PG, Dumont P, Ludicke F, Campana A. Contraceptive practice before and after 11. 12. 13. 14. 15. 16. termination of pregnancy: a prospective study. Contraception 2003;67:107–113. Trussell J. Contraceptive efficacy. In: Hatcher RA, Trussell J, Srewart F, Nelson A, Cates W, Guest F, Kowal D (eds). Contraceptive Technology: Eighteenth Revised Edition. New York, Ardent Media 2004;773–45. d’Arcangues C. Worldwide use of intrauterine devices for contraception. Contraception 2007;75:2–7. Winner B, Peipert JF, Zhao Q, et al. Effectiveness of long-acting reversible contraception. N Engl J Med. 2012;366(21):1998–07. Trussell J. Contraceptive failure in the United States. Contraception. 2011;83:397–04. Yoost J. Understanding benefits and addressing misperceptions and barriers to intrauterine device access among populations in the United States. Patient Preference and Adherence 2014:8 947–57 Mechanism of action, safety and efficacy of intrauterine devices. Report of a WHO Scientific Group. World Health Organ Tech Rep Ser. 1987;753:1–91. Centers for Disease Control and Prevention (CDC). US Medical Eligibility Criteria for Contraceptive Use, 2010. MMWR Recomm Rep. 2010;59(4):1–86. Reddy RS, Premarajan KC, Narayan KA, Mishra A. Rapid appraisal of knowledge, attitude and practices related to family planning methods among men within 5 years of married life Indian J. Prev. Soc. Med. 2003;34(1):63-6. Renjhen P, Gupta SD, Barua A, Jaju S, Khati B. A study of knowledge, attitude and practice of family planning among the women of reproductive age group in Sikkim. J Obstet Gynecol India. 2008;58(1):63-7 Ehsanpour S, Mohammadifard M, Shahidi S, Nekouyi NS. A comparative study on attitude of contraceptive methods users towards common contraceptive methods. Iran J Nurs Midwifery Res. 2010;15(l1): 363–70. 337 Priyanka et al., Int J Med Res Health Sci. 2015;4(2):332-338 17. Hillard PJ. Practical tips for intrauterine devices use in adolescents. J Adolesc Health. 2013;52(4):40–46 18. Management of problems related to intrauterine contraception Available from: www.uptodate. com/contents/management-of-problems-relatedto-intrauterine-contraception#H1 accessed on 2nd feb 2015. 19. Simms I, Rogers P, Charlett A. The rate of diagnosis and demography of pelvic inflammatory disease in general practice: England and Wales. Int J STD AIDS. 1999;10(7):448–51. 20. Weström L. Incidence, prevalence, and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol. 1980; 138(2):880–92. 21. Grimes DA. Intrauterine device and uppergenital-tract infection. Lancet. 2000; 356 (9234):1013–19. 338 Priyanka et al., Int J Med Res Health Sci. 2015;4(2):332-338 DOI: 10.5958/2319-5886.2015.00063.6 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 st Received:31 Dec 2014 Research article BIOFILM FORMATION UROPATHOGENS AND Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 27 Jan 2015 Accepted: 20th Feb 2015 ANTIMICROBIAL RESISTANCE PATTERN AMONG *DardiCharanKaurG1, MaralSanjivani.S2 1 Department of Microbiology, Maharashtra Institute of Medical Education & Research (MIMER), Talegaon Dabhade, Pune, Maharashtra, India 2 Assistant Professor Symbiosis Institute of Health Sciences, Pune Maharashtra, India *Corresponding author email:
[email protected] ABSTRACT Background: Bacterial biofilms play an important role in urinary tract infections and is responsible for persistence infections and also the higher antimicrobial resistance is seen in biofilm forming uropathogen as compared to free floating bacteria. So the present study was undertaken with the aim to know the prevalence of biofilm formation and antimicrobial resistant pattern of biofilm producer and non-biofilm producing uropathogens. Materials & Methods: A total of 146 Gram negative bacilli and 62 S. aureus isolated from patients suspected UTIs were tested for biofilm formation and antimicrobial susceptibility testing by Kirby-Bauer disc diffusion method on Mueller Hinton agar as per CLSI guidelines. Result: Out of 208 isolates from urine, Biofilm formation was noted in 122(58.66%) and no biofilm formation in 86(41.35%).[Strong Biofilm formation in 76(36.54%) and weak biofilm formation in 46(22.12%).In our study, we noted biofilm and non-biofilm forming microorganism showed mark difference in antimicrobial resistance pattern. In Staphylococcus aureus striking difference was noted to ciprofloxacin (100% versus 33.33%) and azithromycin (96%versus 41.67%). Isolates showed no resistance to linezolid. Whereas isolates of Pseudomonas aeruginosa to netilin (100% versus 42.86%).And in other Gram negative bacilli difference was noted to gentamicin (87.93% versus 13.43%) and norfloxacin (84.48% versus 37.31%) Conclusion: Biofilm forming isolates showed higher antimicrobial resistance as compared to non-biofilm producer. Thus, Uropathogen should be routinely screened for biofilm formation. Keywords: Uropathogen, Biofilm formation, Antimicrobial resistance pattern INTRODUCTION Urinary tract infections (UTIs) are the important causes of morbidity affecting 150 million people globally each year and also continue to be the most common causes of infections in hospitalized patients. [1, 2] It is the most common bacterial infections in humans both in the community and hospital settings, and in all age groups, and usually requires urgent treatment. Malnutrition, poor hygiene, low socio-economic status is associated with urinary tract infections and these factors are rife in rural settings.[3]Microorganism associated with UTI has a property to form biofilm and this biofilm can be formed by one or many bacteria which show antimicrobial tolerance. Host factors like age, diabetes, long term hospitalization and catheterization are the predisposing conditions.[4]According to the NIH, urology is one of the main areas of concern where biofilm can become a serious problem and 339 Charan et al., Int J Med Res Health Sci. 2015;4(2):339-344 Biofilm are found in the urothelium, prostate stones, and implanted foreign bodies. [5] The population of bacteria growing on the biotic and biotic surfaces is the biofilms. The bacteria embed themselves in a self-produced extracellular matrix of exopolysaccharide (EPS), proteins and some micro molecules such as DNA. This matrix accounts for about 90% biomass. [6]The extracellular matrix of exopolysaccharide protects the bacteria from host defenses and impedes delivery of antibiotics.[7]Infact higher antimicrobial resistance is seen in biofilm forming uropathogenas compared to free floating bacteria. Bacterial biofilm is responsible for persistence urinary tract infections and the multidrug resistance so the present study was undertaken with the aim To know the prevalence of biofilm formation in uropathogens To know the antimicrobial resistant pattern of biofilm producer and non- biofilm producing uropathogens MATERIAL AND METHODS The Prospective study was carried out in the department of Microbiology of a tertiary care rural hospital from the period of July 2012 to December 2013. Urine specimen from patients suspected of UTIs was collected. The sample was processed and identification of uropathogen was done by standard microbiological techniques. [8]A total of 146 Gram negative bacilli and 62 S. aureus isolated from patients suspected of UTI were randomly selected.The isolates were tested for biofilm formation by Tube method as described by Christensen et al.[9] 1. The tube containing TSBglu (10mL) were inoculated with culture of uropathogen and incubated at 37 degree C for overnight. 2. The tubes were decanted and washed with PBS (pH 7.3) and dried. 3. Dried tubes were than stained with 0.1% crystal violet. 4. Excess stain was removed and tubes were washed with deionized water. 5. Tubes were then placed in inverted position to dry 6. Tubes were finally observed for biofilm formation Assays were performed in triplicate at three different times. The Isolates were tested for antimicrobial susceptibility testing by Kirby-Bauer disc diffusion method on Mueller Hinton agar as per CLSI guidelines.[10] The following antimicrobial agents were tested for Staphylococcus aureus: amikacin(Ak) (30µg), ampiclox(ACX) 20μg, azithromycin(AZ) 15μg, calithromycin (CLR)15 μg, cefoperazone (CFP)30µg,cefotaxime(CF)30μg,cefuroxime(CR)30μ g,ciprofloxacin (CIP)5μg, cotrimoxazole (Cot)5μg, gentamicin (30µg), linezolid (30μg), sparfloxacin (SF)5μg. The antimicrobial agents tested for Pseudomonas aeruginosaare: amikacin(Ak) 30μg, cefepime(CPM) 30μg, cefoperazone (CFP)75μg ,ceftazidime(CAZ) 30μg, ciprofloxacin(CIP) 5μg, gentamicin (GEN)10μg,levofloxacin(Le) 5μg, meropenem(MRP) 10μg, netilin(NET) 30μg, Piperacillin(Pi)100μg, ticarcillin(Ti)75μg, tobramycin(TOB)10μg The antimicrobial agents tested for Gram negative bacilli were amikacin (An) 30μg, cefaclor (CFC) 30μg, cefadroxil (CD) 30μg, ceftriaxone (CTX) 30μg, ciprofloxacin (CIP)5μg, gentamicin (G)10μg, netilin (NET) 30μg, nitrofurantoin (NF) 300μg, norfloxacin (NR) 10μg, ofloxacin (ox) 5μg, The Antimicrobial disc was obtained from Hi-media Laboratories Pvt. Ltd, Mumbai, India. RESULTS Out of 208 isolates from urine, Strong Biofilm formation was noted in 76(36.54%) and Weak Biofilm formation in 46(22.12%) and no biofilm formation in 86(41.35%). (Table No 1).Higher Biofilm formation was seen in females 140(67.31%) as compared to males 68(32.69%), Table 1: Biofilm producers in uropathogens Isolates No of Samples E .coli 93 Staphylococcus aureus Pseudomonas sps 62 21 Strong Biofilm formation Weak Biofilm formation Negative Biofilm formation 27(29.03) 16(17.20) 50(53.76) 32(51.61) 18(29.03) 12(19.35) 8(38.09) 6(28.57) 7(33.33) Klebsiellasps 13 5(38.46) 3(23.07) 5(38.46) Citrobactersps 13 4(30.77 3(23.07) 6(4615) Proteus sps 4 0 4 0 1 0 1 Morganellamor ganii Serratiamarcesc ens Total 1 1 208 76(36.54%) 46(22.12%) 86(41.35%) 340 Charan et al., Int J Med Res Health Sci. 2015;4(2):339-344 Overall strong biofilm formation was 36.54%, weak in 22.12% and 41.35%were Negative for Biofilm. Strong biofilm formation and weak biofilm formation was significantly less for E.coli. (Chi2test =5.99; P0.05). As against that Strong biofilm formation was significantly more in Staphylococcus aureus (Chi2test =12.44; P0.05). Outcome of P. aeruginosa was comparable to the overall outcome. The above table depicts highest Biofilm producers were Staphylococcus aureus 50/62 (80.65%) followed by P. aeruginosa 14/21(66.67%) antimicrobial agent tested and on Y axis is the percentage of resistance shown by the isolates. Biofilm formation and antimicrobial resistance pattern of Gram negative bacilli 100 80 Biofilm formation (N=58)% Non-Biofilm formation (N=67)% 60 40 20 0 Biofilm formation and antimicrobial resistance pattern of Staphylococcus aureus Sparfloxa… linezolid Gentamy… Cotrimox… Ciproflox… Cefuroxi… Cefotaxi… Calithro… Cefopera… Ampiclox Amikacin 120 100 80 60 40 20 0 Azithrom… Biofilm formation (No=50)% Non-Biofilm formation(N=12) % Fig 1: Biofilm formation and antimicrobial resistance pattern of Staphylococcus aureus The above chart depicts Biofilm formation and nonBiofilm producer showed mark difference in antimicrobial resistance pattern to ciprofloxacin and azithromycin. Isolated showed no resistance to linezolid. On the X axis are the antimicrobial agent tested and on Y axis is the percentage of resistance shown by the isolate Biofilm formation and antimicrobial resistance pattern of Ps. aeruginosa Tobram… Ticarcillin Piperaci… Netilin Merope… Levoflo… Gentam… Ciprofl… Ceftazi… Cefoper… Cefepime Biofilm formation(N=14)% Non-Biofilm formation (N=7) % Amikacin 120 100 80 60 40 20 0 Fig 2: Biofilm formation and antimicrobial resistance pattern of Ps. aeruginosa In the above table it is observed Biofilm formation and non-Biofilm producer Pseudomonas aeruginosa showed significant difference in antimicrobial resistance pattern to netilin. On the X axis are the Fig 3: Biofilm formation and antimicrobial resistance pattern of Gram negative bacilli In the above table it is depicted that Gram negative bacilli (Biofilm formation and non-Biofilm producer), showed significant difference in antimicrobial resistance pattern to gentamicin and norfloxacin. On the X axis are the antimicrobial agent tested and on Y axis is the percentage of resistance shown by the isolates. DISCUSSION Biofilms are estimated to be responsible for over 65% of nosocomial infections and 80% of all microbial infections as stated by U. Römling.[11] E .coli, Staphylococcus aureus, Pseudomonas sps Klebsiellasps, Citrobactersps, Proteus sps, Morganellamorganii, Serratiamarcescens are the pathogen isolated from urine similar were the findings of Sara M. Soto. [12]In our study E.coli was the predominant organism agent from urinary tract infections whereas in a study by Lucchetti et al P. aeruginosa. According to epidemiologic data, 35.0% to all acquired nosocomial infections are urinary and 80.0% are related to catheter use. [13] In our study higher prevalence of UTI was seen in females as compared to the males 68 (32.69%), thus showing a female predominance. Our study is similar to the findings of Syed M A,Devanand P et al. [14,15] Kamat US et al in their study noted females are more prone to develop UTIs, probably due to their anatomical physiological changes like short urethra, its proximity to the anus, dilatation of the urethra and the stasis urine during pregnancy. [2] 341 Charan et al., Int J Med Res Health Sci. 2015;4(2):339-344 In our study we observed for Biofilm formation among the uropathogen. We noted highest Biofilm producers were Staphylococcus aureus 50/62 (80.65%) followed by P. aeruginosa 14/21(66.67%) and E.coli 43/93(46.24%). The bacteria from the bowelmove to the bladder and adhere to the uroepithelium and form biofilm which can invade the renal tissue causing pyelonephritis. The clinical spectrum of complicated UTIs may range from cystitis to urosepsis with septic shock and relapse is due to the biofilm forming capacity of the microorganism.[16, 17] Alicia ValériaZaranzain their study showed biofilm production by the Congo Red Agar method in 52.0% & biofilm formation by 86% on polystyrene microplates. Among them strong biofilm formation was found in 22.1%, moderate in 47.7% and weak in 30.2%. Carlos J et al reported biofilm formation in P. aeruginosa in 83% of clinical strains & that biofilm formation was higher in MDR isolates. [18,19] The components of the EPS involved in the formation of P. aeruginosa biofilm are encoded mainly by different genes located in three independent operons: algU, psl, and pel andin S. aureus by gene icaABDC.[20, 21] The persistent cells shows reduced metabolism leading to higher antimicrobial resistance. Biofilm are difficult to eradicate so combined therapy is recommended for the treatment of biofilm-associated infections. In our study, we noted Biofilm and non-Biofilm forming Staphylococcus aureus isolates showed mark difference in antimicrobial resistance pattern to ciprofloxacin (100% versus 33.33%)and azithromycin (96% versus 41.67%). Isolates showed no resistance to linezolid. Pseudomonas aeruginosa isolates showed significant difference to netilin (100% versus 42.86%). In the Gram negative bacilli (Biofilm formation and non-Biofilm producer), significant difference in antimicrobial resistance pattern was observed to gentamicin (87.93% versus 13.43%) and norfloxacin (84.48% versus 37.31%). (Chart 1-3) Fatima Khan et al found ciprofloxacin was effective against biofilm producers and Zheng Z et al noted rifampicin has putative antibiofilm properties, to penetrate StaphylococcalBiofilm. [22, 23] Donlan R.M., et al in their study on Biofilm’s Survival mechanisms of clinically relevant microorganisms observed the age of the biofilm also affects the susceptibility to antibiotics. In their study they highlighted 10-day-old biofilms are more resistant than 2-day-old biofilms. This emphasizes the need for prompt diagnosis and treatment.[24] Sara M. Soto in the review article analyzed some workers observed Macrolides (erythromycin, clarithromycin, and azithromycin) present high "in vitro" and "in vivo" activity, against biofilm-forming organism P. aeruginosa, other Gram-negative bacteria, and Staphylococcus spp. Other workers reported macrolides enhances biofilm formation in Gram-positive bacteria with the explanation that there is increase in the expression of biofilm-related genes (icaAatlE fruA, pyrR, sarA, and sigB). [12] In our study we found higher antimicrobial resistance in biofilm producers as compared to thenegative biofilm producers. Similar were the findings of other workers Fatima Khan et al, BijayiniBehera et al[22,25] Sara M. Soto in study, noted higher antimicrobial resistance by biofilm may be due to the some antimicrobial agents are not able to diffuse through the matrix or sometimes the time taken to diffuse through is longer than the duration of treatment or the antibiotic lifetime. Or an antimicrobial agent that diffuses can be inactivated by the pH inside biofilm.[12] CONCLUSION Biofilm forming isolates showed higher antimicrobial resistance as compared to non-Biofilm producer. This is due to metabolically inactive persister cells. Antimicrobial resistance is a global issue, so uropathogen should be routinely screened for biofilm formation and antimicrobial resistance before initiating the treatment. Conflict of Interest: Nil REFERENCES 1. Orenstein R, Wong ES. Urinary tract infections in adults. Am Fam Physician. 1999; 59:1225–34. 2. Kamat US, Fereirra A, Amonkar D, Motghare DD, KulkarniMS. Epidemiology of the hospital acquired urinary tract infections in a medical college hospital in Goa. IJU. 2009; 25(1):76. 3. Ahmed SM, Avasara AK. Urinary tract infections (UTI) among adolescent girls in rural Karimnagar District, AP K.A.P. STUDY. Indian J Pre Soc Med. 2008;(1)39 342 Charan et al., Int J Med Res Health Sci. 2015;4(2):339-344 4. http://www.infectioncontroltoday.com/news/2013 /10/women-most-often-suffer-utis-but-men-morelikely-to-be-hospitalized.aspx 5. P. Tenke, B. Kovacs, M. Jäckel, and E. Nagy, “The role of biofilm infection in urology,” World Journal of Urology. 2006; 24(1):13–20. 6. H.-C. Flemming and J. Wingender, “The biofilm matrix,” Nature Reviews Microbiology. 2010; 8(9):623–33. 7. Stewart, P.S. Mechanisms of antibiotic resistance in bacterial biofilms. Ind. J. Med. Microbiol. 2002; 29: 107-13. 8. Forbes BA. Sahm DF, Weissfeld AS. Bailey and Scott's Diagnostic microbiology. 12th edition, chapter 57. Infection of the urinary tract. Mosby Elsevier; 2007:842-55 9. Gordon D. Christensen,W. Andrew Simpson, Alan L. Bisno, And Edwin H. Beachey. Adherence of Slime- Producing Strains of Staphylococcus epidermidis to Smooth Surfaces. Infection and Immunity, July 1982; Vol. 37(1):318-26. 10. Clinical and Laboratory Standard Institute. Performance standards for antimicrobial disc susceptibility tests, twentieth supplement.2012; 32(3):100-21. 11. U. Römling and C. Balsalobre, “Biofilm infections, their resilience to therapy and innovative treatment strategies,” Journal of Internal Medicine. 2012; 272(6):541–61. 12. Sara M. Soto. Importance of Biofilms in Urinary Tract Infections: New Therapeutic Approaches. Advances in Biology. 2014; 13 http:/ dx.doi. org/ 10.1155/2014/543974 13. G. Lucchetti, A. J. Silva, S. M. Y. Ueda, M. C. D. Perez and L. M. J. Mimica, “Infecções Do TratoUrinário: Aná- lise da Freqüência e Do Perfil de Sensibilidade Dos AgentesCausadores de Infecções Do TratoUrinárioEmPacientes Com CateterizaçãoVesicalCrônica,” Journal Brasileiro de Patologia e Medicina Laboratorial. , 2005; 41(6) 383-89. 14. Syed M A, Ramakrishna P J, shaniyakoyakutty, Arya B, ShakirVPA. Urinary Tract Infections – An overview on the Prevalence and the Antibiogram of Gram Negative Uropathogens in a Tertiary Care Centre in North Kerala, India. Journal of Clinical and Diagnostic Research. 2012; 6(7): 1192-95. 15. Devanand P and Ramchandra S S. Distribution and antimicrobial susceptibility pattern of bacterial pathogens causing urinary tract infection in urban community of Meerut city, India. ISRN Microbiology 2013, 13 16. J. C. Nickel, I. Ruseska, J. B. Wright, and J. W. Costerton, “Tobramycin resistance of Pseudomonas aeruginosa cells growing as a biofilm on urinary catheter material,” Antimicrobial Agents and Chemotherapy/ 1985;27(4):619–24. 17. S. M. Soto, A. Smithson, J. P. Horcajada, J. A. Martinez, J. P. Mensa, and J. Vila, “Implication of biofilm formation in the persistence of urinary tract infection caused by uropathogenic Escherichia coli,” Clinical Microbiology and Infection. 2006; 12(10): 1034–36. 18. Alicia ValériaZaranza, Francyelle Costa Morais, Monique Santos do Carmo, Adriana de Mendonça Marques, Cristina Andrade-Monteiro, ThiagoFeitosa Ferro, ValérioMonteiro-Neto, Patrícia de Maria Silva Figueiredo. Antimicrobial Susceptibility, Biofilm Production and Adhesion to HEp-2 Cells of Pseudomonas aeruginosa Strains Isolated from Clinical Samples. Journal of Biomaterials and Nanobiotechnology, 2013, 4, 98-06. 19. Carlos J Sanchez Jr, KatrinMende, Miriam L Beckius, Kevin S Akers, Desiree R Romano, Joseph C Wenke and Clinton K Murray, BMC Infectious Diseases. 2013;13:4720. Xicohtencatl-Cortes J, Monteiro-Neto V, Saldaña Z, Ledesma MA, Puente JL, Girón JA. The type 4 pili of enterohemorrhagic Escherichia coli O157:H7 are multipurpose structures with pathogenic attributes. J Bacteriol 2009; 191:41121. 21. Ammendolia, M.G., R.D. Rosa, L. Montanaro, C.R. Arciola and L. Baldassarri. Slime production and expression of slime associated antigen by staphylococcal clinical isolates. J. Clin. Microbiol. 1999; 37: 3235-38. 22. Fatima Khan, InduShukla, MeherRizvi, Tariq Mansoor and S.C. Sharma. Detection of Biofilm Formation in Staphylococcus aureus. Does it have a role in Treatment of MRSA Infections? Trends in Medical Research. 2011; 6: 116-23. 343 Charan et al., Int J Med Res Health Sci. 2015;4(2):339-344 23. Zheng Z, Stewart PS. Penetration of rifampin through Staphylococcus epidermidis biofilms. Antimicrob Agents Chemother 2002; 46:900-03. 24. Donlan R.M., Costerton W., Biofilms: Survival mechanisms of clinically relevant microorganisms. Clin. Microbiol. Rev., 2002, 15(2): 167-93. 25. BijayiniBehera, Anupam Das, PurvaMathur&ArtiKapil. High prevalence of carbapenem resistant Pseudomonas aeruginosa at a tertiary care centre of north India. Are we under-reporting? Indian J Med Res.2008; 128:324-25. 344 Charan et al., Int J Med Res Health Sci. 2015;4(2):339-344 DOI: 10.5958/2319-5886.2015.00064.8 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS th Received: 8 Jan 2015 Revised: 10th Feb 2015 Research article Copyright @2015 ISSN: 2319-5886 Accepted: 17th Feb 2015 HEPATITIS B VIRUS (HBV) AND SYPHILIS CO-INFECTIONS AMONG THE PEOPLE OF EKITI, SOUTH-WEST, NIGERIA *Akinbolaji Thompson J1, Odeyemi Festus A2, Adegeye Festus O3, Ojo Olalekan I4, Akinseye Funmilayo J5. 1 Haematology and Blood Transfusion Unit, Ekiti State University Hospital, Ado-Ekiti, Ekiti State, Nigeria Kidney Clinics Nigeria, Kemta Housing Estate, Idi-Aba, Abeokuta, Ogun State, Nigeria 3 Clina-Lancet Laboratory 3, Jose Babatunde Ademola Adetokunbo Area, Victoria Island, Lagos 4 Primary Health Centre, Saki East Local Gvt, Oyo State 5 Medical Laboratory Services, State Specialist Hospital, Akure, Ondo State, Nigeria 2 *Corresponding author email:
[email protected] ABSTRACT This study was carried out to know the prevalence of hepatitis B, syphilis and co-infection of both among the people of Ekiti, South-West, Nigeria. Individuals and patients who visited the Haematology and Blood Transfusion Unit of Ekiti State University Teaching Hospital, Ado-Ekiti to screen themselves for HBV and Syphilis infections between January to November, 2014 were recruited for this study having obtained their consent. 4ml of blood sample was collected from each subject into a plain bottle and was allowed to stand for 1hour for clotting and clot retraction to take place. Sera were separated into khan tubes labeled appropriately and were screened for the presence of antibodies to HVB and syphilis using One-Stage Rapid Test Kits (DiaSpot Diagnostics) and were later confirmed using enzyme linked immune sorbent assay (ELISA) (Stat Fax Awareness, England). One Thousand Six Hundred and Thirty-Nine subjects were recruited for this study, out of which Seven Hundred and Seventy-Four were males while Eight Hundred and Sixty-Five were females. 101(6.16%) were positive to HBV, 51(0.92%) positive to syphilis and 5(0.31%) were co-infected with both infections. The results of this study showed higher prevalence of hepatitis B infection than syphilis infection with the highest prevalence found within the age group 31-40 years and 21-30 years indicating that most of the infected people got the infection through sexual intercourse. Keywords: Prevalence, Hepatitis B, Syphilis, Co-infection, Ekiti people INTRODUCTION Syphilis is an infection caused by bacterium, Treponema pallidum, and it remains a serious public health problem in sub-Sahara Africa. It is spread through sexual intercourse, transfusion of blood and/or blood products, vertical transmission [1]. According to some researchers, prevalence of active syphilis infection among African countries has been reported to be 12.8% in Tanzania [2], and 3.8% in Kenya [3]. In 1995, a study was conducted to know the prevalence of HIV, syphilis and HBV infections among blood donors in Ethopia and it was reported that HIV has sero-prevalence of 16.7%, syphilis has 12.8% while HBV has 14.4% [4]. Infection with syphilis can take up to 3 months for symptoms to show and some people may never have noticeable symptoms of this infection, people infected with the infection can transmit it to other persons even if they show no sign or symptoms of the infection [5]. The globally important health problems are viral hepatitis infections [6, 7, 8]. Chronic hepatitis B has 345 Akinbolaji et al., Int J Med Res Health Sci. 2015;4(2):345-349 been reported to be the leading cause of chronic liver disease and a leading cause of death worldwide [6]. Chronic hepatitis B, which can be referred to as persistence of hepatitis B surface antigen (HBsAg) for a period more than 6 months, has differing epidemiology in regions of high versus low endemicity. Usually people successfully manage to get rid of the infection within a few months by developing an immunity that lasts a lifetime. Evidence of this immunity may be shown by blood tests but there will be no signs of active infection, while some don’t get rid of the infection and such people are considered carriers. Sero-prevalence of HBV and syphilis infections are well recognized worldwide but has been reported to be more common in developing countries in Africa and Asia [9]. Aim: This study was embarked upon to actually know how prevalent are hepatitis B virus (HBV), syphilis and their co-infections in this part of the country because there is no documented or published report on such. MATERIAL AND METHODS Nine Patients and individuals (males and females) who visited the Haematology and Blood Transfusion Unit of Ekiti State University Teaching Hospital, Ado-Ekiti, to screen themselves for HBV and Syphilis infections were recruited into this study having obtained the consent of those 18years and above and those below 18years gotten from their parents. The maximum age of the subjects was 70years. Ethical approval was obtained for this study from ethical and research committee. Methodology: 4ml of blood was aseptically collected from each subject into plain bottles. Each blood sample was allowed to stand for one hour at room temperature (25º) for clotting and clot retraction to take place. It was spun and sera separated into plain khan tubes labeled appropriately and the sera were screened for the presence of antibody to HBV and Syphilis using One-Stage Rapid Test kit (DiaSpot Diagnostics, USA) which were later confirmed using enzyme linked immuno sorbent assay (ELISA) (Stat Fax Awareness, England). The manufacturer’s instructions were strictly followed. RESULTS Type of study: This work is a case study research Study Area: This study was conducted at the Haematology and Blood Transfusion Unit of Ekiti State University Teaching Hospital, Ado-Ekiti, between January to November, 2014. Ekiti State University Teaching Hospital is located in Ado-Ekiti in Ado Local Government Area of Ekiti State and Ado-Ekiti is the capital city of Ekiti State, situated in the tropical rain forest belt of Southwest of Nigeria. It is about 450km from Abuja (the capital city of Nigeria). People from different parts of the state visit the Teaching Hospital for Healthcare Services. Subjects: One Thousand Six Hundred and Thirty- Out of the One Thousand Six Hundred and ThirtyNine subjects screened for the presence of antibodies to HBV and T. pallidum (syphilis), One Hundred and One were positive to HBV giving rise to 6.16%, Fifteen positive to syphilis infection amounting to 0.92% while only Five of the subjects were coinfected with both HBV and syphilis infections which is 0.31%. the highest prevalence to HBV, syphilis and co-infections were found in the age group 31-40 years followed by 21-30 years as shown in the (table 1) below Table 1: Sero-prevalence of HBV and syphilis co-infection in different age groups among Ekiti people HBV Syphilis Co-infection(HBV/syph) Age-Groups (years) No. Exam. No. Pos. %Pos. No. Pos. %Pos. No. Pos. % Pos ≤ 10 53 11-20 154 06 3.90 01 0.65 21-30 709 44 6.21 05 0.71 02 0.28 31-40 410 40 9.75 08 1.95 03 0.73 41-50 178 09 5.06 01 0.56 ≥ 51 135 02 1.48 Total 1639 101 6.16 15 0.92 05 0.31 346 Akinbolaji et al., Int J Med Res Health Sci. 2015;4(2):345-349 Key; No. Exam.-------------Number Examined,No. 49(6.33%), 09(1.16%) and 02(0.26%) out of the 774 Pos.----------------Number Positive, % Pos.------------males were positive to HBV, syphilis and -----Percentage Positive. coinfections respectively while 52(6.01%), In the table 2 below, One Thousand Six Hundred and 06(0.69%) and 03(0.35%) out of the 865 females Thirty-Nine subjects were recruited, out of which were positive to HBV, syphilis and co-infection Seven Hundred and Seventy-Four were males while respectively Eight Hundred and Sixty-Five were females. Table 2: Sero-prevalence of HBV and syphilis co-infection among males and females in Ekiti HBV Syphilis Co-infection(HBV/syph) Gender No. Exam. No. Pos. %Pos. No. Pos. %Pos. No. Pos. %Pos. Male Female Total 774 865 1639 49 52 101 6.33 6.01 6.16 DISCUSSION Hepatitis B virus (HBV) is important and has several implications among the blood-borne viruses transmissible through the parenteral route, by blood transfusion, as well as by sexual intercourse. It does not only establish asymptomatic persistent infection but also cause significant morbidity and mortality when transmitted through transfusion of blood and blood products [10]. Prevalence of HBV has been reported to vary between 2% in developed countries where the prevalence is low to about 8% in developing countries where infection is endemic with sex, age and socioeconomic status as important risk factors for infection [11, 12, 13]. In 2006, Centers for Disease Control and Prevention (CDC) reported more than 36,000 cases of syphilis in the United States, and the rate of syphilis among homosexual men has been rising consistently since 2000 [14]. The results of this study showed a higher prevalence of hepatitis B infection (6.16%) than that of syphilis infection (0.92%). The higher prevalence of hepatitis B infection than syphilis infection in this study correlates with reports of [15, 16, 17, 18] who all reported the prevalence of hepatitis B infection to be higher than that of syphilis infection in their various researches, but it is against the reports of [19] who reported higher prevalence for syphilis than hepatitis B infection. The prevalence of hepatitis B infection (6.16%) in this study is a little higher than the reports of [18, 20, 21, 22] who reported prevalence of hepatitis B infection to be 4.7%, 5.9%, 5.3% and 4.9% respectively, and much higher than the reports of [19, 23] who reported 09 06 15 1.16 0.69 0.92 02 03 05 0.26 0.35 0.31 2.9% and 3.0% respectively, but it is lesser than the prevalence reported by [24, 25]. The prevalence of syphilis infection (0.92%) according to this study is considerably low among the people of Ekiti when compared to the prevalence reported by [15, 18, 19, 21] but is also higher than the reports of [16, 17, 26]. The prevalence of people coinfected with both hepatitis B and syphilis infections was 0.31% which is against the reports of [16, 18] who both reported no co-infection between hepatitis B and syphilis infections. And this study also showed that both hepatitis B and syphilis infections are more common in males than females which correlates with the reports of [25], and the highest prevalence is found within the age group 31-40 years followed by 21-30 years which is line with the reports of [27, 28]. CONCLUSION Based on the results of this study, the prevalence of hepatitis B infection is higher than that of syphilis and it can be said that hepatitis B infection is considerably high among the people of Ekiti with the highest prevalence found within the age groups 31-40 years and 21-30 years which indicates that most of the infected people would have got infected through sexual intercourse because the age groups within which the infections are mostly found is referred to as the sexually active age group. ACKNOWLEDGEMENT We want to appreciate the most-high God who made this study a reality and we also extend our profound gratitude to all individuals who contributed their 347 Akinbolaji et al., Int J Med Res Health Sci. 2015;4(2):345-349 quota towards the success of this study. We thank you all. 10. Conflict of Interest: Nil REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. Murray P, Rosenthal K, Kobayashi G, Pfaller M: Medical Microbiology. 4th edition. Mosby company, St.Loius. 2002:379-80. Todd J, Munguti K, Grosskurth H, Mngara J, Changalucha J, Mayaud P, Mosha F, Gavyole A, Mabey D, Hayes R. Risk factors for active syphilis and TPHA sero conversion in rural African population. Sex Transm infect. 2001; 77:37 45. Temmerman M, Fonck K, Bashir F, Inion I, Ndinya-Achola JO, Bwayo J, Kirui P, Claeys P, Fransen L. Declining syphilis prevalence in pregnant women in Nairobi since 1995: another success story in STDs. Int J STD AIDS. 1999; 10:405-08. Rahlenbeck SI, Yohannes G, Molla K, Reifen R, Assefa A. Infection with HIV, syphilis and hepatitis B in Ethiopia: a survey in blood donors. Int J STD AIDS. 1997; 8:261-4. Peel Public Health. Sexual Health Information/Communicable Disease Program. Available at peelsexualhealth.ca Chacko EC, Surrun SK, Mubarack Sani TP, Pappachan JM. Chronic viral hepatitis and chronic kidney disease. Postgrad Med J. 2010; 86:486-92. Nelson PK, Mathers BM, Cowie B, et al. Global epidemiology of hepatitis B and hepatitis C in people who inject drugs: results of systematic reviews. Lancet. 2011; 378:57183. Barth RE, Huijgen Q, Taljaard J, Hoepelman AI. Hepatitis B/C and HIV in sub-Saharan Africa: an association between highly prevalent infectious diseases. A systematic review and meta-analysis. Int J Infect Dis. 2010; 14:102431. Munshi SU, Hoque MM, Mondol M, Jalaluddin M, Tabassum S, Islam MN. HBV, HCV, and syphilis co-infections in human immunodeficiency virus positive Bangladeshi patients. Observations at two reference 11. 12. 13. 14. 15. 16. 17. 18. laboratories. Indian J Med Microbiol.2008; 26:282–3. De LG, Paola WM. Carpenter. Blood-borne pathogens: current concepts. Compend Contin Educ Den. 2002; 23:207–10. Alikor EA and Erhabor ON. Seroprevalence of hepatitis B surface antigenaemia in children in a tertiary health institution in the Niger delta of Nigeria. Niger J Med. 2007; 16: 250-51. Ezegbudo CN, Agbonlahor DE, Nwobu GO, Igwe CU, Agba MI, Okpala HO, Ikaraoha CI. The seroprevalence of hepatitis B surface antigen and Human Immunodeficiency Virus among pregnant women in Anambra state, Nigeria. Shiraz E-medical Journal. 2004; 5: 125. Odusanya OO, Alufohai FE, Meurice FP, Wellens R, Weil J, Ahonkhai VI. Prevalence of hepatitis B surface antigen in vaccinated children and controls in rural Nigeria. International J Infect Dis. 2005; 9: 139-43. Shannon Johnson. Syphilis; Overview, Stages, Diagnosis, Treatment and Prevention. 2012 Akinleye OM, Olaniyan JAT, Akintola JO, Okoye CA and Eke CF. Blood Safety and Prevalence of transfusion Transmissible Viral Infections among Blood Donors in Lagos, Nigeria. Int.J.Trop.Med. 2013; 8(5-6). 113-18. Ajayi BB, Ajayi OD, Hamidu I, Dawurung JS, Ballah AD, Isah J and Chama CM. Seroprevalence of some sexually transmitted infections among antenatal attendees in university of Maiduguri teaching hospital, Maiduguri-Nigeria. Annals of Biological Research. 2013; 4 (2):141-45. Krunal D. Mehta, Sejul Antala, Madhulika Mistry, Yogesh Goswami. Seropositivity of hepatitis B, hepatitis C, syphilis, and HIV in antenatal women in India. J Infect Dev Ctries. 2013; 7(11):832-37. Belay Tessema, Gizachew Yismaw, Afework Kassu, Anteneh Amsalu, Andargachew Mulu, Frank Emmrich and Ulrich Sack. Seroprevalence of HIV, HBV, HCV and syphilis infections among blood donors at Gondar University Teaching Hospital, Northwest Ethiopia: declining trends over a period of five years. BMC Infectious Diseases. 2010; 10:111 348 Akinbolaji et al., Int J Med Res Health Sci. 2015;4(2):345-349 19. 20. 21. 22. 23. 24. 25. 26. 27. Hussain T, Kulshreshtha KK, Shikha Sinha, Yadav VS, Katoch VM. HIV, HBV, HCV, and syphilis co-infections among patients attending the STD clinics of district hospitals in Northern India. International Journal of Infectious Diseases. 2006; 10(5): 358–63. Afolabi AY, Abraham A, Oladipo EK, Adefolarin AO and Fagbami AH. Transfusion Transmissible Viral Infections among potential Blood donors in Ibadan, Nigeria. Afr. J. Cln. Exper. Microbiol. 2013; 14(2): 84-87. Buseri FI, Seiyaboh E, and Jeremiah ZA. Surveying Infections among Pregnant Women in the Niger Delta, Nigeria. J Glob Infect Dis. 2010; 2(3): 203–11 Landes M, Newell ML, Barlow P, Fiore S, Malyuta R, Martinelli P, Posokhova S, Savasi V, Semenenko I, Stelmah A, Tibaldi C,Thorne C. Hepatitis B or hepatitis C coinfection in HIV-infected pregnant women in Europe. HIV Med. 2008; 9(7):526-34. Adeleke MA, Adebimpe WO, SAM-Wobo SO, Wahab AA, Akinyosoye LS, Adelowo TO. Sero-prevalence of malaria, hepatitis B and syphilis among pregnant women in osogbo, Southwestern Nigeria. J. Infect. Dis. Immun. 2013; 5(2):13-17 Esan AJ, Omisakin CT, Ojo-Bola T, Owoseni MF, Fasakin KA, Ogunleye AA. SeroPrevalence of Hepatitis B and Hepatitis C Virue Co-Infection among Pregnant Women in Nigeria. American Journal of Biomedical Research.2014; 2(1): 11-15. David OM, Oluduro AO, Ariyo AB, Ayeni D and Famurewa O. Sero-epidemiological survey of hepatitis B surface antigenaemia in children and adolescents in Ekiti State, Nigeria. J. Public Health Epidemiol. 2013; 5(1), 11-14. Omisakin CT, Esan AJ, Fasakin KA, Owoseni MF, Ojo-Bola O, Aina OO and Omoniyi DP. Syphilis and Human Immunodeficiency Virus Co-infection among Pregnant Women in Nigeria: Prevalence and Trend. International STD Research & Reviews. 2014; 2(2): 94-100. Volf V, Marx D, Pliscova L, Sumega L, Celko A. A survey of Hepatitis B and C prevalence among the homeless community of Parague. Eur. J. Pub. Health 2008; 18: 44-47. 28. Liu Z, Hou J. Hepatitis B virus (HBV) and Hepatitis C virus (HCV) dual infection. Int. J. Med. Sci. 2006; 3: 57–62 349 Akinbolaji et al., Int J Med Res Health Sci. 2015;4(2):345-349 DOI: 10.5958/2319-5886.2015.00065.X International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 9 Jan 2015 Research article Coden: IJMRHS Revised: 6th Feb 2015 Copyright @2015 ISSN: 2319-5886 Accepted: 12th Feb 2015 CLINICO PATHOLOGICAL CORRELATION OF LEPROSY: A 4 YEARS RETROSPECTIVE STUDY FROM A TERTIARY REFERRAL CENTRE IN NORTH INDIA *Shirazi Nadia1, Jindal Rashmi2, Ahmad Sohaib3, Rawat SDS2, Selvi Thamarai N1, Harsh Meena1 1 Department of Pathology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, India Dermatology, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, India 3 Internal Medicine, Himalayan Institute of Medical Sciences, Jolly Grant, Dehradun, India 2 *Corresponding author email:
[email protected] ABSTRACT Introduction: Leprosy is a chronic infectious disease caused by Mycobacterium leprae that primarily affects the skin and nerves. The histopathological findings in leprosy are related to the immunological status of the patient. Aim: To tabulate the incidence of different clinical and pathological patterns of leprosy and establish their correlation. Materials and Methods: A total of 118 consecutive skin biopsies of leprosy patients were studied in the Department of Pathology over 4 year duration (2010 – 2014). A Ridley-Jopling criterion was used for the diagnosis and classification of the disease. All biopsies were stained with H&E and Fite Faraco. Clinicohistopathological correlation was calculated using percentage values. Results: A total of 118 cases of leprosy were studied out of which 76 were males. The age of the patients ranged from 8 years to 76 years. Majority were in the 31-40 year age group ( n= 52.44%). Both clinically (n=55, 46.6%) and histologically (n=41, 34.7%), the maximum patients were in the BT category. Histopathologically LL (21.2%) and BB (16.1%) were the other common groups. The overall concordance between clinical and histopathological classification was 61.8%. Maximum concordance was seen in LL (79.2%) & TT (72.7%). The concordance was lower in borderline groups and least in BL (18.7%). Fite Faraco stain demonstrated acid fast bacilli in 28 cases (23.7%). Conclusion: The clinicohistopathological correlation is best at the polar ends of spectrum as compared to borderline cases. Histopathology remains the most powerful indicator of shift in patient’s immune status. Keywords: Leprosy, Clinico histopathological correlation INTRODUCTION Leprosy is an infectious disease which was considered a curse to mankind since times immemorial. The earliest possible account for leprosy has been found in ancient Egyptian Papyrus documents as early as 600 B.C. It was Hansen’s discovery of causative organism: Mycobacterium leprae in1873 which proved that leprosy was a bacterial disease and not a curse or sin. It occurs more commonly among those living in poverty or overcrowded areas and is transmitted by respiratory Nadia et al., droplets. Entry into susceptible host is by respiratory route or broken skin. The disease has a slow incubation period ranging from few weeks to as long as 30 years (average being 3-5 years). India alone reports over 50% of world’s leprosy cases.[1] Skin lesions (macules, papules, nodules), sensory loss and thickened nerves are the reliable signs of leprosy. Positive skin smear for Acid Fast lepra bacilli are considered diagnostic. The WHO system subclassifies leprosy as ‘paucibacillary’ or 350 Int J Med Res Health Sci. 2015;4(2):350-354 ‘multibacillary’ based on the number of bacteria present. These two types are clinically distinguished by the number of hypopigmented, numb skin patches with paucibacillary having five or less such lesions while multibacillary having more than five.[ 2]. The ICD-10 however uses Ridley-Jopling classification and also adds an indeterminate or ‘I’ category . Access to information, diagnosis and treatment with Multidrug therapy (MDT) remain the cardinal points in eliminating the disease. Since 1995 WHO provides free (MDT) to all patients.[3]. Prior to starting MDT for particular type of leprosy, the clinical findings should be correlated and confirmed with histopathological examination and bacteriological index of skin biopsy Aims: To tabulate the incidence of different clinical and histopathological forms of leprosy and to establish their correlation. MATERIALS AND METHODS Type of study: Retrospective study Study place & Duration: Carried out in the Department of Pathology during a 4 year period (2010-2014). Inclusion Criteria: Cases where histopathological diagnosis of leprosy was made or considered in the differential diagnosis irrespective of age and sex of the patient or nature of the lesion were selected for the study. Exclusion criteria: Those cases where leprosy was suspected clinically but not confirmed on biopsy were not included. Lepra reactions were excluded. Ethical Clearance: The present study was approved by the Institutional Ethics Committee. Methodology: The requisition form accompanying the biopsy specimen as well as the copy of issued histopathology report that were preserved in the Department of Pathology were routinely used to obtain data pertaining to age, sex, clinical information and histopathology findings. The Ridley Jopling criteria was used to diagnose and classify leprosy clinically and histopathologically into the following subgroups: [4] Tuberculoid (TT): shows epithelioid granulomas with Langhans giant cells surrounded by dense lymphocytic infiltrate. Nerve infiltration is usually seen. AFB is negative. Nadia et al., Borderline Tuberculoid (BT): Epithelioid granulomas with peripheral lymphocytes and Langhans giant cells. Clear subepidermal zone, nerve infiltration present. AFB may or may not be seen. Borderline(BB): Epithelioid granulomas with diffusely spread lymphocytes, presence of subepidermal clear zone. AFB usually seen. Borderline Leprosy (BL): Loose granulomas composed of histiocytic cells with dense lymphocytic infiltrate. AFB usually seen but large globi are not present. Lepromatous Leprosy (LL): Histiocytes and foam cells are abundant. Lymphocytes are scanty, if present they are diffusely spread. Nerves are without cellular infiltrate or cuffing. Grenz zone is present. AFB are numerous. Indeterminate (I): Lymphocytes and histiocytes are localized around skin structures. AFB are very scanty. Histoid Leprosy (HLL): Nodular form of leprosy. Microscopy shows circumscribed histoid lepromas characterized by predominance of histiocytes. AFB is numerous. All the biopsies were fixed in 10% formalin. Serial sections of 5µ thickness were cut and stained with Haematoxylin and Eosin (H&E) along with Fite Faraco to demonstrate Acid Fast Bacilli. Histopathology findings described in detail epidermal atrophy, subepidermal clear zone, distribution and nature of epithelioid granulomas, density of lymphocytes and nerve involvement along with presence of acid fast bacilli. RESULTS A total of 118 cases of leprosy were studied over a duration of 4 years (July 2010- July2014). There were 76 males and 42 females. The age of the patients ranged from 8 years to 72 years. Majority of cases (n=52, 44%) were in the 31-40 year age group followed by 23.7 % in the 21-30 year age bracket. The most common presenting complain was hypopigmented patch with loss of sensations (n=67, 56.7%) followed by erythematous macules (n=27,22.8%), nodules (n=14,11.8%) and thickened nerves (n=11,9.3%). (Figures 1,2). All the skin biopsies were taken from the edge of the lesion. Nerve biopsy was not performed in any case. 351 Int J Med Res Health Sci. 2015;4(2):350-354 Fig.1 : Lepromatous leprosy Concordance was 80% for histoid leprosy. (Table 2) (Fig 5). Epidermal changes varied from atrophic (64.8%) to unremarkable to acanthotic. Lymphocytes were most numerous in BB and most scanty in LL. Fite Faraco stain demonstrated Acid Fast Bacilli (AFB) in 28 cases (23.7%). The AFB were mostly seen in LL and HLL forms and only 2 cases in BT type while none in TT type showed AFB positivity. (Fig 6). Table 2: Correlation of clinical and histopathological diagnosis in leprosy cases (n=118) Clinical Clinically TT Type diagnosed TT BT BB BL LL IL Histoid Fig 2: Histoid leprosy Both clinically (n=55, 46.6%) and histologically (n=41,34.7%), the maximum patients were in the BT category. Histopathologically LL (21.2%) and BB (16.1%) were the other common groups. (Table 1) (Fig 3,4). Table 1: Clinical and histopathological spectrum of leprosy using Ridley-Jopling classification (n=118) Clinical No. % HPE No. % Type type TT 11 9.3 TT 17 14.4 BT 55 46.6 BT 41 34.7 BB 06 5.1 BB 19 16.1 BL 16 13.5 BL 07 5.9 LL 24 20.3 LL 25 21.2 IL 01 0.8 IL 05 4.2 Histoid 05 4.2 Histoid 04 3.4 Total 118 100 Total 118 100 The overall concordance between clinical and histopathological classification was 61.8%. Maximum concordance was seen in LL (79.2%) & TT (72.7%). The concordance was lower in borderline groups and least in BL (18.7%). Nadia et al., 11 55 06 16 24 01 05 8 3 6 - BT BB BL 2 36 2 1 - 9 3 3 3 1 - 2 1 3 1 - LL 1 4 19 01 IL Histoid Concord ance (%) 1 4 - 4 72.7 65.4 50.0 18.7 79.2 0 80.0 Fig 3: Numerous epithelioid granulomas in BT Hansens (10x10X:H&E:) Fig 4: Foamy macrophages in LL Hansens(20x10X H&E) 352 Int J Med Res Health Sci. 2015;4(2):350-354 is supposed to be better at stable poles LL and TT probably because of clinical and histological stability of the disease. Maximum discordance was seen in midborderline cases as was also noted by Singhi et al, Sharma et al, Manandhar et al, Mitra et al, Moorthy et al [11,12,13,14,15] (Table 3). Table 3: Comparative study of Clinicopathological correlation of Hansens disease by different authors Study Fig 5: Histoid Hansens disease(20x10X H&E) Fig 6: Fite Faraco: Acid Fast Bacilli seen in LL Hansens(100x10X) DISCUSSION Leprosy is a chronic infectious disease caused by Mycobacterium leprae and is present in a wide variety of clinical and histopathological forms depending on the immune status of the host. The clinicopathologic correlation studies have provided further insights into the disease, it’s manifestations and complications[5]. Ridley-Jopling classification is based upon clinical, histopathological and immunological features and is widely accepted by pathologists and dermatologists. The clinicopathological discordance is noted because clinical diagnosis is based on Ridley-Jopling classification even when biopsy has not been done[5]. Since biopsy findings may be influenced by biopsy site, age of the lesion, morphology of the lesion, immunological and treatment status of the patient; these may also contribute to discordance between clinical and pathological findings. The best correlation in our study was found with histoid (80%), LL (79.2%) and TT (72.7%). This is similar to study by Bhatia et al, Kalla et al, Kar et al, Jerath et al [6,7,8,9]. Nandkarni et al found 98% correlation in LL form[10]. Correlation Nadia et al., No. of cases studied % correlation Present study (2014) 118 61.8 ManandharU et al (2013)[13] 75 45.33 Vargas- Ocampo et al 6000 42.9 (2004)[16] Mitra K et al(2001)[14] 92 57.16 Moorthy BN et al(2001) [15] 372 62.6 [7] Kalla G et al (2000) 736 64.7 [10] Nandkarni NSet al(1999) 2640 81.8 Kar PK et al (1994)[8] 120 70 [6] Bhatia AS et al (1993) 1272 69 Jerath VP et al (1982)[9] 130 68.5 [18] Sehgal VN et al (1977) 95 33 In the present study 5 cases (4.2 %) were diagnosed as Indeterminate leprosy as compared to only 1 case clinically. Indeterminate lesions cannot be classified within Ridley-Jopling spectrum due to lack of distinguishing features like not finding granulomas and this happens more often histologically. All 5 cases in our study diagnosed as IL were clinically TT or BT types. A large study of 6000 cases in Mexico by Vargas-Ocampo encountered LL as the most common form of leprosy[16]. They also found cases of diffuse lepromatosis (Lucio phenomenon) which was not seen in any study done in India. The predominance of LL cases as well as diffuse lepromatosis indicate that a high percentage of population in Mexico has a very low degree of resistance to lepra bacilli as compared to those in Indian subcontinent. In a study by Bal et al , out of 303 leprosy cases , 206 were BT and only 27 were TT. Out of 206 BT cases only 6 were positive for lepra bacilli while none of TT were positive[17]. This was similar to our study where none of TT cases showed AFB positivity. Most previous authors have recorded a higher frequency rate in children (<14 years) and that LL is infrequently seen in this age group[18,19].In our study only 4.2% cases were seen in children and all the cases were of TT+BT subtype. 353 Int J Med Res Health Sci. 2015;4(2):350-354 Though definite diagnosis can be made on histopathological examination, size of specimen, site of biopsy, nature and depth of biopsy, quality of sections, immune status, treatment history and interobserver variation (both clinically and histologically) should be kept in mind which may lead to clinicopathological discordance[20] CONCLUSION Histopathology is the confirmatory test for early diagnosis and proper labelling of all cases of leprosy. It also gives indication of progression or regression of disease under treatment. Clinicopathological correlation of the disease is maximum in polar groups because they are stable and showed a uniform pathology. Maximum disparity is seen in borderline cases because they may have different histopathology in different sites and in different lesions. Conflict of interest: Nil REFERENCES 1. World Health Organization. Epidemiology of leprosy in relation to control. Report of a WHO study group. World Health Organ Tech Rep Ser (Geneva: World Health Organization). 1985; 716:160. ISBN 92-7-120716-7.OCLC 12095109 2. Suzuki K, Akama T, KawashimaA, Yoshihara A, Yotsu RR, Ishii n. Current status of leprosy: epidemiology, basic science and clinical perspectives. The Journal of Dermatology. 2012;39(2): 121-9. 3. WHO Action Programme for the elimination of Leprosy. A guide to eliminating leprosy as a public health problem. Geneva, World Health Organization, 1995 (Unpublished document WHO/LEP/95.1; available on request from Action Programme for the Elimination of Leprosy, World Health Organization,1211 Geneva 27, Switzerland) 4. What is leprosy?” The Medical News and Research from Around the World. http://www.newsmedical.net/health/what-is-leprosy 5. Ridley DS, Jopling WH. Classification of leprosy according to immunity. A five group system. Int J Lepr Other Mycobact Dis 1966; 34: 255-73 6. Bhatia AS, Katoch K, Narayanan RB. Clinical and histopathological correlation in the classification of leprosy. Int J Lepr 1993;61: 433-38 Nadia et al., 7. Kalla G, Salodkar A, Kachhawa D. Clinical and histopathological correlation in leprosy. Int J Lepr 2000; 68: 184-85 8. Kar PK, Arora PN. Clinicopathological study of macular lesions in leprosy. Indian J Lepr 1994; 66: 435-41 9. Jerath VP, Desai SR. Diversities in clinical and histopathological classification of leprosy. Lepr India 1982; 54: 130-34 10. Nandkarni NS, Rege VL. Significance of histopathological classification in leprosy. Ind J Lepr 1999; 71(3): 325-32 11. Singhi MK, Kachhawa D, Ghiya BC. A retrospective study of clinic-histological correlation in leprosy. Ind J Pathol Microbiol 2003; 46: 47-8 12. Sharma A, Sharma RK, Goswami KC, Bardwaj S. Clinico-histopathological correlation in leprosy. JK Science 2008; 10(3): 120-23 13. Manandhar U, Adhikari RC, Sayami G. Clinicohistopathological correlation of skin biopsies in leprosy. Journal of Pathology of Nepal 2013; 3: 452-58 14. Mitra K, Biswas S, Saha B, Dasgupta A. Correlation between clinical and Histopathological criteria for the classification of Leprosy. Ind J Dermatol 46(3): 135-7 15. Moorthy B, Kumar P, Chatura KR, Chandrashekhar HR, Basavaraja PK. Histopathological correlation of skin biopsies in leprosy. Ind J Dermatol Venereol Leprol 2001; 67 (6): 299-31 16. Vargas-Ocampo. Analysis of 6000 skin biopsies of the National Leprosy Control Programme In Mexico. Int J Lepr. Other Mycobact Dis 1966; (34): 255-73 17. Bal A, Mohan H, Dhani GP. Infectious granulomatous dermatitis: A clinico-pathological study. Ind J Dermatol 2006; 51: 217-20 18. Sehgal VN, Srivastava G. Leprosy in children. Int J Dermatol 1987; (26): 557-66 19. Kumar B, Kaur I. Childhood leprosy in Chandigarh: Clinico-histopathological correlation. Int J Lepr. Other Mycobact Dis 2000; (68): 330-31 20. Chacko CJG. Role of histopathology in the early diagnosis of leprosy. Ind J Lepr 1993; 65: 23-27 354 Int J Med Res Health Sci. 2015;4(2):350-354 DOI: 10.5958/2319-5886.2015.00066.1 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 10 Jan 2014 Research article Coden: IJMRHS Revised: 5thFeb 2015 Copyright @2015 ISSN: 2319-5886 Accepted: 12th Feb 2015 ASSOCIATION BETWEEN REFRACTIVE ERRORS AND SENILE CATARACT IN RURAL AREA OF WESTERN MAHARASHTRA *Chaudhari SagarV1, Shelke SanjayT2, BangalSurekha V3, Bhandari Akshay J4, Kulkarni AmeyaA1 1 Post graduate student, 2Associate Professor, 3Professor, 4Assistant Professor, Department of Ophthalmology, Rural Medical College, Loni, Ahmednagar, Maharashtra, India *Corresponding author email:
[email protected] ABSTRACT Purpose: To study the association between refractive errors and senile cataract in rural area of western MaharashtraMaterials & Methods: It is a prospective cross sectional study carried out on 420 eyes of 210 patients with senile cataract was included in the study. The age and sex of the patient, grade and the refractive status of the cataract of the eyes were recorded. The grade of the cataract was recorded by the LOCS III (Lens Opacities Classification System, version III). Refractive status was measured subjectively using retinoscope and refractive error for each eye was converted into spherical equivalent units. Results: The age variation in the study was between 60-85 years.The maximum number of patients was in the age group of 60-65 years.The spherical equivalent ranged between -3.0 D to +4.25D.45.95% of the study population had a spherical equivalent between 2 to -1.73.81 % of the study population had a myopic refraction.20% had a hypermetropic refraction. Percentage of patients with a score of nuclear opalescence and colour between 1.0-2.0 was 41.90%, between 2.1-3.0 was 26.67% and above 3.0 was 31.43%.Percentage of patients with a score of cortical cataract between 0.1-1.0 was 69.76% and with a grade between 2.1-3.0 was 26.91 %. Percentage of patients with a score of posterior subcapsular cataract between 0.1-1.0 was 53.57% and with a grade between 2.1-3.0 was 39.05%. Conclusion: The myopic refraction was associated with nuclear, cortical and posterior subcapsular cataract and this refractive error was stastically significant with nuclear, cortical and posterior subcapsular cataract. Keywords: Cataract, Refraction. INTRODUCTION Cataract is defined as opacity within the clear lens inside the eye that reduces the amount of incoming light and results in deterioration of vision. Natural lens is a crystalline substance and a precise structure of water and protein to create a clear passage for light. Cataract is one amongst the major cause blindness in India’ accounting for nearly 50-80% of blindness in both eyes in the country[1]. There are several known risk factors for cataract formation. These include individual factors like age, smoking, systemic factors like diabetes mellitus, environmental factors like Chaudhari et al., ultraviolet light exposure, trauma, dehydration and drugs like steroids[2]. An additional hurdle arises from the fact that different types of cataracts may have different etiologies and risk factors which are difficult to measure.Cataract is often described as being similar to looking through a waterfall or waxed paper.[3]. Refractive errors are frequently associated with age related cataract. Myopia has been associated with cataract[4]. It is a well known fact that nuclear cataract can cause myopic shift in some cases which accounts for the second sight in the elderly that provides 355 Int J Med Res Health Sci. 2015;4(2):355-359 normal reading ability without glasses but distant vision worsens. The effect of posterior subcapsular cataract and cortical cataract on refractive error is less clear. The present study evaluates the association between refractive status and senile cataract. MATERIAL AND METHODS Study was conducted at Department of Ophthalmology, in a tertiary care teaching hospital located in rural area of western Maharashtra. The study was carried out over a period of two years, from September 2012 to August 2014. Total 210 patients with 420 eyes fulfilling the inclusion and exclusion criteria were enrolled in the study. Fig 1: LOCS III Classification Inclusion criteria: Patients above the age of 60 years with diminished vision. Patients of either sex. Patients ready to give informed consent. Exclusion criteria:History of intraocular surgery, ocular trauma, Corneal scar or opacity, Known case of dry eye syndrome, Lens induced glaucoma.Patients with the following risk factors for cataract: uveitis, glaucoma and steroid medications. Patients with the following conditions which are likely to affect the refractive status of the eye: keratoconus, trauma, orbital mass, pterygium and eyelid mass such as chalazion. Cases where refraction cannot be carried out due to extreme media opacity will also be excluded. Patients with the chronic systemic illness. Fig 2: Nuclear Cataract Each patient documenting as per proforma: 1. Sociodemographic information. 2. Clinical findings like Vision, anterior segment examination, fundus examination. Age, sex, grade of the cataract, the refractive status of the eye was recorded. The grade of the cataract was then be recorded by the LOCS III (Lens Opacities Classification System, version III)[5] (Fig-1)and categorized as nuclear(Fig-2) and cortical(Fig-3) and posterior subcapsular type(fig-4). After recording visual acuity, pupil will be dilated and funduscopy done by direct ophthalmoscope or 78D or 90D. The refractive status of the patient was evaluated by performing retinoscopy on dilated pupils. Pupillary dilatation was achieved by putting Phenylephrine or Tropicamide eye drops. Refractive status was measured objectively by trial and error method[6]. Fig3: Cortical Cataract Fig4: Posterior subcapsular Cataract 356 Chaudhari et al., Int J Med Res Health Sci. 2015;4(2):355-359 RESULTS Table 1: Age and sex wise distribution of cases studied Out of the 420 eyes of 210 patients studied 225 patients (53.57%) had Posterior subcapsular cataract between 0.1-1.0, 31 patients (7.38%)between 1.1-2.0 and 164 patients (39.05%) had PSC above 2.1.(Fig no-5) Males Females Total 60-65 No. (%) 59(63.44%) No. (%) 83(70.94%) No. (%) 142(67.62%) 66-70 19(20.43%) 26(22.22%) 45(21.43%) 250 71-75 13(13.98%) 2(1.71%) 15(7.14%) 200 76-80 0 6(5.13%) 6(2.86%) 81-85 2(2.15%) 0 2(0.95%) Total 93(44.29%) 117(55.71%) 210(100%) In the present study the age variation was from 60 to 85 years. Highest number of 142 patients were found in the age group of 60-65 years. (Table no.1) There were 93 male and 117 female patients in the study group comprising of 44.29% and 55.71 % of the study population respectively. Table 2: Nuclear Colour & Opalescence of cases studied Nuclear Colour Total no eyes Percentage &Opalescence No. (%) 1—2 176 41.90% 2.1—3.0 112 26.67% > 3.0 132 31.43% Total 420 100% Mean ± SD 1.74 ± 0.47 Out of the 420 eyes of 210 patients studied 176 patients (41.90%) had nuclear colour (NC)& (NO)between 1.0-2.0, 112 patients (26.67%) had NC& (NO) between 2.1-3.0 and 132 patients (31.43%) had (NC) & (NO) above 3.0. (Table -2) Out of the 420 eyes of 210 patients studied 293 patients (69.76%) had cortical cataract between 0.11.0, 14 patients (3.33%) had cataract between 1.1-2.0 and 113 patients (29.91%) had cortical cataract above 2.1. (Table 3) Table 3: Cortical Cataract of cases studied 225 164 150 No of eyes Age in years 100 31 50 0 0.1-1.0 1.1-2.0 2.1-3.0 Posterior subcapsular cataract Fig 5: Posterior subcapsular cataract of cases studied The pre-op refraction was expressed in terms of spherical equivalent. Spherical equivalent was calculated using the formula sphere (D) + ½ cylinder (D). The spherical equivalent ranged between – 3.0 to + 4.25 D. About 45.95 % of the study population had a spherical equivalent of -2 to -1 followed by 21.90% with a spherical equivalent of -1 to -0.5D.(Table 4) Table 4: Spherical equivalent of cases studied Total eyes Percentage Spherical equivalent No. (%) -3 to -2 25 5.95% -2 to -1 193 45.95% -1 to -0.5 92 21.90% -0.5 to 0.5 26 6.20% 0.5 to 1 48 11.43% 1 to 2 19 4.52% 2 to 3 9 2.15% 3 to 4 4 0.95% >4 4 0.95% Total 420 100% Mean ± SD -1.04±0.027 Definition: Total eyes Percentage No. (%) Emmetropia: -0.5 TO +0.5 D 0.1-1.0 293 69.76% Myopia : LESS THAN -0.5D 1.1-2.0 14 3.33% Hypermetropia: MORE THAN +0.5D 2.1-3.0 113 26.91% Total 420 100 Mean ± SD 0.94±0.03 Cortical cataract 73.81 % of the study population had a myopic refraction while only 20% had a hypermetropic refraction 357 Chaudhari et al., Int J Med Res Health Sci. 2015;4(2):355-359 26 84 Less than -0.5 310 -0.5 to 0.5 More than 0.5 Fig 6:Spherical equivalent as per definition of cases studied Association of Grading LOCS and Spherical Equivalence of patients studied Statistically significant association was found for nuclear, cortical and posterior subcapsular cataract. Table 5:Association of Grading LOCS and Spherical Equivalence of patients studied LOCS No. of patients Nuclear opalescence 1.0 – 2.0 176 2.1 – 3.0 112 > 3.0 132 Nuclear colour 1.0 – 2.0 176 2.1 – 3.0 112 > 3.0 132 Cortical cataract 0.1 – 1.0 293 1.1 – 2.0 2.1 - 3.0 14 113 Mean ± SD, Spherical equivalence P value -1.23±0.05 -1.03±0.08 -1.42±0.09 χ² = 16.13, p<0.05 -1.23±0.05 -1.03±0.08 -1.42±0.09 χ² = 16.13, p<0.05 -1.34±0.06 -1.56±0.09 -1.07±0.07 Posterior subcapsular cataract 0.1 – 1.0 225 -1.26±0.01 1.1 – 2.0 31 -1.31±0.05 2.1 - 3.0 164 -1.56±0.07 χ² = 24.128, p<0.05 χ² = 26.415, p<0.05 DISCUSSION ASSOCIATION BETWEEN CATARACT AND SPHERICAL EQUIVALENT: For nuclear cataract:In my study, 193 eyes had spherical equivalent between -2 to -1 and 92 eyes had spherical equivalent of -1 to -0.5. The mean spherical equivalent of -1.23±0.05D was found in the group with a score between 1.0-2.0 while the group with a score of more than 3.0 had-1.42±0.09D and mean spherical equivalent of -1.03±0.08was found in the group between 2.1 to 3. Myopic refraction being associated with nuclear cataract. This correlation was statistically significant. In the study by Kubo et al[7] mean spherical equivalent of −0.33 ± 4.06 D was found in the group with a score between 1.0-2.0 while the group with a score 4.0-5.0 had a spherical equivalent of −3.96 ± 5.8D.In the Tanjong Pagar survey[8] nuclear cataract was associated with a myopic refraction. Nuclear cataract was associated with myopia (-1.25 D vs -0.11 D, p<0.001) In the Beaver Dam Eye study[9], myopia was related to prevalent nuclear but not cortical and posterior subcapsular cataracts.In Singapore Malay study[10], myopia (spherical equivalent less than 0.5D) was associated with increased prevalence of nuclear cataract. In blue mountain eye study [11], myopia subject who had worn distance glasses were more likely to have nuclear cataract. High myopia was associated with late nuclear cataract.In Tehran eye study[12], myopia was significantly higher with nuclear cataract. High myopia seen in higher grade of nuclear cataract. For cortical cataract: In my study, 193 eyes had spherical equivalent -2 to -1 and 92eyes had spherical equivalent -1 to -0.5. The mean spherical equivalent of -1.07±0.07D was found in the group with a score 2.1-3.0 and the group with a score of 1.1-2.0 has a spherical equivalent of-1.56±0.09D and mean spherical equivalent of -1.34±0.06 was found in the group with score 0.1 to 1.0. Myopic association was found in cortical cataract and this correlation was statistically significant. In the study by Kubo et al[7], spherical equivalent of −1.96 ± 5.07 D was found in the group with a score of 1.0-2.0. The group with score 3.0-5.0 had a spherical equivalent of −0.97 ± 4.44 D. Thus myopic refraction was associated with cortical cataract in this study. In the Tanjong Pagarsurvey[8] no refractive association was seen in cortical cataract. In the Beaver Dam Eye study9, cortical cataracts were possibly related to hyperopia.In blue mountain eye study[11], high myopia was associated with cortical cataract.In Singapore Malay study[10],myopia (spherical equivalent less than 0.5D) was not associated with cortical cataract.In Tehran eye study[12], high percentage of hyperopia was significant in patient with cortical cataract.For posterior subcapsular cataract: In my study, 358 Chaudhari et al., Int J Med Res Health Sci. 2015;4(2):355-359 193 eyes had spherical equivalent between -2 to 1and 92 eyes had spherical equivalent to -1 to 0.5. The mean spherical equivalent of -1.56±0.07 was found in the group with a score of 2.1-3.0 and the mean spherical equivalent of 1.26±0.01D was found in the group with a score of 0.1-1.0 and mean spherical equivalent of 1.31±0.05D was found in the group with the score of 1.1 to 2. Myopic refraction was associated with posterior subcapsular cataract in this study. However there was statically significant correlation found. In the study by Kubo et al[7], mean spherical equivalent of −1.85 ± 5.09D was found in the group with score 3-5 and the mean spherical equivalent of −0.97 ± 4.39 D was found in the group with a score 1.0-2.0.In the Tanjong Pagar survey [8],posterior subcapsular cataract correlated with myopic refraction. Posterior subcapsular cataract was associated with myopia,deeper anterior chamber, thinner lens, and longer vitreous chamber.In the Beaver Dam Eye study[9],no refractive association was found with posterior subcapsular cataract. In Singapore Malay study[10]. Myopia (spherical equivalent less than 0.5D) was associated with increased prevalence of posterior subcapsular cataract.In blue mountain eye study, was supported by the finding of an association between current myopic refraction and PSC cataract (OR 2.5 ; CI 1.64.1). PSC was inversely associated with hyperopia. High myopia was associated with PSC.In Tehran eye study12, PSC shows a significantly higher prevalence of myopia. Limitations of the study:. 1. Prior refractive status of the patient could not be studied as many patients were presenting for the first time with the cataract. 2. Patients with early cataract could not be followed up to study the refractive changes as the cataract develops. CONCLUSION The myopic refraction was associated with nuclear, cortical and posterior subcapsular cataract and this refractive error (spherical equivalent) was statically significant with nuclear, cortical and posterior subcapsular cataract. Acknowledgement: We thank Professor and HOD Dr. Mrs.Neeta Misra Department of ophthalmology, RMC, Loni for permission to carry out the study. Conflict of Interest: Nil REFERENCES 1. Murthy G, Gupta SK, John N, Vashist P. Current status of cataract blindness and Vision 2020: the right to sight initiative in India. Indian J Ophthalmol.-Dec 2008; 56(6):489-94. 2. Taylor HR. Epidemiology of age-related cataract. Eye (Lond). 1999; 13(3): 445-8. 3. Robert S, Randall LK, editors. Cataracts Overview (Internet). Life Extension, Available from:http://www.garynullforum.com/articles/pdf/fo undarticles1/lef/CATARACTS 4. Wu Z, Lim JI, Sadda SR. Axial length: a risk factor for cataractogenesis. Ann Acad Med Singapore. 2006;35(6):416-9. 5. Chylack LT Jr, Wolfe JK, Singer DM, Leske MC, Bullimore MA, Bailey IL et al. The Lens Opacities Classification System III. The Longitudinal Study of Cataract Study Group. Arch Ophthalmol. 1993;111(6):831-6 6. Abrams D. Duke-Elder’s Practice of Refraction. Tenth edition. Edinburgh: Churchill Livingstone; 1993 7. Kubo E, Kumamoto Y, Tsuzuki S, Akagi Y. Axial Length, Myopia, and the Severity of Lens Opacity at the Time of Cataract Surgery. Arch Ophthalmol. 2006;124: 1586-90 8. Wong TY, Foster PJ, Johnson GJ, Seah SK. Refractive errors, axial ocular dimensions, and age‑related cataracts: The TanjongPagar Survey. Invest Ophthalmol Vis Sci 2003;44:1479‑85. 9. Lee KE, Klein BE, Klein R, Wong TY. Changes in refraction over 10 years in an adult population: the Beaver Dam Eye study. Invest Ophthalmol Vis Sci. 2002:2566-71. 10. Pan CW, Boey PY, Cheng CY. Myopia, axial length, and age related cataract: the Singapore Malay Eye Study. Invest Ophthalmol Vis Sci. 2013;54:4498–02. 11. Pan CW, Boey PY, Cheng CY, et al. Myopia, axial length, and age Related cataract: the Singapore Malay Eye Study. Invest Ophthalmol Vis Sci. 2013;54:4498–02. 12. Hashemi H, Khabazkhoob M, Miraftab M, Mohammad K, Fotouhi A. The association between refractive errors and cataract: the tehran eye study. Middle East Afr J Ophthalmol. 2011;18(2):154-8. 359 Chaudhari et al., Int J Med Res Health Sci. 2015;4(2):355-359 DOI: 10.5958/2319-5886.2015.00067.3 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 14 Jan 2014 Research article Coden: IJMRHS Revised: 10th Jan 2015 Copyright @2015 ISSN: 2319-5886 Accepted: 27th Feb 2015 COMPARATIVE STUDY FOR EVALUATING T SPOT-TB IN ANALYSIS BETWEEN LOW AND HIGH RISK SUBJECTS - A PILOT STUDY *Gupta V1, Athavale A.U2, Natraj G3 1 Registrar, 2Professor and Head, Department of Pulmonary Medicine, 3Professor, Department of Microbiology, Seth Gordhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai *Corresponding author email:
[email protected] ABSTRACT Latent tuberculosis infection (LTBI) is a non- communicable asymptomatic condition, which might develop into active tuberculosis. Health care workers in contact with active TB cases are at high risk. Impact of exposure in high TB endemic population remains to be studied. Objective: To study the prevalence of IGRA positivity in high risk health care worker and comparing with clinical and radiological data. Methods: From a tertiary care institute, 40 subjects of which low risk subjects (16), high risk subjects / health care workers (24) were recruited randomly. TSPOT TB spot counting was done and correlation with the clinical data and radiology was analysed. Results: Out of 18 positive results, 16 were HCWs (66.67%), 2 were of low risk group (12.5%). Among the HCWs, doctors had the maximum percentage of the positive results (71.42%). Administration related workers all had negative results. Correlation was established between different antigens used. 8 subjects with normal chest x ray also had TSPOT positive result. Conclusion: HCW’s especially those proximally exposed are at greater risk of having positive T SPOT assay. Chest X ray may not be an adequate screening tool. The exact significance and clinical implication need study even in high endemic population. Keywords: IGRAS, Interferon-γ, Health Care workers, Latent Tuberculosis INTRODUCTION Latent tuberculosis infection (LTBI) is a noncommunicable asymptomatic condition, which can develop into active tuberculosis months or years later [1] . There are two principle approaches for tests used in clinical practice to detect latent infection with M. tuberculosis. These are, the in vivo tuberculin skin test (TST), which uses a mixture of antigens obtained as a protein precipitate from the liquid cultures of M. tuberculosis, and the ex vivo interferon-γ release assays (IGRAs), which are designed to identify a memory of an adaptive immune response against mycobacterial antigens [2].IGRAS most popularly available includes the T SPOT TBTM and the Quantiferon Gold (QFT-GTM). T SPOT-TBTM measures release of IFN-γ from sensitized lymphocytes in vitro. Although TST and IFN-γ assay use different antigen combinations, these tests had comparable prevalence estimates (41% and 40%, respectively) and a high level of agreement [3]. TSPOT. TB is intended for use for detection of M. tuberculosis infection in conjunction with risk assessment, radiography and other medical and diagnostic evaluation [4]. The use of the Tuberculin skin test in diagnosing active infection is limited to the category of people who have high levels of exposure to tubercular antigens like the health care worker [5,6]. A community based tuberculosis elimination strategy will require a reduction in the prevalence of infection with M. tuberculosis through identification of latent 360 Gupta et al., Int J Med Res Health Sci. 2015;4(2):360-365 TB infection (in future possibly treatment) that may later develop into active tuberculosis disease [7], thus possible early diagnosis of active disease. An Indian study by Mahomed et al. showed that there was poor agreement between TST and QFT tests, and also between the different generations of QFT tests (K = 0.12-0.50). Of the subset with TST indurations >15 mm, 30- 56% had negative QFT test [8]. A study conducted by Pai et al.[9] on health workers in India demonstrated a high prevalence of LTBI in Indian health care workers as has been in studies from around the world[10]. Increasing age and years in the health profession were risk factors for both IFN-γ assay and TST positivity, and the risk factor associations were fairly similar for both tests [3,10]. Aims and Objectives: To determine the clinical utility and prevalence of significant result of TSPOT.TBTM in health care workers. To determine the extent of correlation of A and B antigen wells of TSPOT test. MATERIAL AND METHODS Research Design: Prospective observational study Sample size: A total of forty subjects were included of which 16 were categorized as low risk subjects (group 1) and 24 as high risk subjects / health care workers (group 2). Sampling Method: Purposive sampling; non randommised. Inclusion criteria: Health Care workers between the ages of 18-60 years and consenting for the study. In order to rule out disease in the subjects, history, clinical examination, chest radiography, blood counts and sputum evaluation was done. Exclusion criteria: History of past or current treatment with anti-tuberculosis drugs or any other active disease state. Low risk subject: Subject not involved in active patient care, thus unlikely to be having exposure to tubercle bacillus more than baseline population. High risk subject: Subject involved in the active patient care having high likelihood of contact with tubercle bacillus. Study period: 2 years from obtaining the ethical committee approval. (June 2012). Procedure: The subjects (male and female) working in all departments in a tertiary care hospital were recruited for the study after consenting as per the institutional ethical committee requirements. They were grouped into high and low risk categories (CDC 2010 criteria) [4] based on their risk of exposure to sputum AFB positive cases in the hospital. After detailed history and examination, the blood sample was drawn and the T SPOT TBTM test was done on the heparinised sample within an average time span of 6 hours. The T SPOT TBTM test was performed as per the kit literature provided with PANEL A representing the ESAT -6 and PANEL B representing the CFP-10 (TB specific antigens). (as per kit literature for TSPOT TBTM ) The results of the TSPOT TBTM of the serum sample obtained from both groups one and two were tallied and analysed using chi square test of analysis on the SPSS data analysis software. p<0.05 was considered significant. RESULTS Of the total 40 subjects tested (Table1), a positive T SPOT TB result was detected in 16 subjects (66.67%) of the high risk group and 2 (12.5 %) in the low risk group. Table1: Risk v/s Result of T SPOT TBTM RISK RESULT OF T SPOT TB TM Total Positive Negative High 16 (66.6%) 8(33.33%) 24 2(12.5%) 14(87.5 %) 16 Low 18 22 40 Total The difference was found to be statistically significant. (p=0.002) (Table2) Table 2: Chi-square test for the statistical analysis of the study Asymp. Exact Exact Sig. Sig. Sig. Value Df (2-sided) (2-sided) (1-sided) 9.82a 1 .002 Pearson Chi-Square Continuity 7.88 1 .005 Correction Likelihood 10.73 1 .001 Ratio Fisher's .003 .002 Exact Test Linear-by9.57 1 .002 Linear Association No. of Valid 40 Cases a. 0 cells (.0%) have expected count less than 5. The minimum expected count is 6.80. b. Computed only for a 2x2 table 361 Gupta et al., Int J Med Res Health Sci. 2015;4(2):360-365 Comparing the cadre of work with the results of the T SPOTB TM test (Table 3), it was observed that doctors had the maximum percentage of positive results (71.42%) followed by the labour class workers (61.53%) whereas the administrative workers who had minimal exposure to active TB cases, had no positive results. The labour class workers who were directly exposed to the patients in ward activities were found to be all positive for TSPOT TBTM. Table 3: Comparing the result and the cadre of work cadre of work Doctor Staff nurse Class Four Worker Ward work Administrative work Administration Total Result of T SPOT TB Positive Negative 5 (71.42%) 2 (28.6%) 5 (50%) 5 (50%) Total 7 10 13 8 (61.53%) 0 (0 %) 0 (0%) 5 (38.47%) 0 (0)% 10 (100%) 18 22 10 40 Comparing the findings of Chest X ray abnormalities and the TSPOT TB (Table4), the one subject with the upper zone opacities had a strongly positive TSPOT TBTM. There were 8 subjects who had no symptoms and had normal chest x-ray, but still had positive T SPOT TB results. Table 4: CXR findings v/s Result of T SPOT TBTM Result of T SPOT TB CXR findings Positive Negative Total CXR not available 9 7 16 Minimal UZ infiltrates 1 0 1 Normal 8 14 22 Opacities 0 1 1 Total 18 22 40 Comparing the results of the individual antigen panels A and B (TABLE 5), it was observed that there was good correlation between the two panel antigen tests as a majority (11 subjects) had both titres positive ( >10 spots). Table 5: Panel A and B assays as compared with the results of the test PANEL A spots <6 6 to 10 >10 PANEL B spots <6 6-10 >10 22 0 0 0 4 0 2 1 11 NEGATIVE RESULT POSITIVE RESULT Gupta et al., However, one subject had low PANEL B titre while 2 subjects had low PANEL A titres. Thus, a low cut off value at 6 is likely to optimise the sensitivity while maintaining the specificity of the test. Likely a lower cut off value will be helpful in a high incidence setting. Correlation between the titres and the magnitude of the exposure will need further study. Further evaluation of the utility of the test to detect the latent TB cases in the high risk population especially doctors, staff nurses and the labour class workers will be needed DISCUSSION T SPOT-TBTM measures release of IFN-γ from sensitized lymphocytes in vitro. These tests have enhanced specificity because they selectively detect responses to CFP-10 and ESAT- 6, antigens secreted by M. tuberculosis that are not present in BCG, hence diminishing false positives seen in TST due to prior BCG vaccination and NTM[11]. Therefore, in countries with adequate resources, QFT-GTM or T SPOT-TBTM may ultimately replace skin testing in the diagnosis of latent TB infection while also serving as an adjunct in the diagnosis of active TB by conducting risk assessment, radiography and other medical and diagnostic evaluations [4]. In light of the above, it was worthwhile considering the specific tests like IGRAS in the evaluation of high risk candidates (health care workers) and comparing its titres with the low risk population. For IGRAs, the reported sensitivity of T-SPOT was highest, reaching a pooled value of 87.5% while pooled sensitivity from the QFT-IT studies was 81%. This figure is remarkably different from the pooled sensitivity of 70% based on the six QFT-IT studies referenced by Pai et al [12]. Because most of the TSPOT studies with respect to sensitivity were also performed in developed countries, the pooled sensitivity estimate for QFT-IT increases to 84.5% (and 88.5% for T-SPOT) in developing countries [13]. In the current study, it was shown that the probability of the subject having the low risk and the negative result (specificity) was about 87.5% which was close to the figure projected by the study by Pai et al.[9] The sensitivity (positive TSPOT TB test in high risk candidates) is likely to be low, in this case is about 66.6 % from the total population considered. The significantly lower sensitivity of the IGRAS observed in this study and few other studies from resource 362 Int J Med Res Health Sci. 2015;4(2):360-365 limited settings needs further evaluation and should be addressed in upcoming studies with larger sample size [14]. Studies with patients have attributed this to the immunologic status of patients in such settings i.e., HIV co infection, advanced disease, or malnutrition) and to logistic requirements of the studies [14]. QFT-IT cut off is drawn to achieve maximum specificity, whereas the commonly used European T-Spot cut off of 6 spots appears to maximize sensitivity [13]. No such cut off values have been set for high burden, high endemic countries. Thus, the current study has also used the cutoff of TSPOT-TBTM test as per the European standards. The results of the same have been satisfactory but need confirmation in larger trials. CDC USA guidelines [4] suggest that QFT-G can be used in place of the TST for infection control surveillance, and conversion (i.e. new infection) has been defined as change from a negative to a positive result. The UK National Institute for Health and Clinical Excellence (NICE) TB guidelines were published in March 2006 [15]. This guideline recommends a two-step (hybrid) strategy for LTBI diagnosis: initial screen with TST and those who are positive (or in whom TST may be unreliable) should then be considered for IGRA testing, if available, to confirm positive TST results. There are no consensus guidelines in India for the IGRAS but for serial testing of health care workers, the IFN-γ assay will be appropriate [16]. It will eliminate the need for repeat visits, avoid boosting, and minimize interpretational difficulties. [7,17]. However; the limited evidence on the use of IGRAs in serial testing of healthcare workers suggests that the diagnostic threshold for conversion does not take into account the possibility of misclassifying nonspecific IFN-γ changes as true conversions [3,18]. Several studies have shown that working in healthcare is a well-known risk factor for TB infection [9, 10, 19, 20, 16, 5, 6]. However, older studies did not test for LTBI [3, 18]. Positive result from the current study 66.67 % of high risk subjects being positive against the 12.5 % of low risk subjects. TST and the IGRAS conversion may have significance in detecting active cases but IGRAS yield fewer false positives in the BCG vaccinated HCWs.[12,20] In the current study, the subject with upper zone opacity on chest X ray was found to have a positive T SPOT test while those with normal chest X ray had a significantly positive result in 8 of 22 subjects (36.36%). This is likely to represent the load of latent TB infection in this population. The prevalence of the TSPOT TB positive result in our study is 45 % (TABLE1). Which correlates with the study by Pai et al. [9] might be an underestimate because of the varied people involved in the health care and the differing degree of exposure to TB bacilli. Although age and years in health care reflect cumulative exposure to M. tuberculosis, variability of risk across job categories as both these studies may reflect variations in exposure frequency and intensity. Lalvani et.al [21] showed the prevalence of LTBI to be 80% in healthy adults (affluent corporate executives) in Bombay who were Enzyme-Linked Immuno Spot positive to either ESAT-6 or CFP-10. In contrast, only 55.8% of our high-risk cohort was positive by IFN-γ assay. The epidemiological estimate for LTBI in India is 41% TST positivity [21]. The limitations to the TPSOT TB testing in general have been: Cost of testing is extremely high. Skilled lab technicians and laboratory setup are needed. Not all the laboratory reagents and reading equipment are included by the manufacturer. Inter observer variability is high. There is no true way of differentiating the latent and the active TB infection i.e. lack of a gold standard. TST has higher sensitivity according to many studies as compared to the IGRAS. But some newer trials have suggested that the true positives may in fact be higher for the QFTG-IT and the TSPOT TB tests for variable reasons. [3, 19] Thus, while TST conversion remains as an indication for treatment, the same cannot be reliably stated for TSPOT TB. Association between the conversion and benefit of therapy still remain to be proven. Thus, more studies are needed to evaluate the transmission of the TB bacillus in the nosocomial setting. Cut off titres for TSPOT TB and definition of conversion in high TB prevalent population are yet to be confirmed. Guidelines from low income and high prevalence countries are needed for the screening and initiation of treatment of LTBI. The value of these tests in follow up of patients has an added value in TB management. Cost-effectiveness of the IGRAS in various settings (low and high risk populations) will need to be studied. 363 Gupta et al., Int J Med Res Health Sci. 2015;4(2):360-365 Overall, our findings highlight the need to study tuberculosis among Indian health care workers. The safety and well-being of health care workers is important for the continued expansion of the TB program. The current study consisted of health care workers in a high prevalence country. Although this may limit our ability to generalize the results to settings with different baseline prevalence, we believe our data will be helpful in understanding the performance of IGRAS in high-burden settings for which data are scarce. The results and the available evidence suggest that the test has its advantages and limitations and, as of this time, it may have a useful role, depending on factors unique to each setting.[3] Subjects from the high risk group who had a positive result later developed constitutional features and radiological manifestation of disease activity and responded to ATT. CONCLUSION The study highlights the high prevalence of latent TB infection especially in high risk groups such as health care workers ( 66.5 % positive in the health care workers as compared to 12.5 % in low risk population). Since the low risk group had most negatives, the test is likely to have a high specificity. Even though there is sparse data to allow broad application, the correlation between positive and negative results is significant and should prompt physicians to evaluate such individuals to be evaluated for active / latent disease with sputum and radiography. 1. 2. 3. 4. 5. 6. 7. 8. ACKNOWLEDGEMENT I am extremely grateful to the staff, fellow residents and administration for their valuable support in the study. I am also grateful to the ICMR ( Indian Council Of Medical Research ) and the Diamond Jubilee Research Trust, KEM Hospital and RNTCP (DOTS) programme for the support with funding of this project. Special mention to Dr. Rupali Suryavanshi ( Asst. Professor, Microbiology ) and Dr. Jairaj Nair ( Asst. Professor, Pulmonary Medicine ) for their valuable help and technical expertise from time to time. 9. Conflict of Interest: Nil 12. REFERENCES 10. 11. World Health Organization. Guidelines for the Prevention of Tuberculosis in Health Care Facilities in Resource-Limited Settings. Geneva, Switzerland: World Health Organization; 1999; 269: 8-13. Lalvani A, Millington KA. T cell-based diagnosis of childhood tuberculosis infection. Curr Opin Infect Dis 2007; 20: 264–71. Pai M, Kalantri S, Dheda K. New tools and emerging technologies for the diagnosis of tuberculosis: Part I. Latent tuberculosis. Expert Rev Mol Diagn. 2006 ; 6 (3):413-22. Updated Guidelines for Using Interferon Gamma Release Assays to Detect Mycobacterium tuberculosis Infection - United States, 2010. CDC Gerald H. Mazurek, John Jereb, Andrew Vernon,et al. June 25, 2010;59;1-25. 21. Christopher D.J, Daley P, Armstrong L , James P, Gupta R, Premkumar B,et al. Tuberculosis Infection among Young Nursing Trainees in South India. PLoS One. 2010; 5(4): 10408. Joshi R, Reingold AL, Menzies D, Pai M. Tuberculosis among health-care workers in lowand middle-income countries: a systematic review. PLoS Med. 2006;3: 494. Rieder HL. Reconciling historical epidemiological, bacteriological and immunological observations in tuberculosis. Int J Epidemiol 2008; 37: 932–34. H. Mahomed et al. Comparison of Mantoux skin test with three generations of a whole blood IFNγ assay for tuberculosis infection. Int J Tuberc Lung Dis 2006; 10(3): 310-16. Pai M, Gokhale K, Joshi R et al. Mycobacterium tuberculosis infection in health care workers in rural dia: comparison of a whole-blood, interferon-γ assay with tuberculin skin testing. JAMA 2005 (293), 2746–2755. J. Torres Costa, R. Sa, M.J. Cardoso, et al Tuberculosis screening in Portuguese healthcare workers using the tuberculin skin test and the interferon-γ release assay, Eur Respir J 2009; 34: 1423–28. Juan Carlos Palomino, Sylvia Cardoso Leão, Viviana Ritacco “From basic science to patient care.” Tuberculosis 2007.184-85. Madhukar Pai, Guidelines on IGRAS cordant or discordant 2nd symposium on IGRAS. 2009. 364 Gupta et al., Int J Med Res Health Sci. 2015;4(2):360-365 13. R. Diel, R. Loddenkemper, and A. Nienhaus, Evidence-Based Comparison of Commercial Interferon-γ Release Assays for Detecting Active TB- A Metaanalysis chest 2010 ;137 (4): 952-68. 14. Dick Menzies, Madhukar Pai, and George Comstock Meta-analysis: New Tests for the Diagnosis of Latent Tuberculosis Infection: Areas of Uncertainty and Recommendations for Research. Ann Intern Med. 2007; 146: 340-54. 15. National Institute for Health and Clinical Excellence. Tuberculosis: Clinical Diagnosis and Management of Tuberculosis, and Measures for its Prevention and Control. London, National Institute for Health and Clinical Excellence, 2006. www.nice.org.uk. 16. Pai M, Joshi R, Dogra S, Mendiratta DK, Narang P, Kalantri SP, Reingold AL, Colford JM, Riley LW, Menzies D: Serial testing of health care workers for tuberculosis using interferon-g assay. American Journal of Respiratory and Critical Care Medicine 2006 (174): 349-55. 17. Gopinath KG, Siddique S, Kirubakaran H, Shanmugam A,Mathai E, Chandy GM. Tuberculosis among healthcare workers in a tertiary-care hospital in South India. J Hosp Infect. 2004; 57:339-42. 18. Jasmer RM, Nahid P, Hopewell PC. Clinical practice. Latent tuberculosis infection. N Engl J Med 2002; 347(23):1860–6. 19. Rao KG, Aggarwal AN, Behera D. Tuberculosis among physicians in training. International Journal of Tuberculous Lung Disease 2004; 8:1392-94. 20. Madhukar Pai, JessicaMinion, Hojoon Sohn, et al Novel and Improved Technologies for Tuberculosis Diagnosis: Progress and Challenges, Clin Chest Med 2009; 30: 701–16. 21. Lalvani A, Nagvenkar P, Udwadia Z. et al. Enumeration of T cells specific for RD1encoded antigens suggests a high prevalence of latent Mycobacterium tuberculosis infection in healthy urban Indians. J Infect Dis. 2001; 183: 469-77 365 Gupta et al., Int J Med Res Health Sci. 2015;4(2):360-365 DOI: 10.5958/2319-5886.2015.00068.5 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS st Received: 21 Jan 2015 Revised: 10th Feb 2015 Research article Copyright @2015 ISSN: 2319-5886 Accepted: 6th Mar 2015 STUDY OF PRIOR PREPAREDNESS AND AWARENESS REGARDING THE MBBS COURSE AMONGST FIRST YEAR STUDENTS ADMITTED AT RURAL MEDICAL COLLEGE, OF PIMS-DU, LONI *Padmanabhan P1, Kunkulol R2, Jangle SN3 1 Associate Professor, 3Prof and Head, Department of Biochemistry, 2Professor, Department of Pharmacology Rural Medical College, Pravara Institute of Medical Sciences-Deemed University, Loni, Ahmednagar, Maharashtra, India *Corresponding author email:
[email protected] ABSTRACT Background: Adolescents in India choose career in medicine under the influence and pressure from parents, family members, peers and external sources. There are no measures taken to study whether these medical students understand the demands and priorities of a career in medicine once they decide to choose it. Hence the study was undertaken at PIMS-DU with Ist year MBBS students as participants. Aims: 1) Assess the factors influencing the choice of MBBS. 2) Analyze the prior knowledge and awareness of medical students regarding the course. 3) Their career trend in future. Material and Methods: All newly admitted students present at the orientation programme in September 2014 at PIMS –DU were included as participants. Their written responses to a 14 point questionnaire were entered into a Microsoft Excel Spreadsheet and descriptive analysis was done. Results: A majority of students had their parents and family members in medical profession indicating prior idea amongst the students regarding the course, even when the choice was made at an early stage of academics or without appearing for aptitude tests due to unawareness. Appearance for entrance exams to kept their options wide open but caused unnecessary stress, anxiety and economic burden to parents. However, these participants had limited knowledge about medical curriculum but had decisive ideas regarding future trend in career. Conclusions: Family being strong motivator for career choice for medical students; should encourage students to undertake aptitude tests, career guidance courses and investigate about future prospects to create a strong foundation as MBBS students. Keywords: Career, Medical students, Awareness, Medical curriculum. INTRODUCTION The personnels opting for medical profession must have the right approach, aptitude, attitude, selfless service motto and ability to work relentlessly for the patients. Other attributes are ability to overcome sleep, preparedness for a kaleidoscope of emotions, service over economics and empathy [1]. To enable the medical students to make the right choice of professional career, aptitude tests are developed by trained expert psychologists to prevent frustrations in future in case of failures. Consequently, educational authorities have realized the need for institutions to have career guidance counselors who enable the students to select appropriate career in co-ordination with their intellectual abilities and virtues [2]. In some cases students are forced to choose a professional course such as MBBS at an early stage in student life and persist in their choices until their Padmanabhan et al., Int J Med Res Health Sci. 2015;4(2):366-372 366 early academic goals are completed [3,4].At this juncture of selection, their choice is influenced by parents, relatives, peers and other external sources as well as their own perceptions [5] . After the decision of choosing MBBS as a course of study, there are some requirements which the medical student should possess, such as comprehension of English language, competence in communication, empathy, independent thinking and decision making, integrity, dedication to lifelong learning, as well as ability to cope with stress [6]. However, several studies indicated that stress due to the profession is dominating problem amongst the current medical practitioners suggesting the choice regarding the career is replaced by pessimism and cynicism [7, 8]. It has been noted that students in India opt for a career in medicine because of influence and pressure from parents, even they lack self motivation. It should be kept in mind that in our country the majority of children taking this decision are very young (17-18 years old) and have a protected life with plenty of parental guidance in nuclear family with not much career counseling. Nothing much has been done to know whether they really understand the high demands and rigours of a career in medicine once they decide to choose it [9]. At the Pravara Institute of Medical Sciences-Deemed University the MBBS course has tenure of 5½ years, which is inclusive of one year of internship. As soon as they get admission in the First year, subjects like Anatomy, Physiology, Biochemistry and Community Medicine are taught for two terms. In the Second year for 3 terms Pharmacology, Microbiology, Pathology, Forensic Medicine and Community Medicine are taught along with clinical posting. In Final MBBS Part I of 2 terms cover the subjects Community Medicine, Ophthalmology and Oto-rhino laryngology and Final MBBS Part II of 2 terms includes the subjects Medicine, Surgery including Orthopedics, Obstetrics and Gynaecology and Pediatrics. Internship lasts for a period of one year which is as per MCI guidelines. The objectives of the present study were to: 1) Assess the factors influencing the choice of MBBS as a course of study. 2) Analyze the prior knowledge and awareness of newly admitted medical students regarding the MBBS course and 3) Their career trend in future. Padmanabhan et al., Int J Med Res Health Sci. 2015;4(2):366-372 MATERIAL AND METHODS All newly admitted medical students (n= 91) of first year MBBS course admitted in an observational study in September 2014, at Pravara Institute of Medical Sciences- Deemed University were included as volunteers in the 2 month study. On the first day of orientation programme of the newly recruited students who were present and the questionnaire with 14 point questions were distributed amongst the students. The modified questionnaire [10] was anonymous and self administered. Further data confidentiality was ensured over and above the anonymity. The primary outcome measures were the number of attempts taken by students for admission and the people who motivated them for a profession in medicine. The secondary outcome measures were number and type of career preparation activities pursued prior to admission and the extent of prior knowledge and awareness about the various aspects of medical curriculum. Ethics: After approval from the Institutional Ethical Committee, Registration No: PIMS/RMC/2014/86. Statistics: Responses were entered into a Microsoft Excel Spreadsheet and descriptive analysis was done. RESULTS Table 1: Distribution of characteristics and responses of newly admitted first year MBBS students according to gender. Student Age Boys (%) Girls (%) 17 yrs 20 (45.45) 24 (51.06) 18 yrs 14 (31.82) 11 (23.40) 19 yrs 06 (13.64) 11 (23.40) 20 yrs 04 (9.09) 01 (2.12) Total 44 47 Figure 1: Age and Genderwise distribution of Ist year MBBS students. 60 50 Percentage 40 Boys(%) Girls (%) 30 51.06 20 31.82 23.4 10 45.45 2.12 23.4 13.64 0 17 yrs 18 yrs 9.09 20 yrs 19 yrs Age in years 367 Fig: Age and Gender wise distribution of 1st year MBBS students Table 1: Distribution of characteristics and responses of newly admitted first year MBBS students according to gender. Parameter Boys (%) Girls (%) Number of attempts in entrance exam for MBBS course First attempt 28 (63.64) 36 (76.60) Second attempt 16 (36.36) 10(21.28) > two attempts 00 (0.00) 01 (2.13) Decision to choose MBBS course Before 10th Std 25 (56.82) 30 (63.83) During Junior College 17 (38.64) 17 (36.17) Not disclosed 02 (4.55) 00 (0.00) Reason for selecting MBBS course Answered and explained 34 (77.27) 45 (95.74) Unanswered 10 (22.72) 03 (4.25) Consideration of other option if not admitted to MBBS BDS 14 (31.81) 07 (14.89) BPT 12 (27.27) 20 (42.55) B .Pharm 00 (00.00) Biotech 03 (6.82) B.Sc 03 (6.82) BAMS 02 (4.55) Engineering 01 (2.27) Any other 01 (2.27) Not disclosed 08(18.18) Awareness that ragging is prohibited Yes 42 (95.45) No 02 (4.55) 05 (10.64) 01 (2.13) 00 (0.00) 01 (2.13) 03 (6.82) 02 (4.26) 08 (17.02) 47 (100) 00 (0.00) Parameter Boys (%) Girls (%) Any other member of the family in medical profession Mother 11 (25.00) 20 (42.55) Father 09 (20.45) 07 (14.89) Maternal uncle 08 (18.18) 11 (23.40) Paternal uncle 07 (15.90) 03 (6.38) Grandparents 05 (11.36) 03 (6.38) Sister 03 (6.82) 03 (6.38) None 01 (2.27) 00 (0.00) Profession of family Nursing 10 (22.73) 23 (48.94) Hospital 12 (27.27) 08 (17.02) administration Pharmaceutical 08 (18.18) 08 (17.02) Business 08 (18.18) 03 (6.38) Bank 04 (9.09) 02 (4.26) Education 01 (2.27) 02 (4.26) Not disclosed 01 (2.27) 01 (2.13) Table 2: Guidance availed before admission to MBBS course. Boys (%) Girls (%) Decision to choose MBBS encouraged by Mother 06 (13.64) 10 (21.28) Father 06 (13.64) 06 (12.77) Maternal uncle 03 (6.18) 06 (12.77) Paternal uncle 07 (15.91) 05 (10.64) Teacher 07 (15.91) 09 (19.15) Friend 08 (18.18) 07 (14.89) Grandmother 00(0.00) 01 (2.13) Inner voice 01 (2.27) 01 (2.13) Not disclosed 06 (13.64) 02 (4.25) Taken prior Aptitude test Yes 12 (27.27) 22 (46.80) No 19 (43.18) 18 (38.30) Was not aware 06 (13.64) 04 (8.51) Not disclosed 07 (15.91) 03 (6.38) Common entrance test for admission to MBBS other than test conducted by PIMS-DU One 05 (11.36) 01 (2.13) Two 08(18.18) 06 (12.77) Three 05 (11.36) 02 (4.26) Four 05 (11.36) 09 (19.15) Five 17 (38.64) 26 (55.32) Not disclosed 04 (9.09) 03 (6.38) Table 3: Medical students awareness about MBBS course Boys (%) Duration of study in years 4 02 (4.55) 4½ 38 (86.36) 5 02 (4.55) 5½ 01 (2.27) Not disclosed 01 (2.27) Awareness of Internship duration 1 42 (95.45) 1½ 0 (0.00) Not disclosed 02 (4.55) Parameter Boys (%) Names of subjects in I MBBS 3 35 (79.55) 4 02 (4.55) Not disclosed 07 (15.90) Names of subjects in II MBBS 2 03 (6.82) 3 10 (22.72) 4 18 (40.90) 5 01 (2.27) Not disclosed 12 (27.27) Names of subjects in III MBBS 2 03 (6.82) 3 02 (4.55) 4 06 (13.66) 5 05 (11.36) 6 10 (22.72) 7 14 (31.82) 8 01 (2.27) Number of attempts to clear University Exam 1 09 (20.45) 2 01(2.27) 3 12 (27.27) 4 0 (0.00) Not disclosed 22 (50.00) Girls (%) 02 (4.25) 41 (87.23) 0 (0.00) 04 (8.51) 0 (0.00) 42 (89.36) 02 (4.25) 03 (6.38) Girls (%) 43 (91.49) 02 (4.26) 02 (4.26) 07 (14.89) 13 (27.66) 12 (25.53) 02 (4.26) 12 (27.66) 03 (6.38) 02 (4.26) 07 (14.89) 10 (21.28) 13 (27.65) 12 (25.53) 0 (0.00) 04 (8.51) 02 (4.26) 0 (0.00) 0 (0.00) 41 (87.23) 368 Padmanabhan et al., Int J Med Res Health Sci. 2015;4(2):366-372 Table 4: Decision about future after opting for MBBS Boys (%) Girls (%) After MBBS opting for Post-graduation 35 (86.36) 42 (89.36) Private practice 01 (2.27) 04 (8.51) Teaching 02 (4.55) 0 (0.00) Any other 02 (4.55) 0 (0.00) Not disclosed 01 (2.27) 01 (2.13) Aware of USMLE Exam Yes 16 (36.36) 13 (27.66) No 28 (61.36) 29 (63.83) Not disclosed 01 (2.27) 04 (8.51) Total 44 47 The number of students admitted to the first semester of Ist MBBS in 2014 was 125.On the day of the study 91 students were available who duly filled the questionnaire and all were included in the study. As depicted in Figure 1 of age and gender wise distribution of Ist year MBBS students, amongst the total number of newly admitted students 51.06% were girl students of 17 years age group and 23.4% were girls in the age group of 19 years which were higher in percentage when compared to boy students of the same age group. Whereas there was a majority of boy students as compared to girl students in the age group of 18 years (31.82%) and 20 years (9.09%). Success in an entrance exam conducted by the Pravara Institute of Medical Sciences- Deemed University (PIMS-DU) is a pre-requisite to gain admission into PIMS-DU. A higher percentage of girl students made their first attempt (76.6%) as compared to boy students. Whereas higher percentage of boy students (36.36%) as compared to girl students were attempting the second time to secure admission. Girl students (2.13%) were more competent and ensured their chances of gaining admission by making more than two attempts. These data are represented in Table 1. Table 1 also the time period during which the I st year MBBS students had made their decision to uptake MBBS course, As compared to boy students 63.83% of the girl students had made their firm decision in 10th standard. But 38.64%of the boy students as compared to girl students had made their choice during Junior College. All the girl students were prompt in disclosing but 4.55% of boy students preferred not to disclose about when they had made their decision. Ragging is strictly prohibited amongst students at Pravara Institute of Medical Sciences – Deemed University. Amongst the newly admitted first year MBBS students; all girl students were fully aware about this fact as compared to boy students.4.55% of the boy students were unaware that ragging is prohibited at PIMS –DU. Table 1 further depicts the consideration of other options if not admitted to MBBS. 31.81% of the boy students preferred BDS as next option .The same percentage (6.82%) of boy students would have opted for either of the streams that Biotechnology or B.Sc as next option. For girl students (42.55%) their next choice was BPT. None of the boy students were interested in opting for B.Pharm. Whereas none of the girl students showed interest in opting for B.Sc.6.82%of the girl students were interested in Engineering or 4.26% for any other course as next option.18.18% of the boy students and 17.02% of girl students preferred not to disclose about their consideration for of other option of study courses. As shown in Table1 a higher percentage of girl students (42.55%) had their mothers in medical profession and (23.4%) had their maternal uncles in medical profession. Fathers (20.45%), paternal uncles (15.9%), grandparents (11.36%), sisters (6.82%) of the boy students were involved in medical profession. However, 2.27% of boy students did not disclose about which member in the family were in medical profession; but all girl students were prompt in their response. The data shown Table 1 ascertains that larger numbers of family members of girl students are in nursing field (48.94%) and education (4.26%). As compared to girl students the family members of boy students were in hospital administration (27.27%), pharmaceuticals (18.18%), business (18.18%) and banking (4.26%).However, 2.27% of boy students and 2.13 % of girl students did not divulge information about the profession of their family members. Since, 42.55% of the mothers and 23.4% of maternal uncles of girl students (as depicted in Table 1) were in medical profession they must have encouraged and influenced their daughters and nieces to choose MBBS course. Fathers (13.64%), paternal uncles (15.9%), friends (18.18%) were pivotal in encouraging the boy students but had lesser influence of the same family members on the girl students to choose MBBS course. Padmanabhan et al., Int J Med Res Health Sci. 2015;4(2):366-372 369 However, none of the girl students were encouraged by their grandmothers. Whereas, 13.64% of boy students and 4.25% of the girl students preferred not to disclose about their kins are influential in their decision to choose MBBS course. These data are represented in figures in Table 2.The inner voice was also an encouraging factor in 2.27% boys and 2.13% girl students. As represented in Table 2 , girl students (46.8%) as compared to boy students were career conscious and cautious enough to have undergone a prior an aptitude test.13.64% of the boy students were unaware as compared to girl students about the aptitude tests.Whereas,15.91% of the boy students and 6.38% of the girl students preferred not to disclose. According to Table 2, 38.64% of the boy students and 55.34% of the girl students had applied for more than 5 entrance tests other than tests conducted by Pravara Institute of Medical Sciences – Deemed University thus causing economic burden, stress and anxiety to them and their families. With reference to Table 3, as compared to boy students 87.23% of girl students were aware regarding the duration of the MBBS course; as compared to girl students 95.45% of the boy students were aware of the internship duration. Table 4 represents that 36.36%of the boy students were aware of USMLE exam and 63.83% of the girl students were totally unaware of the competitive USMLE exam. 2.27% of the boys and 8.51% of the girls preferred not to disclose. Table 1 depicts the reasoning amongst medical students regarding MBBS course selection. Most of the girl students (95.74%) have perfect understanding regarding their career choice and made conscientious decision to choose MBBS course. According to Table 3 most of the girl students (87.23%) were totally unaware regarding the number of attempts required to pass the University Exam. As depicted in Table 3 only 4.55 % of boy students and 4.26% of the girl students correctly reported the number of subjects that is Anatomy, Physiology, Biochemistry and Preventive & Social Medicine taught in I st year MBBS. It is evident from Table 3 that uncertainty and ignorance existed amongst the boys and girls regarding the number and names of subjects taught in II nd and III rd year MBBS. Table 4 represents that majority of boy students (86.36%) as well as girl students (89.36%) were interested in doing post-graduation and a negligible percentage opted for private practice amongst both boy students (2.27%) and girl students (8.51%).None of the girl students were interested in teaching profession as future career after completion of MBBS course. Padmanabhan et al., Int J Med Res Health Sci. 2015;4(2):366-372 DISCUSSION Our study indicates that amongst the total students admitted for MBBS course at Pravara Institute of Medical Sciences –Deemed University (PIMS-DU) the number of girl students admitted had outnumbered the boy students. This trend of statistics even extends to the number of attempts at the entrance exam whether at PIMS-DU or at other university entrance exam. Thus it appears that the girl students are found to maintain their perseverance regarding their career choice even when selecting their course of study. The medical profession faces a changing gender composition with larger number of girls opting for medicine as their career choice. Our study findings are in unison with this fact. A study in the United Kingdom showed an increase in feminization of the medical profession [11]. The choice of a particular career is largely influenced by certain factors; such as peer group influence and parental influence. Family influence is an important factor in career choice of the students [12]. Adolescents have young minds therefore develop many attitudes about occupation and career as a resultant effect of interactions with their families. Family background according to our study provides the basis from which their career plans and decision making evolves. Our study indicates that parents and other members in the family have significant influence on career choice. Teachers and friends contribute equally to the decision of choosing MBBS as course of study. Parents, family members of medical students probably recognized their wards ability at an early age and guided them into academically suitable careers [13]. A study by Penick and Jepsen reported that parental influence surpasses that of peer influence [14].This fact bears resemblance to findings of our study. But this is a variable factor since it is pertaining to the student’s rapport with their parents and peers. Our study also indicates that inner voice of students can also influence and can be a guiding factor regarding career choice. A study by Csinady et al found that altruistic motivations were the most 370 significant career choice reason among medical students [15]. It is also observed that nearly majority of the students had their parents and family members in medical profession; which means that the students had prior idea regarding the type of scenario awaiting them. It also ascertains the findings of a previous study that family is a very strong motivating force regarding career choice in India [9]. In our study, the medical students have made the decision of their career choice before 10th standard and in Junior College. In a similar study by Noble et al who dealt with factors influencing career choice of orthodontic residents in the United States, found that career decision was made at an early stage in life [16].However, this fact is debatable that students at the tender schooling age and junior college days are able to make such an important decision such as career choice in medicine. Aptitude career tests are specially designed and developed by trained, expert psychologists; who guide and enable the students to decide their career in future. The test analyses the inclinations and skill sets of students like logical thinking skills, analytical skills, leadership capabilities, power of comprehension, communi- cation skills etc along with capabilities that can be improvised. Hidden potential or talents can be assessed and explored [16]. Our study depicts a significant number of students did not appear for aptitude tests or were not aware of the same. There is also a notable observation that girls outnumbered the boy students in appearing at the aptitude tests, a clear indication of their conscientious decision taken especially by the girl students. The fact lies that by appearing for aptitude tests prior to entering any profession can be beneficial and directional to the students immensely. Aptitude tests can be used to narrow down the career options and also give a definite motivation which navigates and gives a head start to their careers [17]. Our study indicates that majority of medical students had appeared for five entrance exams other than that at our institution. Also to be noted is the fact the remaining students had appeared for more than one entrance exam. This may result in unnecessary economic burden, stress and anxiety to the students as well as their family members. But when considering the same scenario in a different perspective, it also means that the students were keeping their options and probability of securing admissions to various institutions wide open. According to findings of the present study the awareness amongst the students regarding the medical curriculum was limited. Most of the medical students did not have correct information hence knowledge regarding the duration of the study, internship duration, about the number of attempts required to clear the university exam nor the subjects taught at the level of first year, second year or final year MBBS. However, nearly all students which included all girl students were aware that ragging is prohibited in college and college premises. A majority of the medical students had a clear decisive idea regarding their future career choice after MBBS course and would opt for further studies or post-graduation. However, an insignificant number will opt for private practice and teaching. According to our study teaching profession was an unpopular choice amongst the girl students since none opted for it. The present study also indicates that majority of the medical students were unaware regarding the qualifying exams for education aboard after completion of MBBS course. But, it is satisfying to observe that students had a perfect understanding, reasoning and firm ideas as to why they had eventually chosen MBBS as course of study? Students should not be “encouraged” to make a career out of medicine unless they are explained in detail about the dedication and hardwork that awaits them in future. Perhaps students who make an informed choice and have a prior idea will excel, perform and score in the study course selected [18, 19]. Our study has limitations that the findings are confined to a single medical college and does not generalize to other medical colleges in India. Gender issues, as well as socio-economic and cultural issues may also influence the decision to opt for MBBS course, into which we did not study or delve; perhaps further studies may enlighten the possible associations and outcomes. However, the strength of the study is that it denotes the major motivational force of family and its members in the student’s life in choice of selecting medicine as study course. But these newly recruited medical students are not fully informed regarding the study course of MBBS which suggests scope for improvement in the form of new reforms and policies that would enable the students to be better informed. Padmanabhan et al., Int J Med Res Health Sci. 2015;4(2):366-372 CONCLUSION The study is a subjective evaluation of the prior 371 knowledge, awareness and preparedness regarding MBBS course. The findings suggest that students themselves are responsible for the choice with strong motivation from family and members quite early in their lives. But they have not undergone aptitude tests to strengthen their candidature as a medical student. However, they have appeared in more than one entrance tests in order to ensure a seat in a medical college. Their knowledge about the medical curriculum and future prospects are poor which may lead to a burnout in future. Hence it is suggestive that since family is the strong motivating factor they should encourage the students to take aptitude tests, career guidance courses and give picture of future that would create a strong foundation for their future course as MBBS students. ACKNOWLEDGMENT: None Conflict of Interest: Nil REFERENCES 1. Salpekar R, Mujawar N. Aptitude evaluation for medical profession in first year and final year MBBS students. PIMS, 2012; 2(2):41-45. 2. Bennet GK, Seashore HG, Wesman AG. The differential aptitude tests: An overview. The Personnel and Guidance J, 1956; 35:81-91. 3. Middleton EB, Loughead TA. Parental influence on career development, An integrative framework for adolescent career counseling Journal of Career Development, 1992; 3:161-73. 4. Germeijs V, Vershueren K. High school student’s career decision –making process consequences for choice implementation in higher education. Journal of Vocational Behaviour, 2007; 70 (2):223-41. 5. Kosine N, Lewis M. Growth and Exploration: Career Development Theory and Program of study. Career and Technical Education Research, 2006; 33(3):227-43. 6. Cenkseven –Onder F, Kirdok O, Isik E. High school students career decision-making pattern across parenting styles and parental attachment levels. Electronic Journal of Research in Educational /Psychology. [Internet] 2010 Cited 2010;8(1):263-80. 7. Maharjan S, Dixit H.MBBS student selection: search for proper criteria. Kathmandu University Medical Journal, 2003; 2(3): 252-59. 8. Kay J. Traumatic deidealization and the future of medicine. JAMA, 1990; 263:572-73. 9. Prka M, Daniae A, Glavas E. What do medical students want from their professional and private life? CMJ, 2002; 42:80-83. 10. Shankar N, Singh S, Gautam S, Dhaliwal U. Motivation and preparedness of first semester medical students for a career in medicine. Indian J Physiol Pharmacol, 2013; 57(4), 432-38. 11. Miller DS, Slocombe TE. Preparing students for the new reality. College Student Journal, 2012, 46(1):18-21. 12. De Ridder L. The Impact of Parents and Parenting on Career Development. Comprehensive Career Development Project, 1990; 32528. 13. Ausman J, Javed A, Ahmed S, Samad MA, Pour AS, Mathew E, Shaikh RB, Al-Sharbatti S, Sreedharan J. Social factors influencing Career choice in a Medical School in the United Arab Emirates. Education in Medical Journal, 2013; 5(1): 14- 20. 14. Penick N, Jepsen D. Family Functioning and Adolescent Career Development. Career Development Quarterly, 1992; 4:208-22. 15. Csinady A, Molnar R, Hazag A. Career choice motivations of medical students and some characteristics of the decision process in Hungary. Central European Journal of Medicine, 2008; 3(4):494-96. 16. Noble J, Hechter FJ, Karaikos N, Wiltshire WA. Motivational factors and future plans of orthodontic residents in the United States. Am J Orthod Dentofacial Orthop, 2010; 137:623-30. 17. Clark D, Miller K. “Knife before wife”: An exploratory study of gender and the UK Medical profession. Journal of Health Organization and Management, 2008; 22(3):238-42. 18. Graham P, Tso S Wood E. Shadowing a foundation-year doctor: a third year medical student’s perspective. Clin Teach, 2011; 8:15659. 19. Hernandez J, Al-Saadi S, Boyle R, Villadolid D, Ross S, Murr M et al. Surgeons can favourably influence career choices and goals for students interested in careers in medicine. J Am Coll Surg, 2009, 209: 62-67. 372 Padmanabhan et al., Int J Med Res Health Sci. 2015;4(2):366-372 DOI: 10.5958/2319-5886.2015.00069.7 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 28 Jan 2015 Research article Coden: IJMRHS Copyright @2015 ISSN: 2319-5886 th Revised: 5 Mar 2015 Accepted: 18th Mar 2015 ROLE OF COMPUTED TOMOGRAPHY IN EVALUATION OF PANCREATIC DISEASES *Santosh N. Pawar1, Aruna S. Deshmukh2, Bharati P. Chavan3 1 Assistant Professor, 2Professor, Dept. of Radio diagnosis, S.R. T. R. Govt. Medical College, Ambajogai, Beed, Maharashtra, India 3 Resident, Dept. of Pediatric, S. R. T. R. Govt. Medical College, Ambajogai, Beed, Maharashtra, India *Corresponding author email:
[email protected] ABSTRACT Context: The evolving role of CT in the study of pancreas is not only in its ability to directly define the presence of an abnormality but it also surpasses the other imaging modalities in being able to demonstrate the extent of the disease and its spread to contiguous areas by virtue of its being a non-organ specific investigation. The ability of CT to image the pancreas adequately regardless of the bowel gas and fat gives it an advantage over ultrasound. Objectives: To study age and size distribution in pancreatic diseases. To differentiate cystic from solid pancreatic lesions. To differentiate inflammatory and neoplastic conditions with their characteristic imaging features. To classify and grade pancreatitis with the help of CT imaging features. Methods: This study comprises 50 patients of different age groups in whom there was clinical suspicion of pancreatic disorder. This includes 35 male and 15 female patients. Each patient had been studied by using plain and contrast computed tomography. Results: Maximum no. of patients’ age was from 23 – 30. Pancreatic diseases were more commonly found in males than in females. Inflammatory diseases were found to be more common than neoplastic masses. Chronic pancreatitis were showing pancreatic duct dilatation, pancreatic atrophy and pancreatic calcification. Pseudocysts were associated with chronic pancreatitis. Pancreatic carcinomas extent and metastases was studied accordingly. Conclusion: CT alone is an excellent noninvasive imaging modality with a sensitivity of about 94% in diagnosing pancreatic diseases when used judiciously in good clinical settings and accuracy of almost 100% when used in conjunction with other imaging modalities like endoscopic retrograde colangiopancreatography, angiography and biopsy whenever indicated. Key words: pancreatic diseases, acute chronic pancreatitis, computed tomography INTRODUCTION Computed Tomography (CT) is a highly accurate, non-invasive imaging modality of choice in evaluating the pancreas[1]. CT enables the imaging of the entire pancreas easily from the surrounding fat and bowel air together with simultaneous imaging of other abdominal organs.[2] It also enables detection of unsuspected additional or ancillary abnormalities which may be responsible for clinical [3,4] manifestations . The evolving role of CT in the study of pancreas is not only in its ability to directly define the presence of an abnormality but it also surpasses the other imaging modalities in being able to demonstrate the extent of the disease and its spread to contiguous areas by virtue of its being a non-organ specific investigation. The ability of CT to image the pancreas adequately regardless of the bowel gas and fat gives it an advantage over ultrasound[5]. 373 Santosh et al., Int J Med Res Health Sci. 2014;4(2):373-379 In present study the role of CT to evaluation of pancreatic disease by studying the following parameters. The normal anatomy of the pancreas and various CT appearances in pancreatic disease with regards to sizes, shape, position, margins (contour) volume, density characteristics, enhancement patterns, vascular landmarks, pancreatic and common bile ducts and the surrounding organs. MATERIALS & METHODS This was the prospective study carried out in the Department of Radio diagnosis, Dr. V.M.Govt. Medical College and Shri. Chatrapati Shivaji Maharaj General Hospital. Ethics committee clearance was obtained for the present study. Informed consent of patients also taken from each patient. Inclusion criteria: This study comprises 50 patients of different age groups in whom there was clinical suspicion of pancreatic disorder complaining pain in abdomen, weight loss and increased serum amylase levels. This includes 35 male and 15 female patients. General clinical history of each patient had been taken and CT scan was done by using plain and contrast dedicated pancreatic imaging on : Third Generation spiral CT- Philips Company (CT Model – CT vision, CT-secura). The following finding were selected for the evaluation of pancreatic diseases Ultrasonographic findings: CT findings Contour (Regular / irregular/Nodular), Size (Focal enlargement, Diffuse enlargement, Diffuse atrophy, Focal atrophy), Attenuation ( Plain, Arterial, Venous), Pancreas (Aorta, IVC), Density(Homogenous/ heterogenous, Focal Hypodense Areas, Focal Isodense areas, Focal hyperdense areas), Necrosis, Calcification (Parenchymal, Ductal, Both), Pancreatic duct (Size, Calculi), Commone Bile duct, (Size, Calculi), Pancreatic abscess, Pancreatic gas, Peripancreatic fat stranding, Phlegmonous changes, Mesentery, Transverse mesocolon, Anterior pararenal fascia, Lesser sac, Pelvis, Acute fluid Accumulations, Intrapancreatic/ Extrapancreatic, Psuedocyst, Ascites, Pleural effusion, Vascular structures,Varices, Fat plane around the vessels, Liver, Intrahepatic biliary radicals.Investigations: Biochemical investigations are done to rule out pancreatic diseases (BSL, Serum Amylase, Serum Bilirubin). RESULTS Table 1: Distribution of pancreatic Disorders Diagnosed on CT (n=50) Age( years) Male % Female % 0-10 00 00 01 02 11-20 02 04 02 04 21-30 06 12 03 06 31-40 09 18 03 06 41-50 08 16 03 06 51-60 05 10 01 02 61-70 05 10 01 02 >70 00 00 01 02 Total 35 75% 15 30% Comments: Pancreatic disorders were more common in males than in females in this study. The commonest age group affected was between 30 to 50 years. Table 2 : Distribution of patients according to various pancreatic pathologies. Pathology No. % Acute pancreatitis 16 32 Chronic pancreatitis 24 48 Pancreatic carcinoma 09 18 Other 01 02 Total 50 100 Comments: The other constitute of only one case of pancreatic cyst associated with VHL ( von Hipple Lindau) syndrome.The commonest pathology in this study was chronic pancreatitis followed by acute pancreatitis and pancreatic carcinoma. Table 3: Age and sex distribution of acute pancreatitis ( n=16) Age ( years) 0-10 11-20 21-30 31-40 41-50 51-60 61-70 >70 Total Male % --1 5 3 1 2 -12 --6.2 31.2 18.7 06.2 12.5 -75% Female --1 2 ---1 4 % Total % --6.25 12.5 ----6.2 --2 7 3 1 2 1 16 --12.50 43.75 18.75 6.25 12.50 6.25 100% Comments: Acute pancreatitis was more common in males than in females in this study.The commonest age group affected was between 30-50 yrs. 374 Santosh et al., Int J Med Res Health Sci. 2014;4(2):373-379 Table 4: Showing the CT signs of acute pancreatitis. Signs No. % Gland Normal 0 0 Diffuse Enlargement 11 68.75 Focal Enlargement 5 31.25 Contour Irregular 10 62.5 Regular 6 37.5 Density Homogenous 5 31.25 Heterogeneous 11 68.75 Necrosis <30% 3 18.75 30-50% 1 6.25 >50% 2 12.50 Phlegmonous 7 43.75 changes Fluid Intrapancreatic 3 18.75 accumulation Extrapancreatic 4 25.00 Both 2 12.50 Presence of 0 0 gas/Abscess Pseudocyst 3 18.75 Ascites 3 18.75 Pleural 8 50.00 effusion Comments: Fluid accumulation is defined as a localized collection of pancreatic fluid in the pancreas, lesser sac, anterior, pararenal space or subperitoneal space.4 patients had extrapancreatic fluid accumulation, while 3 patients had intrapancreatic fluid accumulation and 2 patients had both intra and extrapancreatic fluid accumulations. Extrapancreatic fluid collections noted in Lesser sac and subperitoneal space. Table 5 : Distribution of patients of acute pancreatitis according to grade of pancreatits (n=16) Grade [7] No. of patients % A 0 -B 4 25.00 C 3 18.75 D 7 43.75 E 2 12.50 Grading : [7] Grade A: Normal pancreas Grade B: Focal or diffuse enlargement of the gland, including contour irregularity, non homogenous attenuation of gland, dilatation of the pancreatic duct, foci of small fluid collections with in the gland. Grade C: Intrinsic pancreatic abnormality associated with haziness and streaky densities representing inflammatory changes in the peripancreatic fat. Grade D: single ill defined fluid collection. Grade E: Two or multiple poorly defined fluid collections as presence of gas in or adjacent to pancreas. Table 6 Distribution of Necrosis in various grades of Pancreatitis. (n=6) [5] Grade No. of patients % A --B --C 2 33.33 D 3 50.00 E 1 16.66 Total 6 100% Comments: Necrosis is the non enhancing areas of pancreas on dynamic contrast CT. Necrosis is identified in 6 patients in this study. Table 7 : Age and Sex distribution of chronic pancreatitis. Age ( years) 0-10 11-20 21-30 31-40 41-50 51-60 61-70 Total Male % Female % Total % -02 05 04 03 03 01 18 -8.33 20.83 16.66 12.5 12.5 4.16 75% 01 01 02 -01 -01 06 4.16 4.16 8.33 -4.16 -4.16 25% 01 03 07 04 04 03 02 24 4.16 12.5 29.16 16.66 16.66 12.5 8.33 100% Comments: Incidence of chronic pancreatitis was more in males as compared to females. The commonest age group affected was between 20-40 years. Table 8: Distribution of signs of Chronic pancreatitis. Signs No. % Size Normal 03 12.5 Diffuse atrophy 13 54.16 Focal atrophy 04 16.66 Focal enlargement 04 16.66 Pancreatic Dilatation 19 79.16 duct Calculus 05 20.83 CBD Dilatation 07 29.16 Calculus 01 04.16 Pancreatic Parenchymal Calcification 03 12.5 Pseudocyst 20 83.33 Alternation in peripancreatic fat/fascia 04 16.66 375 Santosh et al., Int J Med Res Health Sci. 2014;4(2):373-379 Comments: Pancreatic ductal dilatation is defined as maximum AP diameter of the duct 5mm in the pancreatic head and 3mm in the body and tail. Pancreatic Neoplasms Table 9: Age and Sex distribution (n=9) Age Male % Female % Total % ( years) 31-40 00 -01 11.1 01 11.1 41-50 03 33.3 02 22.2 05 55.5 51-60 01 11.1 01 11.1 02 22.2 61-70 01 11.1 00 -01 11.1 Comments : The commonest age group affected in this study was elderly ie. Above 40 years with almost equal sex incidence. CT signs of pancreatic carcinomas: Table 10: CT signs of primary mass. Sign No. % Enlargement Head 04 44.44 Head 01 11.11 +Uncinateprocess Body 01 11.11 Head + Body 02 22.22 Tail 01 11.11 Density Hypodense 07 77.77 Isodense 02 22.22 Hyperdense --Size < 3 cm 02 22.22 > 3 cm 07 77.77 PD dilatation 06 66.66 CBD dilatation 05 55.55 IHBR dilatation 05 55.55 Associated pancreatic atrophy 07 77.77 Table 11: Extra pancreatic CT signs: Signs No. % Hepatic metastasis 05 55 Lymph node involvement 04 44 Vascular involvement Encasement 02 22 Occlusion 01 11 Peripancreatic infiltration 06 66 Involvement of Contiguous 03 33 organs Ascites 05 55 Pleural effusion 02 22 Comments: One patient showed presence of direct portal vein invasion and thrombosis. In 3 patients misdiagnosed as pancreatic head adenocarcinoma on USG, CT revealed periampullary carcinoma in one Santosh et al., patient and cholangiocarcinoma in two patients. These patients are not taken in this study. DISCUSSION In our two and half years experience with patients referred for CT scanning of abdomen for pancreatic region, we singled out 50 patients for our study. We had a highly selected group of patients for CT study, because of the availability of US in the hospital and strongly clinically suspected patients were taken for CT examination. Acute pancreatitis: In our study 16 patients were diagnosed as having acute pancreatitis. (32%). 12 patients (75%) were of the male sex and this was correlated with the high incidence of alcohol abuse in these patients as being the commonest cause of acute pancreatitis. Brooke Jeffery et al (1982 )[1] the cause of acute pancreatitis in 24 of 36 patients to be due to alcohol abuse, as was also noted by Gaston Mendez et al (1980) [2]. Peak age of incidence was noted in the 30-50 years age range. In B Jeffery study (1982) [1] the mean age was 41 years. In our study, 11 of 16 patients (68.75%) had diffuse enlargement of the pancreas, with focal enlargement of the pancreas seen in the 5 patients (31.25%). This correlated with Brooke Jeffery et al (1982) [1] study in which 31 of 36 patients showed diffuse enlargement and 2 patients showed focal enlargement. This also compared with Mendez et al (1980) [2] in which 32 patients showed gland enlargement. In this study, peripancreatic phlegmonous changes were noted in 7 patients (43.75%) with involvement of mesenteric root in 5(71%), perinephric spaces in 4 (57%) lesser sac in 3(42%), paraconal spaces in 2(28%) and pelvis in 1 (14%) patient. Out of 7 patients 85.7% (6 patients) were of necrotizing pacreatitis and 14.28% (1 patient) of acute edematous pancreatitis. This correlated with Hill et al (1982) [3] in which phlegmonous changes were reported in 11% of acute edematous pancreatitis and 89% of necrotizing pancreatitis. In our study, 9 patients (56.25%) had acute fluid accumulations, of which 3 patients (18.7%) had intrapancreatic, 4 patients (25%) had extrapancreatic fluid accumulations, and 2 patients (12.50%) had both extra and intrapancreatic fluid collections. Seigleman Stanley et al (1980)[4] also reported pancreatic and extrapancreatic fluid accumulations in 54% cases with 16% having intrapancreatic and 42% 376 Int J Med Res Health Sci. 2014;4(2):373-379 having extrapancreatic collections. Balthazar E J et al [5] also reported acute fluid collections in 40% of patients early in the course of acute pancreatitis of which 50% resolved spontaneously. In our study, the natural history of acute fluid collections could not be followed up, as our patients could not afford rescans. In our study we had 3 cases of pseudocyst, 2 in intrapancreatic locations and one in lesser sac. The commonest site of pseudocyst; a late sequlae of the disease, in our study was intrapancreatic location (66%) in acute pancreatitis. CT is a better investigation than US for detection of remote pseudocysts[6]. Kresses says that CT has 100% sensitivity while US has 50% in detection of extrapancreatic predocysts. In our study, no patient had Grade A, 25% had Grade B, 18.75% Grade C, 43.75% Grade D and 12.50% Grade E pancreatitis. The patients who developed two or multiple poorly defined fluid collections were of Grade E pancreatitis. Further pleural effusion in 50% cases and ascites in 25% were found in more sever grades, Grade D and E pancreatitis. The patients of Grade A, B, C had no or less number of complications like pleural effusion and ascites. Balthazar E. J (1985) [7] reported the following: Grade A 14.5%, Grade B 22.9%, Grade C 25%, Grade D 14.5%, Grade E 27.7%. Our study correlated with the study of Balthazar E J (1985) [7] for the presence of pleural effusion and ascites like complications occurs more in Grade D and E pancreatitis. Pancreatic necrosis described as focal nonenhancing low attenuation areas was noted in 6 patients (37.5%) in our study. Necrosis was not found in Grade A and B pancreatitis, but was found 33.33% in Grade C, 50% in Grade D and 16.66% in Grade E pancreatitis. These findings correlated with Balthazar E J et al (1990) [5] noted total necrosis being 20.4%. Necrosis was not found in Grade A and B pancreatitis, but was found 25% in Grade C, 50% in Grade D and 25% in grade E. Most patients with Grade D and E pancreatitis exhibited higher incidence of pancreatic necrosis detected in our study could be attributed to spiral acquisition of data during peak pancreatic parenchymal enhancement, thus allowing good discrimination between necrosed and viable portions of the gland. Chronic pancreatitis: In our study of total 24 patients were diagnosed on CT having chronic pancreatitis of these 18 were males (75%) and 6 were females (25%) with maximum patients being in the age range of 20 to 40 years (18-70 year range). The commonest findings of chronic pancreatitis in our study were pancreatic duct dilatation 79% (19 out of 24 cases), pancreatic atrophy (70%) (17 out of 24 cases), pancreatic calcification (Ducal and parenchymal) 33.33% (8 out of 24 cases). These findings co-related with the findings of P Luetmer et al (1989)[8] which were pancreatic duct dilatation (68%), pancreatic gland atrophy (54%) and pancreatic calcification (56%). Pancreatic duct dilatation has been found with varying degrees of sensitivity on CT ranging from 4% (J. Ferrucci et al 1979) [9] to 68% ( P Luetmer 1989) [8] . In our study the frequency of duct dilatation was found to be 79%. 5 out of 19 patients showed dilatation of the duct up to the Ampulla of Vater, While this sign is useful in ruling out a proximal pancreatic malignancy, it does not exclude an ampullary carcinoma (P Leutemer 1989) [10]. In our study pancreatic calcification was seen in 8 out of 24 patients (33.3%) showed presence of intraductal and parenchymal calcification. Intraductal calcification was noted in 5 patients while parenchymal calcification noted in 3 patients. This was in comparison to variable reported incidence of calcification in chronic pancreatitis from 36%[9], 52%[11], to 50%[8]. In our study we were able to differentiate intraparenchymal from intraductal calcification. This distinction could be important from the management point of view in patients with chronic pancreatitis [12]. Pseudocyst had an incidence of 83.3% in our study (20 out of 24 patients). We found 24 pseudocysts in 20 patients, with 14 being intrapancreatic located mainly in the head region and 10 being extrapancreatic region mainly in the lesser sac. One patient had the pseudocyst in the spleen. In our study incidence of preudocysts was higher as compared to other studies: 30%[9], 28% [11] and 30 %[8]. This could be attributed to later presentation of our patients of chronic pancreatitis with more severe disease and due to bias of clinical selection of patients undergoing CT. Of the 24 pseudocysts diagnosed, 9 were <6 cms size, while 15 were >6cms size. Patients with pseudocysts >6 cms presented with abdominal pain and an epigastria lump. 6 pseudocysts >6 cms were drained surgically and this correlated with the 377 Santosh et al., Int J Med Res Health Sci. 2014;4(2):373-379 findings of Yehoules Yeo and Augusto Batisdas (1990)[13]. Pancreatic atrophy was noted in 70% (17 out of 24) patients with chronic pancreatitis. Out of 17 patients, 13 patients shows diffuse atrophy and 4 patients shows focal atrophy. Of these patients, 45.8% had associated pancreatic ductal dilatation. Earlier study found frequency of atrophy to be 54%[8]. In this study, 4 patients showed focal enlargement (16.6%); 3 patients normal gland size (12.5%) but no one shows diffuse enlargement. This is comparable to the study of P Luetmer (1989) [8] (16.6%) reported foal enlargement in 30% with no diffuse enlargement. Alterations in the peripancreatic fat and fascia were noted in 16.60% (4 patients) which correlated with P Luetmer et al (1989) [8] study, in which 9% showed fascial thickening. Pancreatic neoplasms: Majority of the neoplasms are solid, adenocarcinomas representing 95% of these. They arise from the epithelium of the main pancreatic duct, accessory duct or their side branches. In our study, a total number of 9 patients with pancreatic carcinomas were diagnosed (18%) with most patients presenting in elderly age group beyond 40 years. Sex incidence is almost equal (55.5% males and 44.4% females). All tumors showed focal enlargement of the pancreas with contour deformation. The tumors were 4 (44.4%) from head, 2 from head and body and 1 each from head and uncinate process, body and tail regions of pancreas, which was in keeping with the findings of Patrick Freeny et al (1988) [14] in which 96% of pancreatic adenocorcinomas presented with focal mass, 62% of which were found in the region of the head. In our study 77.7% of tumors were found to be hypodense and 22.2% were isodense compared to parenchyma. This was in accordance with Alec Megibow’s study (1992)[15], in which 78% of patients had hypoattenuating lesion. This was attributed to the schirrous nature of the tumor, which was the same biologic characteristic that results encasement of vessels. In our study 77.7% of patients had tumor size >3cms. These tumors were found to be non-resectable at surgery. This was in accordance with the findings of David A Bluemke (1995)[16] who found that the average size of resectable tumors was <3.1 cms. The larger size of tumors at presentation could be due to the fact that pancreatic neoplasms are notoriously asymptomatic when small and only on enlarging in size causes symptoms of obstructive jaundice, that they are detected. Upstream dilatation of the main pancreatic duct was noted in 66.6% of our patients with associated pancreatic atrophy seen in 77.7% of cases. Dilatation of the common bile duct was seen in 55.5% patients with intrahepatic biliary dilatation noted in 55.5% of patients. Patrick Freeny et al (1988)[14] noted upstream dilatation of main pancreatic duct in 68% patients with associated pancreatic atrophy in 82%. Intrahepatic biliary ductal dilatation was noted in 58%. As compared to Patrick Freeny’s (1988) [14] study, of 68% local tumor extension and 42% contiguous organ involvement infiltration was noted in 66% and 33% respectively. This could be accounted for the better contrast difference between the tumor, the enhanced pancreas and the surrounding peripancretic tissue due to scanning in the peak enhancement phase of the pancreatic parenchyma using spiral CT, as compared to dynamic contrast enhanced scanning. Hepatic metastasis was discovered in 55% and enlarged nodes in 44% of our patients. Patrick Freeny (1988)[14] in his study noted metastasis to liver (36%) and regional lymph nodes (nodes greater than 2 cm.) (28%). Ascites was noted in 55% of our study patients. The above findings determined the presence of non respectable carcinomas. Vascular involvement by pancreatic carcinomas was noted in 5 patients (55.5%). 2 patients showed loss of perivascular fat planes, 2 patients showed vascular encasement and soft tissue cuffing of the vessels. In 1 patient, portal vein thrombosis was noted. Thrombosis was due to direct infiltration of the tumor into the portal vein. David Bluemke et al (1995) [16] noted portal vein invasion in 2 of 19 patients. Patrick Freeny (1989) [14] showed vascular involvement in 84% of patients. CONCLUSION In present study an attempt has been made to evaluate the role of computed tomography for evaluation of pancreatic diseases. In this study, a total number of 50 patients of pancreatic pathology were studied using spiral CT (35 male and 15 female patients). 24 378 Santosh et al., Int J Med Res Health Sci. 2014;4(2):373-379 patients were diagnosed as having chronic pancreatitis, 16 acute pancreatitis, 9 pancreatic neoplasms and 1 had simple pancreatic cyst. In conclusion, therefore, CT alone is an excellent noninvasive imaging modality with a sensitivity of about 94% in diagnosing pancreatic diseases when used judiciously in good clinical settings and accuracy of almost 100% when used in conjunction with other imaging modalities like ERCP, angiography and biopsy whenever indicated. Conflict of interest: Nil REFERENCES 1. Brooke Jeffery R, Federle Michael P, Jeffery Brooke R, Cello John P : Early computed Tomographic scanning in Acute Severe Pancreatitis ; Surgery, Gynecology & Obstetrics ; February 1982, Volume 154. 2. Mendez Gaston Jr., Isikoff Michael B, Hill Michael C: CT of Acute Pancreatitis : Interim Assessment ; American Journal of Roentgenology 135 : 463-469, September 1980. 3. Hill Michael C, Barkin Jamie, Isikoff Michael B, Silverstein William, Kaster Martin : Acute pancreatitis: Clinical vs. CT findings ; American Journal of Roentgenology 139 : 263-269, August 1982. 4. Seigelman Stanley S; Copeland Bruce E, Saba George P, et al : CT of fluid collections Associated with Pancreatitis ; American Journal of Roentgenology 134 : 1121-1132, June 1980. 5. Balthazar Emil J, Ranson J H C, Naidich David P, Megibow Alec J et al : Acute pancreatitis : Prognostic value of CT; Radiology 1985 ; 156767-772. 6. Margulis A, Kressel, Gooding , Filly , Moss, Kerobkin: CT scanning and US in the evaluation of pancreatic preudocyst – A preliminary comparison , Radiology , 126:53-157, 19778. 7. Baltharar Emil J, Robinson David L, Megibow Alec J, Ranson John HC: Value of CT in Establishing Prognosis; Radiology 1990; 174:331-336. 8. Luetmer Patrick H, Stephens David H, Ward Ellen M : Chronic pancreatitis: Reassessment with current CT; Radiology 1989, 171:353-357. 9. Ferrucci Joseph T. Jr., Wittenberg Jack, Black Edward B., Kirkpatrick Rob H., Hall Deborah A., computed Body tomography in chronic 10. 11. 12. 13. 14. 15. 16. pancreatitis; Radiology 130:175-182, January 1979. Luetmer Patrick H, Stephens David H, Fisher Albert P: Obliteration of the Periarterial Retropancreatic fat on CT in pancreatitis: An exception to the rule; American Journal of Roentgenology 153:63-64, July 1989. Kolmannskoy F., Schrumpt E., Bergan A, Larsens: Diagnostic value of computer tomography in chronic Pancreatitis : Acta Radiologica Diagnosis 22(1981). Haaga John R: The pancreas : In computed Tomography and magnetic Resonance imaging of the whole body (vol.2): Haaga John R. Lanzieri Charles F, Sartoris David J, Zerhouni Elias A; Third Edition 1994; Mosby, Harcourt, Brace & Co. Asia Pvt.Ltd. pg. 1037-1130. Yeo Charles J, Bastidas Augusto, Lynch-Nyhan Alma et al : The Natural History of pancreatic pseudocysts Documented by Computed Tomography; Surg Gynecol Obstet 1990;170:441-417. Freeny Patrick C, Marks William M, Ryan John A, et al : Pancreatic Ductal Adenocarcinoma : Diagnosis and Staging with Dynamic CT; Radiology 1988; 166:125-133. Megibow Alec J: Pancreatic Adenocarcinoma : Designing the examination to evaluate the clinical question; Radiology 1992;183:297-303. Bluemke David A, Cameron John L, Hruban Ralph H, et al : Potentially Rescetable Pancreatic Adenocarcinoma: Spiral CT Assessment with surgical and pathological correlation ; Radiology 1995; 197:381-385. 379 Santosh et al., Int J Med Res Health Sci. 2014;4(2):373-379 DOI: 10.5958/2319-5886.2015.00070.3 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS Copyright @2015 th th Received: 29 Jan 2015 Revised: 15 Feb 2015 Research article ISSN: 2319-5886 Accepted: 21st Mar 2015 MANAGEMENT OF SUPRACONDYLAR HUMERUS FRACTURE WITH CROSS K WIRES BY TRICEPS SPARING APPROACH Mattam Sanjay1, Pandurangarao KR1, Mallikarjuna Reddy C2* 1 Department of Orthopedics, MNR Medical College, Sangareddy, Medak Dist-, Telangana – 500055 Department of Microbiology, Mallareddy Medical College for Women, Suraram X Roads, Hyderabad – 500055 2 *Corresponding author email:
[email protected] ABSTRACT Background: Supracondylar fracture accounts for 60% of all fractures about elbow in children and represent 3 % of all fractures in children. The rate of supra condylar fractures steadily increases with age and reaches peak by 57 years. It is a fracture involving thin portion through coronoid, olecranon fossa or above the fossa or metaphysis of humerus. Aim: This study aimed to anatomical stable reduction of fracture and prevention of injury to ulnar nerve. Material and Methods: We performed prospective study of 122 supracondylar humerus fracture type 3 in children by open reduction and internal fixation with crossed Kirshner wires over 7years duration. The method of surgery was posterior triceps sparing. Diagnoses were made on Gartland’s classification. To study the technique [triceps sparing approach] and evaluate results of open reduction internal fixation with cross k wires. Results: Average duration of follow up of each child was one year and on overall 94 % of parents was satisfied with the results and 6% were unsatisfactory. Boys were more in number compared to girls and left elbow being more in incidence compared to right. Triceps sparing approach showed better elbow movements. Conclusion: Our study concludes that posterior approach gives better visualization of fracture, the delineated ulnar nerve enables passing of k wires without injury. Keywords: Supracondylar fracture, Anatomical stable reduction of fracture, Ulnar nerve INTRODUCTION Supracondylar fracture accounts for 60% of all fractures about elbow in children and represent 3 % of all fractures in children [1]. The rate of supra condylar fractures steadily increases with age and reaches peak by 5-7 years[2]. It is a fracture involving thin portion through coronoid, olecranon fossa or above the fossa or metaphysis of humerus. Pitfalls in management occur frequently and continue to plague the doctor and patients especially in respect to displaced supracondylar humerus fractures even to the most experienced surgeon [3]. Closed manipulation reduction with splint or cast immobilization has tradionally been recommended Mallikarjuna et al., for supracondylar humerus fractures, impending vascular compromise reported, however loss of reduction resulting in malunion of valgus and varus deformity [4]. In displaced fractures trial closed reduction should be discouraged because it predisposes to myositis ossificans, wastes time, energy and anaesthesia. Displaced Supracondylar fracture is juxtaarticular fracture, hence require perfect anatomic restoration and early mobilization. This is difficult; almost impossible to achieve by closed methods [5]. Surgical treatment has the advantage of decreased hospital stay, anatomical stable fixation and early mobilization [6] as the 380 Int J Med Res Health Sci. 2015;4(2):380-385 hematoma is washed away myositis ossificans is prevented[3]. Lateral divergent k wires fixation is equally stable however cross k wires usage is more stable as it prevents axial rotation[7,8]. Triceps sparing approach causes less soft tissue damage. MATERIALS AND METHODS Study design: We conducted cohort prospective study Sample size & study place: 122 supracondylar humerus fractures of type 3 with age range of 1-12 years, 87 male children and remaining female were studied and followed up in MNR medical college, Sangareddy from January 2007 to February 2014. Ethical clearance and informed consent were taken from patient. Inclusion criteria: Cases selected were displaced humerus fractures extension type 3 supracondylar, irreducible fractures and fractures with neurovascular complications. Each case was examined clinically and radiologically on arrival, detail status of neuro vascular structures and soft tissue injuries were noted. Pre operatively carrying angle of unaffected elbow noted. Injection tetanus toxoid and prophylactic antibiotic were administered. 1mm to 1.5 mm k wires thickness used in this series[2]All patients were given posterior elbow slab in flexion and monitoring of pulse is done and the limb kept in elevation. Surgery performed in lateral position under general anesthesia. Under tourniquet control posterior midline incision given Ulnar nerve identified and isolated figure (2). Triceps sparing approach was used in all cases. Triceps mobilized from medial and lateral side helping in better visualization of lateral, medial pillar and fracture could be manipulated with ease figure (1), (2). Under vision fracture reduction, k wire was passed figure (3). In some cases of metaphyseal comminution 3 k wires were used and the rest with two. Lateral wire passed through lateral epicondyle directed upward and medially at angle of 350 to 450 to sagittal plane of humerus at 100 posterior to coronal plane of humerus [9], medial pin passed through center of medial epicondyle which crossed 3 cm above fracture\ and the position confirmed with c-arm. Postoperative vascular status monitoring was performed. All cases were discharged on 3rd post-operative day. Every 10 days patients were called for follow up. On 12th day sutures removed slab weakened at elbow and gentle active motion started. The slab was removed at the end of third week. Pre-operative and postoperative x rays figure (4). Patients follow up was done on 3rdmonth, 6th month, and at one year. Clinical analysis of photos after consent figure (5). Range of motion and carrying angle were compared to normal side by Flynn criteria [9]. RESULTS Our observations made in this study were: incidence was higher in boys(72%) than girls (28%), peak age of incidence was 4-6 years, non-dominant elbow was more prone to injury compared to dominant. All cases were of extension type. 84% were postero medial type and 16% were lateral displacement. Age and Sex wise distribution shown in Table 1&2.In present study maximum age incidence of supracondylar fracture is in 4-6 years (48% ) the next was 10-12 years (28%). The average age incidence is 7.6 years. (Table 2).Non dominant elbow was more commonly involved in supracondylar fractures. (Table 3).All cases in this report were of extension type supracondylar fractures with postero medial displacement. (Table 4). In our series 52% came by 12hrs but 48% presented late. (Table 5).7.2% of complications was due to injury itself. Associated fractures were lower end radius. Two crossed k used wires in 93 patients. 3 k wires used in 23patients with medial comminution(Table 6).In our series the overall incidence of postoperative complication was 3% patients had restriction range of motion. Not a single case of cubtis valgus or varus deformity or other complications seen (Table 7). 3.2 % of patients had poor result, 13.2 % were good and 83% had excellent range of movement. As regards the carrying angle 92 % were excellent and 8% were good. In overall para meters according to Flynn criteria is cosmetic factor is carrying angle, functional factor is movement. (Table 8).Grading of results [Flynn 9 criteria] shown in (Table 9). Table1. Sex wise distribution Sex No of cases Percentage % Male 87 72% Female 35 28% 381 Mallikarjuna et al., Int J Med Res Health Sci. 2015;4(2):380-385 Table 9: Grading of results [Flynn [9] criteria] Table 2: Age wise distribution Age group 0-3 years 4-6 years 7-9 years 10-12years No. of patients 1 58 29 34 Percentage% 0.8% 48.% 23.8% 28% Table 3: Side distribution Side No. cases Percentage% Right side 14 12% Left side 107 88% [10] Table 4: Fracture type [Gartland’s classification] Radiological displacement of distal fragment as follows. Displacement No of cases % Type Extension type Posteromedial 103 88 Posterolateral Anterior Flexion type 19 0 Results Loss of carrying angle No. of cases Loss of carrying angle % of cases Loss of movement No. of cases Loss of movement .% of cases Excellent 112 92% 102 83,6% Good Fair Poor 010 00 00 08% 00 00 16 00 O4 13.2% 00 3.2% 12 0 Table 5: Duration of presentation since trauma Duration 0-12 hours 12-48 hours 2-7 days More than 7 days No. of .cases. 64 39 19 0 Percentage% 52% 32% 16% 0 Table 6: Preoperative complications Complications Severe edema Nerve injury (median nerve) Puncture wound Associated factures total No. of cases 3 4 Percentage 2.4% 3.2% 0 2 9 0 1.6% 7.2% Fig1: Triceps sparing approach, lateral k wire passed after fracture reduction(Triceps sparring method) Table 7: Post-operative complications Complications No of cases % Vascular injury Nerve injury Infection Restriction of motion Deformity [varus or valgus] Myositis ossificans Total 00 00 00 04 00 00 04 patients 00 00 00 3% 00 00 3.2 Fig 2: Triceps retracted ulnar nerve isolate Table 8: Restriction of motion Result excellent Loss of (range) 0-50 Good 6-100 Fair 10-150 Poor 15-20 movement No cases 102 % 00 83.6 % 13.2 % 00 4 3.2% 16 0 of 382 Mallikarjuna et al., Int J Med Res Health Sci. 2015;4(2):380-385 Fig3: k wire passed under vision after fracture reduction Fig 5: a) Elbow in Extension b) Elbow in Flexion with comparison DISCUSSION Fig 4: a) Pre Operative AP b) Pre Operative LAT 4c) Pre Operative AP 4d)Post Operative LAT 4e) Post Operative AP 3 months later 4f) Post Operative LAT 3 months Displaced supracondylar fracture is a dilemma11. Type 3 supracondylar fractures can lead to adverse physical, social and emotional consequences if they are not treated well [12]. Displaced supracondylar fracture should be reduced accurately and stabilized to have satisfactory results [13, 14]. Acceptance of compromised fracture position leads to imperfect results leading to elbow varus or valgus deformity. Peak age incidence in our article was 7.6 years which is comparable to other studies [15, 16], incidence was related to weak bone architecture and also anatomical factors [17, 18]. Our study and other author’s articles were similar in sex wise distribution of supracondylar fractures. Non-dominant or left limb is frequently used in protective reflex to support a fall [19] hence the predominance of left. Extension type of supracondylar humerus fracture were more common [20, 21] and posteromedial displacement is probably secondary to pull of triceps which originates medially and also aided by biceps, the pull of which is also medial. Majority of patients came within 12 hours of injury whereas others came late as they were referred from primary health care center or had some treatment elsewhere which is comparable. In our study we had 3.2% of pre-operative median nerve palsy which almost recovered by 5weeks comparable to fowels about 2.7 and bhan 3.0%. We didn’t have pre-operative or post-operative vascular injuries. Associated with lower end fracture of radius were 3.2% almost the same [22]. We had no pin tract infection as we buried k wires under skin unlike other articles which had pin tract infection [23] due to the percutaneous placement. We had no ulnar nerve injury as k-wires were passed under vision and buried away from the nerves course while others [24] with percutaneous insertion had 1.1% ulnar nerve injury [25], out of 375 patients 19 recovered but 2 had permanent damage [26] lateral pinning showed 3.4 % nerve injury, 4% with medial pinning [27]. Range of motion was 96% satisfactory, comparing to other studies ours was much better. This probably is due to the sparing of the entire triceps from any injury 383 Mallikarjuna et al., Int J Med Res Health Sci. 2015;4(2):380-385 and scarring which would allow recovery of flexion and extension as its tone and strength are maintained. Over and above the posterior approach allows anatomic reduction and the usage of crossed k wires in addition to giving a stable fixation prevents angular rotation [28]. 3.2% had poor results as they were little irregular in follow-up due to economic (poverty) and social (far off distance) factors. Imperfect anatomical alignment and unstable fracture fixation leads to loss of carrying angle [29]. We had 24 % medial comminution so in those patients, we used lateral two pins and medial pin to give better rotational stability [30, 31], and probably this is reason for no cubitus varus cases in our study. We didn’t have migration of k-wire as they were bent and flushed with bone. No pin tract infection was seen as the k wires were not left outside the skin. 5. 6. 7. 8. CONCLUSION Our study concludes that posterior approach gives better visualization of fracture, the delineated ulnar nerve enables passing of k wires without injury. Median nerve injuries protected by pinning the k wire 100 postero-lateral to coronal plane. Triceps sparing approach has less scaring so better flexion and extension, cross k wire gives more stability to enable early mobilization. 9. 10. ACKNOWLEDGEMENT 11. We sincerely thank, Mr. M. RaviVerma, Director, MNR Medical College for his encouragement. 12. Conflict of Interest: Nil REFERENCES 1. D’Amboise, R D: supracondylar fractures of humerus prevention of cubitus varus, JBJS 1972; 54:60-66. 2. Kaye E and Beauty H J: Supracondylar fractures of the distal humerus. Chyapter-14 in: Rockwood and Wilkin’s Fractures in Children, Philadelphia: Lippincott Williams & Wilkins 2001, 3: 577-20. 3. Krishna Kumar S: Operative treatment of supracondylar fracture in children, Indian Journal of Orthopaedic 2000; 4: 271-74. 4. Canale T S. Ed: Fractures and dislocations in children. Chapter-50 in Campbell’s Operative 13. 14. 15. 16. Orthopaedics.. New York; Mosby: 1998; 3:240722 Laud N S, ShekarKumta and Suryanarayana: Open reduction of displaced supracondylar fractures of the humerus in children result of 100 consecutive cases Clinical Ortho. India 1988; 2: 41-55 Weil and A J Meyer Stephan, Tolo V T, Berg H L and Mueller Johanes: Surgical treatment of displaced supracondylar fractures of the humerus in children. Analysis of fifty-two cases followed for five to fifteen years; JBJS 1978; 60: 657-61. Campbell CC; Waters PM , Emans J B, Kasser Jr and Millis MB : Neuro vascular injury and displacement in type III supracondylar humerus fractures : J. Ped. Orthop.1995; 15:47-52. Feng,chao md; guo, yuan MD; zhu, zhenhua MD, zhang, jilaniMD,wang, yukun MD ; Biomechanical analysis of supracondylar humerus fracture pinning for fractures with coronal lateral obliquity . journal of pediatric orthopedics. 2012; 32: 196-200. Flynn J C, Mathews J G and Benoit R L : Blind pinning of displaced Supracondylar fractures of the humerus in children in full extension and supination ; JBJS, 1974;56: 263-73. GartladJ: Management of supracondylar fractures in children; Gynecol. obstet .1995; 109:145-54. Mc Laughlin H L : Trauma Philadelphia , 4th ed W.B. Saunder Co., 1959;90 Mulpuri, Kishore MBBS MS (ortho), wilkin s, kyeDrm, Md; The treatment of displaced supracondylar fractures: evidence based guide lines.journal of pediatric orthopedics,sept-2012; 32: 143-52. Graham H A: Supracondylar fractures of elbow in children .clin. orthop., 1962;54: 85 – 92, Watson-Jones R : Fractures and joint injuries, 4th ed. Edinburgh ES. Livingstone, 1955;100 Edwards Abhram, AlexandarG: Management of supracondylar fracture of humerus with condylar involvement in children: J. Ped. Orthop. 2005; 5:60. Supracondylar humerus fractures: Biomechanical analysis percuteanous pining techniques: Steven S Lee, Andrew T M, Mahar M S, Doughiesn. B S: Displaced pediatric J. Paed. Orthop. 2002; 22:.4 384 Mallikarjuna et al., Int J Med Res Health Sci. 2015;4(2):380-385 17. Fleurinan-Chateau P: An analysis of open reduction of irreducible supracondylar fractures of the humerus in children; Can J. Surgery .1998; 41:2. 18. Wilkins K E: Fractures and dislocations of the elbow region. Chapter 6 in Rockwood and Wilkins Fractures in Children, 3rd edition, Philadelphia; J.B. Lippincott, 1991; 509-28. 19. Swenson A L: The treatment of Supracondylar fractures by Kirschner Wire Transfixation. JBJS; 1948; 30; 993-97. 20. Pirone A M, Krajbich, Graham : Management of displaced Supracondylar fractures of humerus in children – Extension type . JBJS; 1988; 70:641649, 21. Jong Sup Shim, and Yong Seuk Lee: Treatment of completely displaced supracondylar fractures of humerus in children by Cross-fixation with three Kirschner wires. J. Pediatric Orthop. 2002; 22: 1. 22. Kumar R, Kiran E K, Malhotra R, BhanS : Surgical management of the severely displaced supracondylar fractures of the humerus in children. Injury. 2000;33(6): 517-22 23. Fowels J V and Kassab M T: Displaced Supracondylar Fractures of the Elbow in children ; JBJS 1974;56: 490-500. 24. Edmonds , Eric w MD, Roo croft, joannah, MA Mubarak, scott j. MD. Treatment of displaced pediatric supracondylar humerus fractures requiring fixation; reliable and safer cross pinning technique. Journal of pediatric orthopedics. 2012;4: 38-41 25. Lyons, james p MD, Hoffer, M.mark MD; ulnar palsies after percutaneous cross pinning of supracondylar fractures childrens elbow. Journal of pediatric orthopedics, 1998; 18(1): 43-45. 26. Sloboean, Bronwynl, Jakman, Heather, Tenant, sally; iatrogenic ulnar nerve injury after surgical treatment of displaced supracondylar fracture of humerus:-a systemic review. Journal of pediatric orthopedic-2010; 5: 430-36 27. Babal, Jessica C. BS; Mehlman, Charles T. DO, MPH; Klein, Guy BS. Nerve Injuries Associated With Pediatric Supracondylar Humeral Fractures: A Meta-analysis. Journal of Pediatric Ortho paedics: 2010; 4: 3253-63. 28. Gruber martin MD, Healy, William A MD; Posterior approach to elbow revisited; journal of pediatric orthopedics, 1996; 16(2): 215-19. 29. McLennan Alexander: Common fractures about the elbow joint in children. Surg Gynec and Obstet.; 1937; 64: 447-53. 30. Mubarak S J, David S J R: Closed reduction and percutaneous pining of supracondylar fracture of humerus in child. Master techniques in Orthopaedic surgery. Morrey B F: The elbow New York: Raven press 1994: 6:37 –51. 31. Jong Sup Shim, and Yong Seuk Lee: Treatment of completely displaced supracondylar fractures of humerus in children by Cross-fixation with three Kirschner wires. J. Pediatric Orthop. 2002; 22: 1. . 385 Mallikarjuna et al., Int J Med Res Health Sci. 2015;4(2):380-385 DOI: 10.5958/2319-5886.2015.00071.5 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS st Received: 31 Jan 2015 Revised: 10th Feb 2015 Research article Copyright @2015 ISSN: 2319-5886 Accepted: 9th Mar 2015 PATTERN OF ANTIMICROBIAL USE FOR URINARY TRACT INFECTION DURING PREGNANCY IN A TERTIARY CARE TEACHING HOSPITAL *Haldia Priyanka1, Sharma Taruna2, Nautiyal Ruchira3 1,2 Department of Pharmacology, 3Department of Obstetrics & Gynaecology, Himalayan Institute of Medical Sciences (HIMS), Swami Rama Himalayan University (SRHU), India *Corresponding author email:
[email protected] ABSTRACT Background: Urinary Tract Infection (UTI) may be classified as lower (cystitis and asymptomatic bacteriuria) or upper urinary tract infections (pyelonephritis). The recommended antibiotics for use in pregnancy for management of ASB include amoxicillin, oral cephalosporins and nitrofurantoin; and for the treatment of lower UTI during pregnancy include penicillins, oral cephalosporins. Data from the antibiotic usage study in UTI during pregnancy will help in establishing a proper antibiotic utilisation guideline and promotes rational prescribing of medicines. Aim: To study the antimicrobial prescription practices for urinary tract infection during pregnancy. Materials & Methods: The study was conducted in the Department of Pharmacology and Department of Obstetrics & Gynaecology, Himalayan Institute of Medical Sciences (HIMS), Dehradun, over a period of 12 months. This was an observational cross sectional study done in 45 pregnant women with or without symptoms of UTI. Results: 29.4% of the pregnant women with symptomatic UTI were culture positive while all were culture positive who had asymptomatic UTI. Cephalosporins were most frequently prescribed followed by nitrofurantoin. Conclusion: Urine culture should be performed as a screening and diagnostic tool for UTI during pregnancy. Various classes of antimicrobials were being prescribed for UTI during pregnancy. Keywords: Antimicrobials, Urinary Tract Infection, Pregnancy INTRODUCTION Urinary Tract Infection (UTI) is caused by pathogenic invasion of the urinary tract which leads to inflammatory response of the urothelium [1]. Organisms causing bacteriuria are similar in both pregnant and non pregnant women, with Escherichia coli [E. coli] being the most common pathogen [2]. UTI may be classified as lower [cystitis and asymptomatic bacteriuria] or upper urinary tract infections (pyelonephritis). Pregnancy enhances the progression from asymptomatic to symptomatic bacteriuria (abdominal pain, urinary frequency, urgency, fever, loin tenderness) which could lead to pyelonephritis and adverse maternal and fetal outcomes [3]. Early screening of asymptomatic bacteriuria (ASB) in pregnant women should be done [4] . Quantitative urine culture is the gold standard for the diagnosis of bacteriuria [5]. The recommended antibiotics for use in pregnancy for management of ASB include amoxicillin, oral cephalosporins and nitrofurantoin (50-100mg four times daily or 100mg twice daily for 3 days) [6]. Recommended antibiotics for the treatment of lower UTI during pregnancy include the Food & Drug Administration (FDA) category B antimicrobials including penicillins (amoxiciilin 500mg three times daily for 3 days or ampicillin 250mg four times daily for 3 days), oral Priyanka et al., Int J Med Res Health Sci. 2015;4(2):386-390 386 cephalosporins (250mg four times daily for 3 days). Upper UTI during pregnancy should be treated preferably with parenteral cephalosporins, penicillins with beta lactamase inhibitors or monobactams [7]. The antibiotic chosen should have a good maternal & foetal safety profile, excellent efficacy and low resistance rates in a given population [8]. Antibiotics are usually given empirically before the laboratory results of urine culture are available. To ensure appropriate therapy, current knowledge of the organism that causes UTI and their antibiotic susceptibility pattern is mandatory [9]. Data from the antibiotic usage study in UTI during pregnancy will help in establishing a proper antibiotic utilisation guideline and promotes rational prescribing of medicines. Hence this study was carried out to study the pattern of use of antimicrobials for UTI during pregnancy. MATERIAL AND METHODS Ethics clearance: Ethical clearance was obtained from the Ethics Committee prior to initiation of study. Written informed consent was obtained from each subject prior to sample collection. Study design: This was an observational cross sectional study Sample size: 45 pregnant women (20-40 years). Study place & period: The study was conducted in the Department of Pharmacology and Department of Obstetrics & Gynaecology, Himalayan Institute of Medical Sciences (HIMS), Dehradun, over a period of 12 months from November 2012 till October 2013. Inclusion criteria: Pregnant women with or without symptoms of UTI were recruited in the study irrespective of their age, race, parity, gravida and trimester. Exclusion criteria: Those on antimicrobial therapy for any preexisting infection Previous history of UTI, pyelonephritis, obstructive uropathy, chronic renal disease Urine bag collected specimens Specimens submitted in leaking or dirty unsterile container Specimens revealing growth of more than two types of bacteria on culture Relevant information reviewing socio demographic details, medical history, obstetrical and gynaecological history, UTI signs and symptoms and Priyanka et al., drug history were taken on case reporting form. Pregnant women were started on empirical antimicrobial treatment which was modified later according to the susceptibility pattern of the urine culture report. Fresh midstream urine was collected aseptically in sterile wide mouth capped disposable universal container on the same day of enrolment. Urine samples were labelled and immediately the sample was processed for microbiology and parasitology with the help of expert microbiologist. Urine culture was done to study the distribution of pathogens. The isolated organisms from culture plates were identified by standard laboratory techniques. Antimicrobial susceptibility testing was done by Kirby Bauer disc diffusion method as recommended by Clinical Laboratory Standards Institute (CLSI) M2-A9 [10]. Women were followed up weekly for one month to look for symptomatic cure, recurrence due to inadequate therapy or resistance. Repeat urine culture was done on the last follow up to confirm bacteriological cure. Data was analysed using Microsoft (MS) Excel & Statistical Package for Social Sciences (SPSS) version 22. Graphical representation of the data was done in terms of figures using MS Excel 2007. Data was presented in descriptive statistics using percentage and proportions. RESULTS A total of 45 pregnant women were included in the study and followed up weekly till one month. Table 1 show that out of 45 pregnant women, maximum women were found in 20-25 age group. Overall mean of age was 25.04 ± 3.29 years. Figure 1 show that out of 45 pregnant women, maximum were symptomatic. Of the asymptomatic women, all were culture positive while of the symptomatic women only 29.4% were culture positive. Table 2 shows that of the 19 cases, Gram negative bacteria were isolated in 52.3% and Gram positive in 38.1% of the culture isolates. E. coli was the predominant organism among the gram negatives and CONS (Coagulase Negative Staphylococci) among the gram positives. Yeast was also present in 9.6% cases. Table 3 shows that cephalosporins were the most commonly used class of antimicrobials 41.7% followed by nitrofurantoin 29.2%. Figure 2 show that Nitrofurantoin was the most commonly prescribed antimicrobial followed by Cefuroxime axetil. All these antimicrobials were 387 Int J Med Res Health Sci. 2015;4(2):386-390 prescribed empirically while Linezolid and Fluconazole were prescribed after the culture report showed resistance to the initial antibiotic being prescribed. Table 1: Age wise distribution of pregnant women (n=45) Age Group [years] Percentage [%] 64.5 33.3 2.2 Number 20 – 25 26 – 30 > 30 29 15 1 Fig 2: Distribution of various antimicrobials in pregnant women with UTI (n=45) DISCUSSION Fig 1: Clinical presentation of UTI in pregnant women (n=45) Table 2: Distribution of culture isolates in pregnant women with UTI (n=21) Organism E.coli Klebsiella oxytoca Proteus vulgaris Enterobacter aerogenes CONS Staph aureus Enterococcus faecalis Yeast Gram stain GNB GNB GNB Number 8 1 1 % 38.2 4.7 4.7 GNB 1 4.7 GPC GPC 5 2 23.8 9.6 GPC 1 4.7 2 9.6 GNB – Gram Negative Bacilli; GPC – Gram Positive Cocci Table 3: Distribution of class of antimicrobials in pregnant women with UTI (n=45) Class of Antimicrobials Penicillin-beta lactamase inhibitor Cephalosporins 2nd generation 3rd generation Number % 7 14.5 20 14 6 41.7 29.2 12.5 Cephalosporin-beta lactamase inhibitor 5 10.4 Nitrofurantoin 14 29.2 Miscellaneous 2 4.2 Pregnancy is a unique state with profound anatomic and physiologic urinary tract changes that facilitate the development of symptomatic UTI. UTI itself is no threat to the pregnant women or the foetus, but it may progressively spread to the bladder and kidneys causing cystitis and pyelonephritis respectively as well as prematurity, low birth weight, foetal growth retardation, still birth, mental retardation, developmental delay and increased perinatal mortality in the foetus. It is clear that ASB is a major risk factor for developing symptomatic UTI. Screening of ASB in pregnancy has become a standard of obstetric care. All women should be screened at the first antenatal visit preferably in the first trimester for the presence of bacteriuria with urine culture. Prompt treatment is needed to prevent the serious life threatening condition and morbidity due to UTI. It has been recommended that after patients have completed their treatment course, a repeat culture should be done to document successful eradication of bacteriuria. The aim of the treatment is to maintain sterile urine throughout pregnancy without causing toxicity to the mother or foetus [11]. The present study was conducted to study the pattern of antimicrobial usage for UTI during pregnancy. In the current study maximum numbers of women were in age group 20-25 years. Similarly Okonko and Ijandipe et al; and Olsen and Hinderaker et al also showed that maximum number of women were in the age group 15-24 years [12]. The higher prevalence of UTI in younger age group may be attributed to various factors like lack of personal hygiene and 388 Priyanka et al., Int J Med Res Health Sci. 2015;4(2):386-390 health awareness, low education status and early age of marriage in developing countries. Majority of the pregnant women had ASB which is higher than that reported by Sabharwal [13]. Higher prevalence of UTI may be attributed to various factors such as low socioeconomic status, illiteracy, poor housing and drainage system. Furthermore, HIMS acts a tertiary care referral hospital in a rural setting where more serious high risk pregnancies, symptomatic patients with bad obstetric history are referred from nearby nursing homes and private practitioners. Early screening of all pregnant women is therefore recommended because timely intervention with the appropriate antibiotics can prevent drastic consequences. Prevalence of symptomatic bacteriuria in the present study was 29.4% which was similarly seen by Rizvi and Khan et al 25.2% [14]. Gram negative bacterial isolates on culture were more prevalent than gram positive bacterial isolates. Similar pattern has been observed in all other studies. E. coli was the most common gram negative pathogen isolated which is in accordance with all other studies. More prevalence of E. coli could be due to the fact that urinary stasis is common in pregnancy and since most E. coli strains prefer that environment, they cause UTI. Among the gram positive cocci, CONS was isolated more frequently which matches with many other studies. In few cases yeast was also isolated in the present study. They are less common organisms causing UTI. In the present study all pregnant women were screened by urine culture and were started on empirical therapy initially which was modified later according to susceptibility pattern. Linezolid and Fluconazole were prescribed as definitive therapy after the culture report of antibiotic susceptibility pattern showed resistance to the initial antimicrobial prescribed. The study of prescribing pattern is a component of medical audit, which seeks monitoring, evaluation in the prescribing practices of prescribers to achieve rational medical care. Various classes of antimicrobials were prescribed for UTI during pregnancy in the present study. Cephalosporins were most frequently prescribed followed by Nitrofurantoin. Nitrofurantoin has minimal side effects and can be safely used for the treatment of uncomplicated cystitis and ASB even during pregnancy[8].Cephalosporins are recommended for initiating therapy for pyelonephritis[15] and they were the most commonly used antimicrobials in the present study. Widespread empiric use of antibiotics, while convenient, potentially contributes to development of antimicrobial resistance. Although irrational and unnecessary use of drugs in India has been documented before, to the best of our knowledge there are no other studies from India where antibiotic use in pregnant women has been addressed. It is likely that our findings reflect the reality in many other developing countries. Encouraging guideline based treatment is an important aspect of changing prescribing behaviour, a goal of antibiotic stewardship. The main limitation of the study was short duration and small number of pregnant women with UTI. Future studies are recommended with a large sample size and conducted over a longer period of time to establish a trend in antibiotic prescription. The present study has highlighted the need to raise awareness of UTIs during pregnancy and to expand services for prevention and treatment of UTI in pregnant women. Priyanka et al., Int J Med Res Health Sci. 2015;4(2):386-390 CONCLUSION It is concluded from the present study that there was a high prevalence of ASB among pregnant women. It is therefore imperative that early screening of bacteriuria in pregnancy must be considered as a part of routine antenatal care. Urine culture should be performed as screening and diagnostic tool of UTI in pregnancy. Escherichia coli was the most common isolated organism followed by CONS. All pregnant women with UTI should be treated. Cephalosporins were the most commonly prescribed antimicrobials followed by Nitrofurantoin. Periodic and continuous follow up is mandatory to reduce the consequences of ASB and symptomatic UTI. ACKNOWLEDGEMENT We sincerely thank all the subjects who gave consent and participated in the present study. Conflict of Interest: Nil REFERENCES 1. Prakasam KA, Kumar KD, Vijayan M. A cross sectional study on distribution of urinary tract infection and their antibiotic utilisation in Kerala. International Journal of Reasearch in Pharmaceutical and Biomedical Sciences. 2012;3(3):1125-30. 389 2. Macejko AM, Schaeffer AJ. Asymptomatic Bacteriuria and Symptomatic Urinary Tract Infections During Pregnancy. Urologic Clinics of North America. 2007;34(1):35-42. 3. Nicolle LE. Screening for asymptomatic bacteriuria in pregnancy. Canadian Guide to Clinical and Preventative Health Care. Ottawa: Health Canada; 1994;(2) 100-6. 4. Nicolle LE. Asymptomatic bacteriuria: review and discussion of the IDSA guidelines. International Journal of Antimicrobial Agents. 2006;28:42-8. 5. Jennifer P, Cyril R, Pyumi P, Nimesha G, Renuka J. Asymptomatic Bacteriuria in Pregnancy: Prevalence, Risk factors and Causative organisms. Sri Lankan Journal of Infectious Diseases. 2012;1(2):42-6. 6. Law H, Fiadjoe P. Urogynaecological problems in pregnancy. Journal of Obstetrics and Gynaecology. 2012;32:109-12. 7. Krcmery S, Hromec J, Demesova D. Treatment of lower urinary tract infection in pregnancy. International Journal of Antimicrobial Agents. 2001;17(4):279-82. 8. Schnarr J, Smaill F. Asymptomatic bacteriuria and symptomatic urinary tract infections in pregnancy. European Journal of Clinical Investigation. 2008;38(S2):50-7. 9. Alemu A, Moges F, Shiferaw Y, Tafess K, Kassu A, Anagaw B. Bacterial profile and drug susceptibilty pattern of urinary tract infection in pregnant women at University of Gondar teaching Hospital, Northwest Ethiopia.2012; 5:197 10. CLSI. Performance standards for antimicrobial disk susceptibility tests. Clinical Laboratory Standards Institute: M2-A9: Wayne, PA; 2006. 11. Mathai E, Thomas RJ, Chandy S, Mathai M, Bergstrom S. Antimicrobials for the treatment of urinary tract infection in pregnancy: practices in Southern India. Pharmacoepidemiology and Drug Safety. 2004;13:645-52. 12. Okonko IO, Ijandipe LA, Ilusanya OA, Donbraye-Emmanuel OB, Ejembi J, Udeze AO, et al. Incidence of urinary tract infection (UTI) among pregnant women in Ibadan, SouthWestern Nigeria. African Journal of Biotechnology. 2009;8(23):6649-57. 13. Sabharwal ER. Antibiotic Susceptibility Patterns of Uropathogens in Obstetric Patients. North American Journal of Medical Sciences. 2012;4:316-9. 14. Rizvi M, Khan F, Shukla I, Malik A, Shaheen. Rising Prevalene of Antimicrobial Resistance in Urinary Tract Infections During Pregnancy : Necessity for Exploring Newer Treatment Options. Journal of Laboratory Physicians. 2011;3(2):98-03. 15. Duff P. Antibiotic selection in obstetrics: making cost-effective choices. Clin Obstet Gynecol. 2002;45:59-72. Priyanka et al., Int J Med Res Health Sci. 2015;4(2):386-390 390 DOI: 10.5958/2319-5886.2015.00072.7 International Journal of Medical Research 10.5958/2319& Health Sciences5886.2015.00072.7 www.ijmrhs.com Volume 4 Issue 2 rd Received: 3 Feb 2015 Research article Coden: IJMRHS Copyright @2015 ISSN: 2319-5886 th Revised: 28 Feb 2015 Accepted: 16th Mar 2015 SEX PREFERENCESAMONG RURAL COMMUNITY: PUBLIC HEALTH AND SOCIAL CONCERN *Aalok Kumar Singh1, Dr. Sunil Thitame2, Reecha Ghimire3 1,3 M. Sc. Public Health (PG Student), Centre for Social Medicine, Pravara Institute of Medical Science, Loni, Ahmednagar, Maharshtra 2 Assistant Professor, Centre for Social Medicine, Pravara Institute of Medical Science, Loni, Ahmednagar, Maharshtra *Corresponding author email:
[email protected]/
[email protected] ABSTRACT Background: Sex preference is choice of selecting the sex of children by their parents or family members. The objective of the study was to study the existence of sex preference among rural community. Material and methods: A Cross-sectional study was carried out among 200 ever married women of reproductive age group. Random digits sampling method was used to select 10 villages in Rahata Tehsil of Ahmednagar, while systematic sampling was applied for selection of 20 samples in each village. Results: In the previous sex preference for male child was 37.3%, 58.75%, 88.5%, 100% and 100% from firstchild to fifth respectively, while female preference and either sexpreference was decreasing. In the current sex preference for male, female and either was 36.8%, 25% and 38.2% respectively. Future sex preference was 40.9% for male child, 22.7% for female child and 36.4% for either sex. The main reason for son preference was for old age care and support, to continue the family name and earning member in the family. Conclusion: Study confirms that son preference still existsin the rural community of Maharashtra. Attitude for son preference is mainly because of the economic earning, old age care and continuation of the family nameamong all groups. Keywords:Fertility preference, Sex preference, Son preference INTRODUCTION Sex preference is choice of selecting the sex of children by their parents or family members. It is observed from historical evidences that, human beings have tried to influence the sex of their offspring’s, through termination of pregnancy, infanticide and neglected care. In the mid of the 20th century, due to revolution in technologies, easy detection of sex in pregnancy became possible which then led to sex selective abortion’s. Parents mostly prefer male child and ultimately the sex ratio is imbalanced. Son preference, low status of women, social and financial security associated with sons, socio-cultural practices, including a dowry and violence against women are the major reasons for the imbalance in sex ratio.[1,2,3] Though the sex selective abortion is a fairly modern phenomenon, its roots can be traced back to the age old practice of female infanticide.[1]One of the major causes of son preference in India is related to the perceived economic utility of having sons and old age care. Indian men are also responsible for the funeral rites of their parents and are the only ones who can light the funeral pyre. [1,2,4] Sex preference is the social issue and it is also a bad indicator of a healthy society. Hence, this study was carried out to study the existence of sex preference 391 Aalok et al., Int J Med Res Health Sci. 2015;4(2):391-395 among rural community of Rahata tehsil of Ahmednagar district of Maharashtra. MATERIAL AND METHODS Type of study: The cross-sectional study was carried out in the rural community of Ahmednagar district of Maharashtra (November 2013 to April 2014). Sample size:The sample size was calculated by n=z2pq/d2, where p=0.59, q=0.41, d=0.07 and z=1.96. 10 villages were selected by simple random sampling (random digits) method, while in each village 20 samples were selected by a systematic sampling method.This study was carried out among 200 ever married women who had achild less than five years old (unsterilized mother) or had no child. Ethical approval: Ethical clearance was obtained from the Institutional Research Committee prior to research. Confidentiality and privacy were maintained during the interview process and participation in the study was voluntary. Methodology:All the respondents were interviewed with semi-structured questionnaire, which included 37 questions.Sex preference related questions were taken from NFHS-3 survey, other related research and some were designed by research guide and myself and pilot study was conducted in 15 sample cases; finalcorrection was made and approved by institutional research committee.Collected data was analyzed by using SPSS software (version 21). RESULTS Socio-demographic information: Among the total respondent, 51.5% were of the age 20-25 years, followed by 23.5% (15-20 years), 21% (25-30 years) and the remaining were above 30 years old.Nearly one third of respondent got married at age less than 18 years i.e. 34.5% of total respondent and remaining got married at age of 18 and more than 18 years.Among total respondents, 7% were illiterate, 3.5% were educated up to primary level,69% educated up to secondary level, 12.5% higher secondary level and 8% above the higher secondary level. 81% of the respondents were housewife, 8.5% daily wage labour, 6% agriculture worker and remaining were govt. and private job holder. Among the total, 39% of the families were dependent on daily wages, 38.5% had a small business, while 16% had private job, 9.5% had farming and 4.5% had a government job. 66% of respondents belong to above poverty line, while 34% belongs to below poverty line. Previous sex preferences: Previous sex preference is the preference of a particular sex for a previous pregnancy by individuals, couple or family. Out of 200 respondents in the study, 159 respondents had at least one child. Table1: Birth order of children for previous fertility Birth order of child 1st Child 2nd Child 3rd Child 4th Child 5th Child Total children Male (%) 84 (52.8) 29 (36.2) 9 (34.6) 1 (16.6) 1 (50) 124 (45.4) Female (%) 75 (47.1) 51 (63.7) 17 (65.3) 5 (83.3) 1 (50) 149(54.5) Total children(%) n=159 (100) n=80 (100) n=26 (100) n=6 (100) n=2 (100) N=273 (100) The reasons for more than two children were, 76.9% respondents continued for more than two children because they wanted a son, 15.4% wanted more children, while 7.7% had other reasons. Table2: Sex preference of children in previous fertility 1st child Male(%) 60 (37.7) Female(%) 19 (11.9) Either(%) 80 (50.3) Total(%) 159 (100) Preference 2nd child 47 (58.75) 19 (23.75) 14 (17.5) 80 (100) 3rd child 23 (88.5) 2 (7.7) 4th child 6 (100) 0 1 (3.8) 0 26 (100) 6 (100) 5th child 2 (100) 0 Total 138 (50.5) 40 (14.65) 0 95 (34.79) 2 273 (100) (100) Table-2 revealed that; male child preference up to fifth child has increased drastically. Male child preference for the fourth and fifth children was 100%. This may be in the case of families who were waiting for a son. Table 3: Sex preference for second child VS sex of first child Sex of first child Preference for second child Male Female Either Outcome of Total 2ndchild Male (%) 7 (18.9) 18 (48.6) 12 (32.4) 37 29 (36.3) Female(%) 40 (93) 43 51 (63.7) Total (%) 47(59) 80 80 (100) 1 (2.3) 2 (4.7) 19 (23.8) 14 (17.5) χ2 = 45.329, d. f. = 2, P = < 0.001 (CL=95%) 392 Aalok et al., Int J Med Res Health Sci. 2015;4(2):391-395 Among 200 respondents, 80 had at least two children. Those women who had two children, the sex preference for second child was very high and mainly women who had first female child, 93% of them wanted to have a second child as male. Current sex preference: Current sex preference is preference of sex of baby for the current pregnancy. Among 200 respondents in the study, 76 respondents (women) were pregnant. Out of which, 36.8% wanted male child, 25% wanted female child, while remaining 38.2% wanted either sex. For the current pregnancy, sex of the baby was mostly preferred by the couple that is 63.2%, followed by 22.4% by all family members, 7.9% by the husband alone and 6.6% by herself. Table 4: Current sex preference among respondents had one child Current sex preference Sex of first child Male (%) Female (%) Either (%) Total (%) Male 3 (10.3) 14 (48.3) 12 (41.4) 29 Female 18 (100) 0 (0) 0 (0) 18 Total 21(44.7) 14 (29.8) 12 (25.5) 47 χ2 = 36.118, d. f. = 2, P = < 0.001 (CL=95%) 22.72% want female child while remaining wants either sex. There were 13 women who want at least two children, among that 15.38% want male child, 23.07% want a female child, while 61.53% wants either. Table 6: Sex preference future child who had one child Future preference Sex of First child Male (%) Female (%) Either (%) Male 2 (8.3) Female 28 (93.3) Total 30 (55.6) Total (%) 16 (66.7) 6 (25) 24 (100) 0 (0 ) 2 (6.7) 30 (100) 16 (29.6) 8 (14.8) 54 (100) The respondents who had one child and desire for the second child were 54, among those respondents who had one female child, 93.3% of respondentspreferred male child in the future. Attitude towards sex preferences:According to the majority of respondents, they preferred male child in old age care and support, i.e. 66.5%, to continue the family name (47%), active and earning member of the family (26%), other reasons were business, agriculture, funeral values, societal values etc. Those who had a male child at their first pregnancy (29), among them 10.3% wanted a male child again, 48.3 wanted female child and 41.4% wanted either sex. Those who have a female child at their first pregnancy (18), all 100% respondents wanted a male child in their current pregnancy. The chi-square test was applied to find out the association between sex of the first child and preference of the current pregnancy, it was found statistically significant. Reasons for preference of daughter was totake care of family i.e. 38.5%, attachment with the mother (35%), daughter as a son (20%), old age care (8.5%), daughter work hard in the family (7%), societal value related to daughter (6%), take care of two families (6%) and other reasons (8.5%) while 1.5% respondent doesn’t mention any reason or they don’t know. Future sex preferences: Future sex preference is the desire for particular sex of the future baby by individuals, couple or family. Among the total respondents (200) of study, 110 i.e. 55% did not want any more children, 37.5% want one child, 6% want two children and 0.5% want three children, while 1% were not decided at the time of interview. Table 5: Sex preference for future birth order DISCUSSION Sex preference First child Second child Third child Male(%) 36 (40.9) 2 (15.4) 1 (100) Female(%) 20 (22.7) 3 (23.1) 0 Either(%) 32 (36.4) 8 (61.5) 0 Total(%) 88 (100) 13 (100) 1 (100) There were 88 women who want at least one child in the future, among them 40.9% want male child, Aalok et al., The main reasons behind for not preferring a female child was dowry (25.5%), she goes to her husband’s house (27.5%), burden for family (21%), not earning member (4%) other reasons (3%). A sex preference is the main reason for decreased sex ratio in India.[5]From study, it is observed that, more than half of the respondents had no preference for sex. However, sex preference for male child was high. A similar study was conducted in rural Maharashtra among men showed; 53.8% preferred son.[6] Another study was conducted among men and women in rural area of Andhra Pradesh with regard to sex preference for first child, 70% men and 55% of women wanted first male child, which is more than this study.[7] Research conducted in Chandigarh also 393 Int J Med Res Health Sci. 2015;4(2):391-395 showed that, 57.8% of mother wanted a first baby as a boy and only 14.4% wanted a baby as a girl.[8] Sex preference of the second child mainly depends on the sex of a first child and preference is comparatively very high in the second child. From table-2, it is seen that sex preference for male child become stronger for second child. A similar phenomenon was seen for a third, fourth and fifth child. This study revealed that women who had more than three children continued in want of only a male child. The current sex preference was, 36.8% wanted male child, 25% wanted female child and 38.2% wanted either. Among those women who had one child, and currently pregnant; the sex preference was also very high. 100% women who had a first female child preferred male child on current pregnancy. They think at least one son needs for the family. ‘A study on ideal sex composition’ showed that, 59.8% wanted at least two sons and 31.1% wanted one son while 87.1% of women wanted at least one daughter.[9] Sex preference for future children among the total respondents who had a desire for future children was 40.9% for male child, 22.7% for female child and 36.36% for either sex. A study conducted in Bangladesh among men, 31.5% prefer son, 1.4% daughter while remaining 66.9% had no preferences.[10]From cross-table (Table-6), it revealed that 93.3% respondent those who had one female child and willing to have a second child, they preferred male child. The most common reason for preferring a male child was the old age care and support (66.5%), to continue the family name (47%), economically active and earning member for family (26%), agriculture work (1.5%), business (2.5%), societal values (3.5%), funeral values (1.5%) and other reasons were 9%. A similar study was conducted in rural area of Pune district of Maharashtra; the reasons for son preference were ‘support in old age’ i.e. 57.14%, while demand for male child by ‘other family member and community’ (32.88%).[11]In another study in Maharashtra showed that, 46% of men reported strong son preference for supporting each other, while another 23% preferred for old age support and 21% felt that there is a risk of survival of the child and remaining 8% felt the need of sons for continuity of the family name.[6]A research conducted in Gujarat found the reasons for male child preference was social responsibilities carried out by male (42.5%), family name continues (23%), dependable in old age (16%), pressure from family (11%), to perform the cremation (4%), dowry (3%) and females are economic liability (3%).[12]Number of studies conducted all over the India, the reason for the son preference was nearly same. In this study the reasons for female child preference were to take care of family (38.5%), attachment to the mother (35%), daughter as a son (20%), daughter is lovely in the family (15%), old age care (8.5%), to take care of two families (6%), societal values (6%) and other reasons (8.5%). A research conducted in rural area of Pune; the most common reason for preference of girl child was ‘like girl child’ i.e. 62.38%.[11] The belief of people now slowly changing that only son can take care of parents and support the family. Care taking by son is in alarming condition in our society, while the responsibility of taking care of parents is taken by daughter. So people also prefer the daughter, but still daughter preference is low. The reasons for not preferring a female child was ‘she goes to her husband's house’ (27.5%), ‘dowry’ (25.5%), ‘burden for family’ (21%), ‘not earning member’ (4%) and other reasons (2%). Indian society is patrilineal and patriarchal, where sons carry the family name and task of supporting their parents in old age. Parents live as extended families with their sons, daughter-in-laws, and grandchildren. On the other hand, parents of girls are typically socially bound to find suitable husbands for their daughters at an early age, often pay all marriage costs, and provide a dowry. Social norms dictate that parents cannot expect much emotional or economic and further contribution to their birth parent from married daughters, who typically move into and become part of their husband’s household.[2,3,13,14] CONCLUSION The study confirms that son preference exists in the rural community of Maharashtra. Desire for next child remains high where the percentage of female children in previous fertility were high and the desire for next child comes down with previous fertility with a male child. Attitude for son preference is mainly because of the economic earning, old age care and continuation of the family name among all groups. 394 Aalok et al., Int J Med Res Health Sci. 2015;4(2):391-395 Social beliefs and sociocultural practices are the reasons for not preferring a female child. Acknowledgment: This work was undertaken independently and there were no funding sources. The views expressed in the manuscript reflect those of the authors. I am greatly indebted to all individual, who had supported directly or indirectly for completion of research. REFERENCES 1. Miller B. The Endangered Sex: Neglect of Female Children in Rural North India. Ithaca: Cornell University Press (1981). 2. Dyson T, Moore M. On kinship structure, female autonomy, and demographic behaviour in India. Population and Development Review. 1983; 9(1):35–60. 3. Kishor, S. Gender differentials in child mortality: A review of the evidence. In: Das Gupta, MEA, editor. Women’s health in India: Risk and vulnerability. Bombay, India: Oxford University Press; 1995. p. 19-54. 4. Pande R, Astone NM. Explaining son preference in rural India: The independent role of structural versus individual factors. Population Research and Policy Review. 2007; 26(1):1–29. 5. Government of India. Census of India 2001Census 2001 provisional results- population totals: India. Paper-I of 2001 6. Mohan Ghule, D. Balaiah and D. D. Naik, “Son Preference Among Rural Married Men in Maharashtra, India” The Journal of Family Welfare, December 2005; vol. 51, No. 2 7. Varma GR. Son Preference and Desired Family Size in a Rural Community of West Godavari District, Andhra Pradesh, India Journal of Social Science, 2007; 15(1): 5964. 8. Puri S, Bhatia V, Swami HM. Gender Preference and Awareness Regarding Sex Determination amongMarried Women in Slums of Chandigarh Indian Journal of Community Medicine January 2007; 32(1); 60-62. 9. RohiniPande, AnjuMalhotra. Son preference and Daughter Neglect in India” International Center for Research on Women, 30th anniversary report (UNFPA Publication 39764) 10. Rokhsana Reza. Factors influencing fertility preference of men in Bangladesh” Faculty of Graduate Studies, Mahidol University for the Degree of Master of Arts(Population and Reproductive Health Research), 2001 11. MadhuraAshturkar. A Cross-Sectional Study of Factors Influencing Sex Preference of a Child Among Married Women in Reproductive Age Group was carried out in Rural Area of Pune, Maharashtra,” Indian Journal of Community Medicine. 2010;35(3):442-443 12. VaderaBN. Study on knowledge, attitude and practice regarding gender preference and female feticide among pregnant women” Indian Journal of Community Medicine. 2007;32(4):239-307 13. Pande R, Astone NM. Explaining son preference in rural India: The independent role of structural versus individual factors. Population Research and Policy Review. 2007; 26(1):1–29. 14. Jeffery R, Jeffery P. “Female infanticide and amniocentesis.” Social Science and Medicine. 1984; 19 (11): 1207-12. 395 Aalok et al., Int J Med Res Health Sci. 2015;4(2):391-395 DOI: 10.5958/2319-5886.2015.00073.9 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Received: 31st Jan 2015 Research article Coden: IJMRHS Copyright @2015 ISSN: 2319-5886 Revised: 10th Feb 2015 Accepted: 31st Mar 2015 IN VITRO EFFECT OF VITAMIN C ON THE LABORATORY ISOLATES OF MYCOBACTERIUM TUBERCULOSIS WITH KNOWN SENSITIVITY AND RESISTANCE TO THE FIRST LINE ANTI TUBERCULAR DRUGS: AN EXPERIMENTAL PILOT STUDY Talaulikar Nikita.S 1, * Dsouza Delia.B 2, Rodrigues Savio 3, Kulkarni MS 2 1 II MBBS student, Goa Medical College, Bambolim, Goa, India Department of Preventive and Social Medicine, Goa Medical College, Bambolim, Goa,India 3 Department of Microbiology, Goa Medical College, Bambolim, Goa, India, 403202. 2 *Corresponding author email:
[email protected] ABSTRACT Background and Objectives: Globally, 3.5% of new cases of Tuberculosis (TB) and 20.5% of previously treated cases are estimated to have multidrug- resistant tuberculosis, the corresponding estimates for India are 2.2%, and 15% respectively. Progress has been made in research and development of new drugs for TB over the last decade, thus fuelling the need for more innovative options. Recent in-vitro studies that claim Vitamin C to have an inhibitory effect on Mycobacterium tuberculosis could possibly prove to be a major breakthrough in Medicine. Hence this experimental study was conducted on a pilot basis with the objective of studying the in -vitro effect of the active ingredient of vitamin C on the laboratory isolates of Mycobacterium tuberculosis that were known to be sensitive and resistant to the first line anti tubercular drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol) and to compare the dose related response of both sensitive and resistant strains of Mycobacterium tuberculosis to varying concentrations of Vitamin C. Materials and Methods: Using a Completely Randomized Design, a total of 17 viable Mycobacterium tuberculosis strains, 10 of which were sensitive to all first line anti-TB drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol) and seven strains resistant to all first line Anti-TB drugs were experimented upon. Proportion method was used to determine drug susceptibility of Mycobacterium tuberculosis to Ascorbic acid. Data is presented in a summary table. Results: With 1mM (millimole) concentration of Ascorbic acid, growth of Mycobacterium tuberculosis was observed on both drug containing as well as control media, but with higher concentration of Ascorbic acid (10 mM and 100mM), no growth was observed on Ascorbic acid containing Lowenstein Jenson media. Conclusion: Although the findings of this pilot study add to the supportive evidence of an in- vitro susceptibility of Mycobacterium tuberculosis to Vitamin C, the authors recommend that additional studies with larger sample size may be conducted to support the effectiveness of Ascorbic acid used alone or in combination with other anti-tubercular drugs to look for any drug interactions. Keywords: Proportion method, Ascorbic acid, Mycobacterium tuberculosis INTRODUCTION Nearly two decades after the World Health Organization’s declaration of Tuberculosis (TB) as a global public health emergency, major progress has been made towards 2015 global targets set within the context of the Millennium Development Goals [1]. One of the five priority actions required to accelerate progress towards 2015 targets, as listed in the Global TB report, is “to ensure rapid uptake of innovations” 396 Nikita et al., Int J Med Res Health Sci. 2015;4(2)396-400 [1] . The increasing resistance of Mycobacterium tuberculosis (M.tb) to first line anti tubercular drugs is a cause for concern. Globally, 3.5% (95% CI: 2.24.7%) of new TB cases and 20.5% (95% CI: 13.627.5) of previously treated cases are estimated to have multidrug- resistant tuberculosis (MDR-TB), the corresponding estimates for India are 2.2(CI: 1.9-2.6), and 15(CI: 11-19) respectively [2]. Although the statistics reveal a very slow yet a hopeful decrease in the TB related mortality in India over the last few years [1-3], it is a known fact that the Tuberculosis treatment regimen has faced many dead ends with resistance developing rapidly both in vivo and in vitro [4,5] , and the subsequent rise in the MDR and extensively drug-resistant tuberculosis cases has fuelled the need for a more innovative option [1]. Researchers all over the world are looking for innovative ways to treat Tuberculosis. Literature search documents the findings of Dr. Frederick R Klenner who claimed that Vitamin C fulfilled the requirements of an antibiotic due to its capacity to function as a reducing agent or the precursor of such a substance [6]. In a study by McConkey M et al [7], of the twenty-one animals which were given a tuberculous sputum feed along with a diet deficient in Vitamin C or A, C, D; seventeen developed open tuberculous ulcers, three caseous non-ulcerative lesions, and the intestinal tract of only one animal was normal at necropsy. Nine out of the ten animals, receiving supplements of Vitamin C along with tuberculous sputum feed did not develop intestinal TB. Taneja et al [8] showed that Vitamin C mimics multiple intracellular stresses and has wide-ranging regulatory effects on gene expression and physiology of M. tuberculosis which leads to growth arrest and a ‘dormant’ drug-tolerant phenotype ’. Vilchèze C et al [9] demonstrated ability of vitamin C to sterilize M. tuberculosis cultures. Narwadiya SC et al [10] claim Vitamin C to have similar dose related inhibitory effect on Mycobacterium tuberculosis. Given this possibility, the effect of Vitamin C on Mycobacterium tuberculosis could prove to be a major breakthrough in Medicine. This highlighted the need for an in-vitro experimentation of Vitamin C on various strains of Mycobacterium tuberculosis. Therefore this experimental pilot study was aimed at testing the effect of active ingredient of Vitamin C (Ascorbic Acid) on the sensitive as well as the resistant strains of Mycobacterium tuberculosis of routine Tuberculosis patients obtained from the laboratory stocks at Intermediate Reference Laboratory (IRL), Department of Microbiology, Goa Medical College with the following objectives: 1) To study the in vitro effect of the active ingredient of vitamin C on the laboratory isolates of Mycobacterium tuberculosis with known sensitivity and resistance to the first line Anti tubercular drugs currently used in DOTS (Directly Observed Treatment, Short Course) regimen of RNTCP (Revised National Tuberculosis Control Programme). 2) To compare the dose related response of both sensitive and resistant strains of Mycobacterium tuberculosis to varying concentrations of Vitamin C. METHODOLOGY Type of study: This is an experimental laboratory based study. Ethics approval: The study was conducted after prior approval from the Institutional Ethics Committee. Study design: Completely Randomized Design was used. Methodology: M. tuberculosis strains used in this study were obtained from laboratory stocks of year 2011 onwards, isolated from routine TB patients, provided by IRL at the Department of Microbiology, Goa Medical College, Goa. The isolates were first sub cultured on Lowenstein Jenson (LJ) media to ensure their viability. Thirtyeight strains of Mycobacterium tuberculosis from the laboratory stocks were first subjected to subcultures, of which 20 viable strains were further subjected to DST (Drug Susceptibility Testing). Since three strains got subsequently contaminated, a total of 17 viable strains, 10 of which were sensitive to all first line anti-TB drugs (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol) and seven strains resistant to all first line Anti-TB drugs, were finally experimented upon. Drug susceptibility testing (DST) of Mycobacterium tuberculosis to Ascorbic acid (active ingredient of Vitamin C) was done using Proportion Method. [11] . Drug free/plain LJ media was used as control during the procedure for DST and the LJ media containing L-Ascorbic acid (99.7%) AR 2013 served as the drug containing media. Ascorbic acid solution of varying concentrations (1, 10 and 100 millimoles) was sterilised by Membrane filtration. The final LJ media was sterilised by Serum Inspissation. The cultured media were incubated at 37oC; the observations for 397 Nikita et al., Int J Med Res Health Sci. 2015;4(2)396-400 growth were made on days 28 and 42. [11]. Sensitivity and resistance pattern was interpreted as per the Revised National TB Control Programme Training Manual Guidelines [11]. RESULTS Table 1: Results of the Drug susceptibility testing Mycobacterium tuberculosis strains Strains sensitive to all four standard first line anti-TB drugs (H, R, Z, E) Strains resistant to all four standard first line anti-TB drugs (H, R, Z, E) Total Ascorbic acid (1 mM) (n=17) Ascorbic acid (10 mM) (n=17) Ascorbic acid (100 mM) (n=17) No growth of M.tb observed in drug containing media No. Growth of M.tb observed in drug containing media No. No growth of M.tb observed in drug containing media No. Growth of M.tb observed in drug containing media No. No growth of M.tb observed in drug containing media No. Growth of M.tb observed in drug containing media No. 0 10 10 0 10 0 0 7 7 0 7 0 0 17 17 0 17 0 H=Isoniazid, R=Rifampicin, Z=Pyrazinamide and E=Ethambutol One mM concentration of Ascorbic acid, permitted growth of Mycobacterium tuberculosis strains in both drug - containing as well as control media. Dose of Ascorbic acid was further increased to 10 mM and 100 mM, to study the dose-dependant response of the 10 sensitive and seven resistant M.tuberculosis strains. No growth of Mycobacterium tuberculosis strains was observed with higher concentration of Ascorbic acid (10 mM and 100mM). The LJ media with 100 mM concentration of Ascorbic acid however turned dark green in colour and the reason could not be ascertained. The observations made on day 28 and 42 remained unchanged. DISCUSSION In this pilot experiment, both the control (Ascorbic acid free media) as well as Ascorbic acid containing media, showed growth of Mycobacterium tuberculosis colonies at lower concentration (1mM) of Ascorbic acid. However a study done by Vilchèze C et al [9] found the minimum inhibitory concentration (MIC) of Vitamin C that prevented the growth of M. tuberculosis was one mM. This difference in the observations could be attributed to loss of biological activity of Ascorbic acid at lower concentrations subsequent to serum inspissation at 80oC for an hour on consecutive days, which happens to be the standard sterilisation procedure for preparing LJ Media. Another possible explanation to support this could be found in studies done by Alvarado JD et al [12] and Munyaka AW [13] which state that at higher temperatures, conversion of its active ingredient, i.e. l-ascorbic acid to dehydroascorbic (DHAA) takes place. DHAA could be easily converted to other compounds that do not have the biological activity of Vitamin C. The issue of possible loss of biological activity due to heat degradation could be addressed by using a liquid media or any other selective media, which would have allowed the addition of Vitamin C after sterilisation. In our study, we observed a dose related response (no growth of M. tb strains) with higher concentrations of Ascorbic acid. The absence of growth of Mycobacterium tuberculosis (both sensitive and resistant strains) at higher concentrations of Ascorbic acid i.e. 10mM and 100 mM, could either be due to some chemical alteration or shift of pH of LJ medium that may have possibly lead to inability of M. tuberculosis to grow in the media, or the lack of growth may also be due to the unique susceptibility 398 Nikita et al., Int J Med Res Health Sci. 2015;4(2)396-400 of Mycobacteria to Ascorbic acid as claimed by similar research studies conducted in the past. [7-10] CONCLUSION The objectives with which we started the pilot study were largely met. With regards to the first objective the authors found that all 17(100%) of the laboratory isolates of Mycobacterium tuberculosis which were sensitive (10 strains) as well as resistant (seven strains) to first line anti –TB drugs used in RNTCP, showed in-vitro susceptibility to the active ingredient of Vitamin C at higher concentrations (10mM and 100 mM). Our second objective was to compare the dose related response of both sensitive and resistant strains of Mycobacterium tuberculosis to varying concentrations of Vitamin C. We observed that at 1mM concentration, Vitamin C did not have any effect on the Mycobacterium isolates, but had effect only at higher concentrations of 10mM and 100 mM. Although the findings of this pilot study add to the supportive evidence of an in- vitro susceptibility of Mycobacterium tuberculosis to Vitamin C, the authors recommend that further studies with larger sample size may be conducted to support the effectiveness of Ascorbic acid used alone or in combination with other anti-TB drugs to look for any drug interactions. Clinical trials in humans using Vitamin C supplementation to study the in-vivo effect of Vitamin C in patients who are on DOTS regimen for treatment of Tuberculosis could also be thought of. This could revolutionize the current scenario in relation to treatment of Tuberculosis. LIMITATIONS OF THE STUDY 1. Use of a selective liquid media would have allowed the addition of Ascorbic acid after sterilization, thus ruling out the possibility of loss of efficacy of Ascorbic acid due to degradation at higher temperatures (if any) and would probably have given us results with the lower concentration (1mM). 2. The reason for the dark-green colouration of LJ media with 100 mM concentration of Ascorbic acid could not be ascertained. Figure 1: Summary ACKNOWLEDGEMENT The authors would like to thank the Indian Council of Medical Research for the research grant awarded to the first author (undergraduate student from II MBBS) to conduct this experimental pilot study through it’s Short Term Studentship program. The authors express their sincere thanks to Ms Puja A. Parulekar (Senior Laboratory Technician at IRL, Goa Medical College and Dr Cigy C Borges, Microbiologist at IRL, Goa Medical College for the immense guidance, technical support and cooperation, received while conducting this pilot experiment in the Microbiology laboratory of Goa Medical College without whom it would not be possible to conduct such a study. We also thank the Institutional Ethics Committee for approving this pilot research study. Conflict of interest: NIL 399 Nikita et al., Int J Med Res Health Sci. 2015;4(2)396-400 REFERENCES 1. World Health Organisation (WHO). Global Tuberculosis Report 2013. Geneva: WHO; 2013. 2. World Health Organisation (WHO). Global Tuberculosis Report 2014. Geneva: WHO; 2014. 3. World Health Organisation (WHO). Global Tuberculosis Report 2012. Geneva: WHO; 2012. 4. Colijn C, Cohen T, Ganesh A, Murray M. Spontaneous Emergence of Multiple Drug Resistance in Tuberculosis before and during Therapy. PLoS ONE.2011; 6(3): e18327. Doi: 10.1371/journal.pone.0018327. 5. Selkon JB.. The emergence of isoniazid-resistant cultures in patients with pulmonary tuberculosis during treatment with isoniazid alone or isoniazid plus PAS. Bull. World Health Organ. 1964; 31: 273–94. 6. Klenner FR. Massive doses of vitamin C and the virus diseases. South Med Surg. 1951 Apr; CIII (4): 101-7. 7. McConkey M, Smith DT. The Relation of Vitamin C Deficiency to Intestinal Tuberculosis in the Guinea Pig. J. Exp. Med. 1933; 58: 503– 512. 8. Taneja NK, Dhingra S, Mittal A, Naresh M, Tyagi JS. Mycobacterium tuberculosis transcriptional adaptation, growth arrest and dormancy phenotype development is triggered by vitamin C. PLoS One. 2010; 5: e10860. 9. Vilchèze C, Hartman T, Weinrick B, Jacobs W R. Mycobacterium tuberculosis is extraordinarily sensitive to killing by a vitamin C-induced Fenton reaction. Nat Commun.2013; 4: 1881. 10. Narwadiya SC, Sahare KN, Tumane PM, Dhumne UL, Meshram VG. In vitro antituberculosis effect of vitamin C contents of medicinal plants. Asian J. Exp. Biol. Sci. 2011; 2: 151–54. 11. Directorate General of Health Services, Ministry of Heath and Family Welfare, Central TB Division. Revised National TB Control Programme Training Manual for Mycobacterium tuberculosis Culture and Drug Susceptibility Testing. New Delhi: 2009: 1-76. 12. Alvarado JD, Palacios VN. Effect of temperature on the aerobic degradation of vitamin C in citric fruit juices. Arch Latinoam Nutr. 1989 Dec; 39(4): 601-12. 13. Munyaka AW, Makule EE, Oey I, Van Loey A, Hendrickx M.Thermal stability of L-ascorbic acid and ascorbic acid oxidase in broccoli (Brassica oleracea var. italica). J Food Sci. 2010 May; 75(4): C336-40. . doi: 10.1111/j.17503841.2010.01573.x 400 Nikita et al., Int J Med Res Health Sci. 2015;4(2)396-400 DOI: 10.5958/2319-5886.2015.00074.0 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 14 Feb 2015 Research article Coden: IJMRHS Revised: 20th Mar 2015 Copyright @2015 ISSN: 2319-5886 Accepted: 30thMar 2015 PREVALENCE AND FACTORS AFFECTING BURNOUT AMONG SECONDARY CARE DOCTORS IN BAHRAIN- A CROSS SECTIONAL STUDY Husain Isa Hasan1, Yusuf Nooh1, * Adel Salman Alsayyad2 1 Family Physician, 2Consultant Family Medicine, Public Health & Epidemiology, at Ministry of Health, Bahrain *Corresponding author email:
[email protected] ABSTRACT Background: Burnout isa type of prolonged response to chronic job-related stress appears as a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment. Objectives: The present study investigated level of burnout, compare burnout levels in view of demographic factors and to identify the potential risk factors that lead to high level of burnout among secondary care doctors in Ministry of Health in Bahrain kingdom. Methods: The study was carried out in 230 doctors. A questionnaire survey was administered: The level of "burnout" was evaluated using the Maslach Burnout Inventory; socio-demographic variables were collected as well. Results: the mean response rate was 87.8%. The prevalence of the three dimensions of burn out was 43.1% with high emotional exhaustion, 26.7% with high depersonalization and 51.5% reported low personal accomplishment. In general, the profiles of an individual with high burn out were between 30-40 years old Bahraini married physician with no children. Conclusion: a high level burnout was found among the studied population. The study results underline significant relations that were found to link burn out with various sociodemographic variables. Keywords: Prevalence, Factors, Burnout, Secondary care, Doctors, Bahrain INTRODUCTION Burnout definition had come long way since its first definition in 1947. Even though Many Burn out definitions do existfor this research the definition of burnout that will be used is adopted from Maslach and Jackson (1986) because it is the most widely used across the world [1].This definition stated that: “Burnout is a syndrome of emotional exhaustion, depersonalization, and reduced personal accomplishment that can occur among individuals who do ‘people work’ of some kind” [2]. Burnout have a devastating effect on work force and hence on work out come. Burnout is associated with decreased job performance and commitment[3,4] and lower career satisfaction[5,6] which can lead to increased incidence of errors in clinical care[7] and lower quality of care[8,9,10]. People who are experiencing burnout can have a negative impact on Hasan et al., their colleagues, both by causing personal conflicts and disrupting job task[11]. There is also some evidence that burnout has a negative "spill over" effect on both physician's home life as they experience an increasing family problems [7, 12, 13, 14] and the physician's health. Health is highly affected by burnout as burn out might cause mental dysfunction such as anxiety[7,15],depression[7,9,15],Low self-esteem and morale[11], increased use of alcohol and drugs addiction[7,8,15] eating disorder and massive weight gain[7,15]. Burnout is not a new phenomenon – it has its root in the past. However, because of a unique constellation of several factors it was ‘discovered’ in the early 1970’s as a particular type of prolonged occupational stress that seemed to occur most prominently among human services professionals [16]. 401 Int J Med Res Health Sci. 2015;4(2):401-406 Physicians' burnout is common with rates ranging from 25% to 76%, depending on the socio-economic characteristics and working conditions [2, 17, 18, 19, 20]. The level of burnout is higher among employees over 30 years old[18, 21, 22].Some studies show higher burnout for women[23,24,25], some show higher scores for men[8,21,26](males often score higher on cynicism where as women score slightly higher on exhaustion),and others find no overall [3,27,28] differences .Singles seem to experience higher burnout levels[18, 29, 30], even more than those who are divorced[21]. Being a parent [31] and having a physician father are protectors from burnout [32]. MATERIALS AND METHODS Type of study: A cross-sectional design was used in the main secondary care hospital in Bahrain Inclusion criteria: The participants were randomly enrolled from the list of doctors from chief of medical staff in Salmaniya Medical Complex. Doctors working in training pool & service pool in the following SMC departments: medical, surgical, pediatrics, obstetrics& gynecology, orthopedics, psychiatry, ophthalmology, emergency, ENT, radiology, pathology, anesthesia, neuroscience and oncology. The Training pool doctors were those in the specialty training residency program (STRP) which is a recognized program that adapt the training doctors to pass the Arab Board Medical Specializations requirements. The total number of doctors in SMC was obtained from the head of medical education & training office and was confirmed by the secretary of each department which was equal to 675. Sample size: The sample size was calculated using the epi-info program version 6.0 to calculate sample size.The sample size was 230 candidates. Exclusion criteria: Doctors who were on study leave (more than 3months) during the period of data collection were excluded from the study Ethical approval: Privacy and confidentiality was ensured during data collection. The questionnaire was filled anonymously. Ethical approval was received from Technical research committee in ministry of health Bahrain. Methodology: Maslach Burnout Inventory –Human Services questionnaire [2]was used as a tool for measuring the prevalence of burnout syndrome among the secondary care doctors in this research. It was correlated with the participants’ demographic data and the job Characteristics. The Maslach Burnout Inventory (MBI) [2]:The initial research on the (MBI) was based on data from the United States and Canada but subsequent studies had been done in many countries around the world and the (MBI) had been translated burnout. Psychometric studies of the (MBI) in these different settings have into various languages. Nowadays it is considered as the leading measure of continued to validate the three-dimensional structure of the measure. There are now three versions of the (MBI)[2]: 1. The original measure that was designed for professionals in the human services (MBI Human Services Survey or MBI_HSS). 2. An adaptation of the original measure for use with educators (MBI Educators Survey, or MBI_ES; formerly known as MBI Form Ed). 3. A new version of the MBI designed for use with workers in other occupations (MBI General Survey, or MBI_GS). For this research, the Maslach Burnout Inventory_ Human services Survey (MBI_HSS) was devised as an instrument to asses Burnout. It has been found to be reliable, valid, and easy to administer [2]. Permission obtained from the author of the study to use the questionnaire and from the chairperson of secondary care research committee to implement the study.Each participant was given the questionnaire by hand and asked to answer it alone without knowing how the other participants responded to the questions to insure privacy. An accompanying cover letter was attached to inform the participants that the purpose of the study was to explore the job related attitudes of the residents. The word "Burnout" was not mentioned in the cover letter as recommended by the Maslach Burnout Inventory2.No financial or other incentives were offered for participation. Complete instructions were provided for the participants and they were given 10-15 minutes to fill out the questionnaire. Explanations to some difficult words in the questionnaire were added. Once the questionnaire filled, it was collected immediately. Those who were unable to fill it out were requested to fill it in their leisure time and were followed up. Statistical analysis: For data Analysis and interpretation the authors adopted the methods explained in the Maslach Burnout Inventory Manual 3rd edition[2].For 402 Hasan et al., Int J Med Res Health Sci. 2015;4(2):401-406 our study the Statistical Package for Social Sciences (SPSS) version 15 was used to enter and analyze the data collected. Emotional exhaustion. All these relationships were statistically not significance. (Table 3) Table1: Demographic Data of participant of secondary care doctors in ministry of health of Bahrain kingdom. RESULTS 230 full-time doctors were asked to complete a brief Factors N (%) and simple survey that was specifically designed for Male 122 60.7 Gender the purpose of this study. The general response rate Female 79 39.9 was 87.7%.Total number of participants in this study Total 201 100.0 was 202. 60.7% (122) were male. The average age for <30 58 32.0 the participants was 36 years with 9 SD. 41.1 % of Age 30-40 75 41.4 those who answered the Age question were in the age >40 48 26.5 group 30-40 years. Almost three quarters of the Total 181 100.0 participants (72.8%) were married and 79 (76.7%) of Current Marital Not married 54 26.9 them had children. The majority of the participants Married 147 73.1 were Bahraini 164 (83.7%). (Table 1).The prevalence status Total 201 100.0 of the three dimensions of burn out among our No 24 23.3 sample was in the high category in emotional Having Yes 79 76.7 exhaustion (43.1%) and in the low category for both children Total 103 100 depersonalization (DP) and personal accomplishment Bahraini 164 83.7 (51.5%). (Table 2)In terms of the socio-demographic Nationality factors being >40 years old is less likely to Non 32 16.3 experience a high levels of Emotional exhaustion Bahraini (18.8%) and depersonalization (8.3%) but they have a Total 196 100.0 low level of personal-accomplishment (75%) , Table 2: The Prevalence of Burnout dimensions whereas, being Bahraini was associated with a high among secondary care doctors in ministry of levels of Emotional exhaustion (47.6 %). Both health of Bahrain kingdom. relationships were statistically significant (Table Burnout Low Average High 3).On the other hand, males showed lower levels of dimension N (%) N(%) N(%) personal accomplishment (54.1%), females showed Emotional 70(34.7) 45(22.3) 87(43.1) high levels of Emotional exhaustion (49.4%). Married Exhaustion Depersonalization 104(51.5) 44(21.8) 54(26.7) doctors had a higher score of Emotional exhaustion Personal 104(51.5) 53(26.2) 45(22.3) (46.3) and lower levels of personal accomplishment Accomplishment (57.8%). The results also showed that those who N= Number haveno children (62.5%) had high levels of Table 3:The relation between Demographic characteristics and burnout dimensions among secondary care doctors in ministry of health in Bahrain kingdom Factors Age <30 High Emotional Exhaustion N % P value 25 43.1 0.01 Gender 30-40 >40 Male 42 9 48 56.0 18.8 39.3 Female Not married Married No Yes Bahraini Non-Bahraini 39 19 68 15 36 78 7 49.4 35.2 46.3 62.5 45.6 47.6 21.9 Current marital status Having Children Nationality 0.57 0.33 0.35 0.01 High Depersonalization N % P value 18 31.0 0.01 Low Personal accomplishment N % P value 22 37.9 23 4 35 30.7 8.3 28.7 38 36 66 50.7 75.0 54.1 19 16 38 7 16 50 4 24.1 29.6 25.9 29.2 20.3 30.5 12.5 38 19 85 14 51 83 19 48.1 35.2 57.8 58.3 64.6 35.6 59.4 0.15 0.84 0.21 0.07 0.01 0.28 0.08 0.5 0.91 *P value of Chi Square test 403 Hasan et al., Int J Med Res Health Sci. 2015;4(2):401-406 DISCUSSION This study was concerned to demonstrate the interrelationship of the three most important aspects of Burnout which are: Emotional exhaustion (EE), Depersonalization (DP) and Personal accomplishment (PA) among secondary care physicians of the ministry of health in Bahrain. There are a lot of factors which have been studied and have proved the strong association among those aspects. In this study, it was found that doctors who spent 510 years of practicing medicine whom are mainly training doctors who carry most of the work load and decision making have a high levels of depersonalization and emotional exhaustion. Moreover, physicians who were in the age group of (30-40) have shown strong exhibition of burnout among them with a rate of (41.1%). Both of these results reflects the fact that older doctors has less burnout than their younger beers which is similar to previous literature.[18, 21, 22] This protective effect of older age of physician might be due to the increase in financial security and cultural factors that attribute older age with more respect and trust from patients. The study found no significant difference in burn out between males and female participants which is similar to what had been previously shown in other studies[3,27,28]. This might be due to equally distributed work load regardless of gender It was found that Bahraini doctors have lower levels of emotional exhaustion in comparison to NonBahraini doctors. This may be attributed to the fact that non Bahraini doctors has a lower expectations from the work and actually for most of them working in Bahrain may make them feel that they have achieved certain goals In their careers, especially financial. They are less involved in argumentation with senior colleagues and higher authorities, and social and political issues. In addition, they also have- in general- a good working deal that include allowances for housing, annual airline tickets to the home country plus school fees for their children[18, 29, 30]. Limitations of this study were its cross-sectional design which creates difficulties in ascertaining causality. Several factors from in or outside work might have influenced both the perception of the work and the level of burnout and therefore might be confounders. Employees who are currently depressed or burned out perceive the characteristics of their work more negatively compared with healthy employees[31]. The other limitation factor was the nature of the sample which included physicians from different specialties, different institutions, different income, levels and working conditions so it was not possible to draw conclusions regarding specific physician group or working conditions [32]. CONCLUSION A high level burnout was found among the studied population. The study results underline significant relations that were found to link burn out with various socio-demographic variables. Recommendations: In view of Burnout is prevalence and its adverse effect on the doctors wellbeing, doctor patient relationship and quality of care; we recommend periodically surveying physicians and organization for Burnout. Further research is necessary for more comprehensive understanding of the problem of Burnout and psychiatric morbidity among physicians, improvement of medical training and attention to the psychological implications of working in health care may facilitate prevention and treatment of possible emotional problems physicians may encounter during their career. This might in turn, have positive effect on the doctor-patient relationship and quality of care. ACKNOWLEDGMENT We would like to deeply and greatly Mr. Hasan A. Albasri for his great assistance in biostatistics analysis, Mr. Warwick Price for his generous assistance by providing us with to tools to measure burnout. REFERENCES 1. Engelbrecht S. Motivation and Burnout in Human Service Work the Case of Midwifery in Denmark, PhD Thesis, National Institute of Occupational Health, Copenhagen , 1-281. April 2006. 404 Hasan et al., Int J Med Res Health Sci. 2015;4(2):401-406 2. Maslach, C., Jackson, S. E., &Leiter, M. P. (1996). Maslach Burnout Inventory. (3rd ed.). Palo Alto, CA: Consulting Psychologists Press. 3. Esteva M. Mental health in family doctors: effects of satisfaction and stress at work. Rev ClinEsp - -2006; 206(2): 77-83. 4. Li Calzi S. Physical rehabilitation and burnout quantification of its: different aspects of the syndrome and comparison between healthcare professionals involved. EuraMedicophys - -2006; 42(1): 27-36. 5. Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, Papazian L. High Level of Burnout in Intensivists : Prevalence and Associated Factors.Am J RespirCrit Care Med, 2007 Apr 1;175(7):686-92. 6. Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26; 165(22):2595-600. 7. Lyckholm L. Dealing with stress, burnout, and grief in the practice of oncology. Lancet Oncol2001; 2:750–755. 8. Goehring C, BouvierGallacchi M, Kunzi B, Bovier P. Psychosocial and professional characteristics of burnout in Swiss primary care practitioners: a cross-sectional survey. Swiss Med Wkly. 2005 Feb 19; 135(7-8):101-8. 9. Chopra S, Sotile W M., Sotile M O. Physician Burnout. JAMA. 2004; 291:633. 10. Barnett R, Brennan R., Gareisk K. A Closer Look at the Measurement of Burnout,Journal of Applied Biobehavioral Research, 1999, 4(2):6578. 11. Maslach C. &Leiter, M. P. The truth about burnout: How organization cause, personal stress and what to do about It. San Francisco: JosseyBass (1997). 12. Dyrbye L N., Thomas M R , Huntington J L., Lawson K L., Novotny P J. MS, Sloan J.A., Shanafelt T. D. Personal life events and medical student burnout: a multicenter study. Acad Med. 2006 81(4):374-84. 13. Johns MM, Ossoff R H. Burnout in academic chairs of otolaryngology: head and neck surgery. Laryngoscope. 2005; 115(11):2056-61. 14. Travado L, Grassi L, Gil F, Ventura C, Martins C. Physician-patient communication among 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Southern European cancer physicians: the influence of psychosocial orientation and burnout. Psycho oncology. 2005; 14(8):661-70. Bargellini A, Barbieri A, Rovesti S, Vivoli R, Roncaglia R, Borella P. Relation between immune variables and burnout in a sample of physicians .Occup Environ Med. 2000 ;57(7):453-7. Borritz M, Rugulies R, Christensen K B, Villadsen E, Kristensen T S. Burnout as a predictor of self-reported sickness absence among human service workers: prospective finding from three year follow up of the PUMA study. Occup Environ med. 2006 Feb; 63(2): 98-106. Ramarajan, L., Barsade, S.G. &Burack, O. The Influence of Organizational Respect on Emotional Exhaustion in the Human Services, Journal of Positive Psychology (2008), 3, 4-18. Visser M, SmetsE ,Oort F J, La Haes H. Stress, satisfaction and burnout among Dutch medical specialists, CMA.J; 2003; 168, 3. Elit L, Trim K, Mand-Bains IH, Sussman J, Grunfeld E. Job satisfaction, stress, and burnout among Canadian gynecologic oncologists .GynecolOncol. 2004; 94(1):134-9. Korkeila JA, Toyry S, Kumpulainen K, Toivola JM, Rasanen K, Kalimo R. Burnout and selfperceived health among Finnish psychiatrists and child psychiatrists. Scand J Public Health. 2003; 31(2):85-91. Maslach C., Wilmar S., Michael P. Job Burnout. Annu. Rev. Psychol. 2001. 52:397–422 Kirwan M, Armstrong D. Investigation of burnout in a sample of British general practitioners. Br J Gen Pract. 1995 May; 45(394):259-60. Spickard A., Gabbe S., Christensen J. Mid-Career Burnout in Generalist and Specialist Physicians. JAMA 2002; 288:1447-1450. Toyry S., Kalimo R., Aarimaa M., Juntunen J, Seuri M, Rasanen K. Children and work-related stress among physicians. Stress Health Oct 2004.Vol.20, : 213-221. Cathébras P. Burn out among French general practitioners. Presse Med - 18-DEC-2004; 33(22): 1569-74 Michels PJ. Anxiety and anger among family practice residents: a South Carolina family 405 Hasan et al., Int J Med Res Health Sci. 2015;4(2):401-406 27. 28. 29. 30. 31. 32. practice research consortium study.- Acad Med 01-JAN-2003; 78(1): 69-79 Linzer M, McMurray JE, Visser MR, Oort FJ, Smets E, de Haes HC. Sex differences in physician burnout in the United States and The Netherlands .J Am Med Womens Assoc. 2002 Fall; 57(4):191-3. Lemkau J., Rafferty J, Purdy R., Rudisill J. Sex role stress and job burnout among family practice physicians. Journal of Vocational Behavior, v31 n1 p81-90 Aug 1987. Martini S., Arfken C L.,Balon R. Burnout Comparison of burnout among medical residents before and after the implementation of work hours limits. Academic Psychiatry 2006; 30(4):352-355. Antonym M, Efharis P, Alexis B. Burnout in internal medicine physicians: Differences between residents and specialists. EJIM 17 (2006) 195-200. Thomas N K. Resident Burnout. JAMA 2004; 292(23): 2880-2889. Doi:10.100/jama.292.23.2880. Sargent MC, Sotile W, Sotile MO, Rubash H, Barrack RL. Stress and coping among orthopedic surgery residents and faculty. J Bone Joint Surg Am2004; 86(7): 1579-86. 406 Hasan et al., Int J Med Res Health Sci. 2015;4(2):401-406 DOI: 10.5958/2319-5886.2015.00075.2 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS Received: 17th Jan 2015 Revised: 10th Feb 2015 Research article Copyright @2014 ISSN: 2319-5886 Accepted: 31st Mar 2015 COMPARISON OF INDUCTION, INTUBATION AND RECOVERY CHARACTERISTICS OF HALOTHANE + PROPOFOL V/S SEVOFLURANE + PROPOFOL IN CHILDREN UNDERGOING ADENOTONSILLECTOMY Sarabjit kaur 1, Veena Chatrath 2, Gagandeep Kaur 3, Vishal Jarewal 4, *Kulwinder S Sandhu 5, Sudha6 1, 2 Professor, 3,6Senior Resident, 4Resident, Department of Anaesthesia, 5Senior Resident, Department of ENT, GMC Amritsar, India. *Corresponding author: Kulwinder S Sandhu Email:
[email protected] ABSTRACT Purpose: General anaesthesia for oral surgeries in paediatric patients is always challenging for an anaesthesiologist. Aim was to compare halothane+propofol and sevoflurane+propofol in paediatric patients undergoing adenotonsillectomy without muscle relaxant. Method: In a double blind manner, eighty patients of 310 years were premedicated with inj. Atropine and randomly divided into two groups of forty each. In Group A, priming was done with 50% oxygen+50% nitrous oxide+4% halothane for 1 minute, after loss of eye lash reflex and centralisation of pupil intravenous cannulation done. Inj. midazolom, lignocaine and Propofol were given and trachea was intubated. Maintenance was done with 1-2% halothane+ nitrous oxide+ oxygen and continuous propofol infusion. Similar technique was used in group B except for priming done with sevoflurane 7% and maintenance with 2-3%. Both groups were compared for induction, intubating conditions, haemodynamics and emergence characteristics. Results: Induction was rapid in group B as time for loss of eye lash reflex and centralisation of pupil was less in group B (21.88±12.6 &114.40±28.8 seconds) as compared to group A (33.05±4.0 & 140.05±12.1 sec) p<0.001. Intubating conditions were excellent but mean intubation time was less in group B as compared to group A p<0.001. Heart rate and blood pressure remained on lower side in group A. Emergence was significantly rapid in group B. No side effect or complications were noted. Conclusion: Both groups provided excellent intubating conditions but sevoflurane+propofol group was better as it provided faster induction and rapid recovery from anaesthesia with more stable haemodynamics as compared to Halothane+propofol group. Keywords: General anaesthesia, Paediatric, Halothane, Sevoflurane, Propofol. INTRODUCTION General anaesthesia for adeno-tonsillectomy in paediatric patients is always challenging for an anaesthesiologist as there is sharing of the airway with the surgeon, limited access and risk of soiling the airway with blood. Children with adenotonsillar hypertrophy can have nasal obstruction, reactive airways and sometimes obstructive sleep apnoea.[1] They are at increased risk of desaturation, laryngospasm and airway obstruction during induction of anaesthesia.[2] Hence induction in these patients is preferred with potent inhalational agents, which can be used as an alternative to muscle relaxants to facilitate tracheal intubation and to further avoid the potential side effects of muscle relaxants like myalgias, hyperkalemia, masseter spasm or malignant hyperthermia.[3,4] Halothane with its sweet odour and minimal effects on airway reactivity makes it a suitable agent for paediatric anaesthesia, despite its propensity to cause bradycardia, hypotension and arrhythmias.[5] Sevoflurane has nonpungent odour, provides rapid onset and emergence from anaesthesia and has less Sandhu et al., Int J Med Res Health Sci. 2015;4(2):407-414 407 cardiovascular side effects, which makes it an attractive alternative for paediatric anaesthesia.[6] Induction, recovery characteristics and haemodynamics of Halothane and Sevoflurane in paediatric patients have been compared previously also. But in most of the studies, either muscle relaxants were used for intubation [7,8] or where muscle relaxants were omitted, perfect intubating conditions were not obtained.[9,10,11] Propofol an intravenous induction agent, can be considered as an alternative to muscle relaxants as it attenuates laryngeal and pharyngeal reflexes, provides better jaw relaxation [3] and also decreases the extubation related complications.[12] With these considerations in mind, the present study was done to compare induction characteristics, intubating conditions, haemodynamics and recovery profile of Halothane + propofol and Sevoflurane + propofol without muscle relaxants in paediatric patients undergoing adenotonsillectomy. Aim and objectives Induction characteristics and intubating conditions. Haemodynamic parameters Recovery characteristics. Side effects and complications of halothane+propofol and sevoflurane+propofol in paediatric patients. MATERIAL AND METHODS After approval from the institutional ethics committee, this double blind randomised study was conducted on eighty patients of American Society of Anaesthesiologist (ASA) grade I and II in the age group of 3 to 10 years undergoing adenotonsillectomy under general anaesthesia. Patients with history of acute upper respiratory tract infection, Hematocrit < 25%, bleeding disorders, hepatic or renal dysfunction, congenital anomalies, exposure to general anaesthetic agents in previous seven days, any contraindication for using study drugs or personal or family history of malignant hyperthermia were excluded from the study. A well informed written consent was taken from the parents or guardians of the patients included in the study. A day before surgery, a detailed preanaesthetic checkup was done. General physical examination and systemic examination was done. Mallampatti grading was done to assess the airway. Routine investigations were noted and if needed special investigations were ordered. Weight of each patient was recorded. Patients were randomly divided in to two groups of forty each, Group A: (Halothane + propofol) and Group B (Sevoflurane + propofol) is using a computer-generated randomization technique. On the day of surgery, patients were reassessed preoperatively and after confirming overnight fasting, patients were shifted to operating room and multipara monitor was attached to monitor baseline heart rate, respiratory rate, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial blood pressure (MAP), SPO2 and electrocardiograph (ECG). Continuous monitoring of vitals was then started. In group a (halothane + propofol), priming of circuit was done with 4% halothane + 50%: 50% of oxygen and nitrous oxide for one minute. In group B (sevoflurane + propofol), priming of the circuit was done with 7% sevoflurane + 50%: 50% of oxygen and nitrous oxide for one minute. Face mask of appropriate size was kept on the face of spontaneously breathing patient and time taken to loss of eyelash reflex as a sign of loss of consciousness was noted. Time taken to complete induction (centralisation of pupil, no gross bodily movements) was also recorded. Induction was done by a senior anaesthesiologist who was unaware of the inhalation agent used as the vapourisers were concealed by a screen and dial settings were adjusted by a separate anaesthesiologist. The anaesthesiologist doing the induction also recorded all the variables. After centralisation of pupils, intra venous cannulation was done and infusion of Isolyte P was started. Any bodily movements occurring at the time of cannulation were noted. Injection midazolam 0.04 milligram per kilogram body weight, injection lignocaine 1 milligram per kilogram body weight followed by bolus dose of Injection propofol 3 mg/kg body weight intravenously was given. After giving propofol concentration of halothane was reduced to 2% in group A and Sevoflurane was reduced to 4% in group B. Bag and mask ventilation was started and when adequate jaw relaxation was obtained, trachea was intubated with appropriate sized endotracheal tube without using any muscle relaxant. Care was taken that endotracheal tube does not touch the carina. Injection Atropine sulphate was given only if indicated to decrease secretions. The quality of 408 Sandhu et al., Int J Med Res Health Sci. 2015;4(2):407-414 intubating conditions was assessed by using scoring system devised by Helbo-Hansen, Ravio and TrapAnderson [13] and revised by Styne and colleagues. [14] Following parameters were noted: Jaw relaxation, Ease of laryngoscopy, Vocal cord positioning, Coughing on laryngoscopy or intubation and any Limb movements. For all variables, score of 1-4 was taken, where score of 1 was taken as ideal conditions, therefore total score of five was taken as best possible score for all parameters. Other variables like laryngospasm, struggling, oxygen desaturation and hemodynamic changes occurring during induction and intubation were also recorded. Immediately after intubation, paracetamol suppository (20mg/kg body weight) per rectum was given for analgesia. Maintenance of anaesthesia was done with 40% oxygen: 60% nitrous oxide + either 1-2 % halothane in group A or 2-4% sevoflurane in group B. After intubation, Continuous intravenous infusion of propofol was started at the rate of 5-7 milligram per kilogram body weight per hour. Any of the patients requiring muscle relaxant during surgery were excluded from the study. Continuous monitoring of respiratory rate, systolic and diastolic blood pressure, mean arterial pressure, heart rate, SPO2, electrocardiogram was done at 1st minute, 3rd minute, 5th minute and then at every 5 minute interval till the completion of surgery. If the heart rate or blood pressure varies more or less than 20% of the baseline value, then the concentration of inhalational agent was increased or decreased accordingly. At the completion of surgery, oropharyngeal and endotracheal suctioning was done in deep plane of anaesthesia. Nitrous oxide and inhalational agents were stopped and 100% oxygen was given. Intravenous infusion of propofol was continued till the spontaneous respiration was considered adequate and patients were extubated. During recovery, emergence time (time taken from stoppage of all anaesthetic agent to that when patient responds to verbal commands) and time taken to shift the patient to recovery room (time taken from the time when patient start responding to verbal commands to the time when patient regained full consciousness) was noted. Any coughing, laryngospasm and struggling on emergence were noted. Mental state assessment (alert, awake, agitated or Drowsy) was done during shifting the patient to recovery. Any post operative nausea and vomiting was also noted. In the post operative period, syrup Ibuprofen + paracetamol were given as rescue analgesia. Syrup ondansetron was given for managing postoperative nausea and vomiting. All patients were observed for any side effect or complications of the procedure. Statistical analysis: The data from the present study was systematically collected, complied and analysed using SPSS 19.0 evaluation version. Data was expressed as mean and standard deviation. The patients characteristics (non parametric data) were analysed by using the ‘Chi – Square’ tests while the inter group comparison of the parametric data was done by using unpaired “t” test. The p value was determined finally to evaluate the levels of significance. The p value of > 0.05 was considered not significant; p value of 0.01 to 0.05 was considered significant and p value < 0.01 was considered highly significant. Power analysis was done to calculate the power of study by taking α error at 0.05. Effect size was calculated and power was above 90%. Sandhu et al., Int J Med Res Health Sci. 2015;4(2):407-414 RESULTS In the present study both groups were comparable with respect to age, sex ratio, weight, duration of surgery and baseline haemodynamic parameters as shown in table: 1. During induction, time taken for loss of eye lash reflex and centralisation of pupil was significantly less in group B as compared to group A (P=0.00). Mean time taken from induction of anaesthesia to intubation of trachea (intubation time) was also significantly less in group B as compared to group A. (table: 2). However intubating conditions were excellent and comparable in both the groups. There was complete jaw relaxation, open vocal cords on laryngoscopy with no coughing, no laryngospasm, no limb movements or struggling during intubation in both the groups. None of the patient had oxygen desaturation in both groups during induction and intubation. During maintenance of anaesthesia, none of the patient required non depolarising muscle relaxant in both the groups. Total amount of propofol required during maintenance of anaesthesia in group A (88.112 ± 34.54 milligram) and group B (98.187 ± 34.02milligram) was also comparable (P=0.193).Mean heart rate remained on lower side in group A as compared to group B at all measured intervals from 2nd to 60th minutes and the difference between the two groups was highly significant (p=0.00). But after 60 minutes, heart rate remained 409 stable and comparable in both the groups as shown in fig: 1. The maximum percentage fall in heart rate was observed at third minute and that too was significantly more in group A (21.55% fall) as compared to group B(9.93% fall) (p<0.01). Mean systolic blood pressure (SBP) remained stable and comparable in the two groups during first two minutes (p>0.05), after that SBP was significantly on lower side in group A as compared to group B at 3rd, 4th and 5th minute (p<0.001). After 5th minute, mean SBP was comparable in both groups (p>0.05) at all measured intervals upto 60 minutes.(fig: 2). However maximum percentage fall in SBP was significantly more in group A (20.49±2.64%) as compared to group B (13.65 ± 2.85%) at third minute and the difference was highly significant (p<0.001). Mean diastolic blood pressure (DBP) remained comparable (p>0.05) in both groups at all measured intervals from 0-60 minutes.(fig: 2). Maximum percentage fall in DBP was also more in group A (20.45 ± 4.20%) as compared to group B (18 ± 3.5%) and that too at third minute but the difference was non significant. Mean arterial pressure (MAP) also remained comparable in both groups (p>0.05) at all measured intervals. (Fig: 2). Difference in the percentage fall in MAP was statistically non-significant at first five minutes with maximum fall noticed at third minute which was 20.45 ± 4.20% in group A and 18.00 ± 3.5% in group B. Later on MAP remained stable in both groups as shown in fig: 3. Mean heart rate, Systolic blood pressure, Diastolic blood pressure and mean arterial pressure remained stable and comparable in both groups from 60 minutes onwards till the end of study. Mean Respiratory rate and saturation of O2 in peripheral blood remained stable and comparable in both groups at all measured intervals till the end of study. None of the patient had any ECG changes from induction to recovery in both the groups. After completion of surgery, emergence from anaesthesia was significantly more rapid in group B (15.78 ± 3.886 minutes) as compared to group A (19.08 ± 4.492 minutes) (p=0.001). But the mean time taken to shift the patients to recovery room was comparable in both groups (p=0.233) as shown in Table: 2. None of the patient had coughing, laryngospasm, oxygen desaturation or struggling during emergence from anaesthesia in both the groups. Patients in both the groups were drowsy but were responding to verbal commands at the time of shifting to the recovery room. None of the patient developed nausea and vomiting in both the groups during immediate postoperative period. Table1: Demographic profile of patients in Group A and Group B. Group A Group Parameters (Halothane B(Sevoflurane+ p value +propofol) propofol) No. of patients 40 40 Age in years 6.80 ± 2.235 7.175 ± 2.312 0.445 Weight in kg 16.68 ± 5.622 18.93 ± 6.439 0.100 Sex Male 21(52.5%) 22 (55%) ratio 0.823 Female 19 (47.5%) 18 (45%) Duration of surgery Baseline Heart rate Baseline Systolic blood pressure Baseline Diastolic blood pressure Significance NS NS NS 52.23 ± 8.163 118.35 ± 6.747 51.85 ± 5.304 122.85 ± 9.638 0.808 0.068 NS NS 117.08 ± 8.337 113.23 ± 9.449 0.058 NS 72.85 ± 5.811 71.73 ± 8.608 0.495 NS Values are expressed as mean and standard deviation or number and percentage. P >0.05 is no significant (NS). Number of patient in both group were comparable. Mean age, mean weight, sex ratio and duration of surgery in minutes was comparable in both groups (p>0.05). Inter group comparison of age, weight and duration of surgery was done with unpaired “t” test and sex ratio was compared with Chi- Square test. Mean baseline heart rate per minute, systolic blood pressure and diastolic blood pressure in mm of Hg were also comparable in both the groups Sandhu et al., Int J Med Res Health Sci. 2015;4(2):407-414 410 while using unpaired “t” test for statistical analysis. (p>0.05). Table2: Induction, Intubating and Emergence parameters in Group A and Group B. Loss of eye lash reflex in seconds Centralisation of pupil in seconds Group A (Halothane+ propofol) n=40 33.05± 4.015 140.05± 12.106 Group B(Sevoflurane+ propofol) n=40 21.88± 12.652 114.40± 28.811 Mean Intubation time in seconds 211.88±11.305 189.30±33.087 No cyanosis No pain on I/v access No laryngospasm No body movement Jaw relaxation complete – 1 Vocal cord position open – 1 No Cough- 1 No limb movement – 1 No laryngospasm – 1 Total score – 5 19.08±4.492 No cyanosis No pain on i/v access No laryngospasm No body movement Jaw relaxation complete – 1 Vocal cord position open – 1 No Cough- 1 No limb movement – 1 No laryngospasm – 1 Total score – 5 15.78±3.886 11.78±2.516 10.75±4.776 Parameters Quality of induction Intubation parameters (total score) Emergence time in minutes Mean time taken to shift patient to recovery room in minutes Values are expressed as mean and standard deviation. P>0.05 is non significant (NS), p<0.01 is significant (S), p<0.001 is highly significant. In group B (sevoflurane +propofol) loss of eye lash reflex, centralisation of pupil and intubation time was significantly less as compared to group A (halothane +propofol) p<0.001. However quality of induction and intubating conditions were comparable in both groups. Emergence was also earlier in group B as compared to group A. P<0.001. Time taken to shift the patient to recovery room was again comparable in both groups.(p>0.05) Statistical analysis was performed for various parameters of induction and recovery using unpaired “t” test. Fig1: Mean Heart Rate in group A (Halothane+propofol) and group B (Sevoflurane+propofol) at various time intervals. Line diagram showing comparison of Mean heart rate at various time intervals in both groups. It remained on lower side in group A from 3rd to 60th minute of Sandhu et al., p value Significance 0.000 0.000 HS HS 0.000 HS --- --- --- --- 0.001 S 0.233 NS induction as compared to group B. Maximum fall in heart rate was at 4th, 5th, 6th minute of induction in both group and that too was more in group A as compared to group B when unpaired “t” test was applied. (P<0.001) Fig2: Mean Systolic Blood Pressure, Diastolic Blood Pressure and Mean Arterial Pressure at various time intervals in Group A (Halothane+propofol) and Group B (Sevoflurane+propofol). Line diagram showing the comparison of systolic blood pressure (SBP), Diastolic blood pressure (DBP) and mean arterial pressure (MAP) from first minute to 60 minute of induction in group A and group B. There was maximum fall in SBP, DBP and MAP in both groups at 2, 3 and 4 minute of induction. SBP remained on lower side in group A as compared to Group B. DBP and MAP remained comparable in 411 Int J Med Res Health Sci. 2015;4(2):407-414 both groups. Unpaired “t” test was used for intergroup comparison of MAP, SBP and DBP. Fig3: Line diagram showing percentage changes in mean arterial pressure (MAP) in group A (Halothane+propofol) and group B (sevoflurane +propofol) at various time intervals. Line diagram showing percentage change in mean arterial pressure (MAP) in both groups. Percentage fall in MAP was more in group A as compared to group B from second to fifth minute. P was less than 0.001 on applying unpaired “t” test. DISCUSSION Goals of anaesthesia for paediatric patients are fast emergence and short recovery with low incidence of post operative side effects, permitting a rapid and safe discharge.[13] Continuous research for an ideal inhalation agent which has all the induction properties of halothane but with minimal cardiac side effects led to the introduction of sevoflurane. It provides rapid induction and emergence due to its low blood gas solubility.[14] With the advent of potent and short acting intravenous induction agent “Propofol”, intubating the trachea without using muscle relaxant has been under evaluation. Propofol has faster onset, provides good intubating conditions by decreasing muscle tone and depressing airway reflexes, allows smooth transition to emergence and rapid recovery from anaesthesia.[15] In the present study, both groups were comparable with respect to demographic profile and duration of surgery. Induction of anaesthesia was more rapid in sevoflurane group, as the time taken to loss of eye lash reflex and centralisation of pupil was significantly less in sevoflurane group as compared to halothane group (p<0.01). Previous studies also reported that time taken for loss of eye lash reflex and centralisation of pupil was less with sevoflurane than with halothane induction, but in these studies induction time was slightly more than the present study.[6,7,9,16,17] This difference might be due to fact that either no priming of the circuit was done [6,16] or step wise increased concentration technique, starting with low concentration of inhalational agent was used for induction in these studies.[7,9,17] However in the present study, quality of induction was good and comparable in both the groups as none of the patient had any cyanosis, laryngospasm, breath holding or pain during intravenous cannulation. Batra Y K et al [10] used graded inhalational technique for bronchoscopic removal of foreign body in children. Induction was done with either Halothane or sevoflurane in oxygen only. Slight incidence of coughing, breath holding, layngospasm and excitement was observed during induction in both groups. In a study done by Abdel-Halem et al [16] induction was done with either 5% halothane or 8% sevoflurane in oxygen only. Struggling, bodily movements and laryngospasm during induction was observed in both the groups. In the present study, use of nitrous oxide during priming of the circuit for induction might be helpful for smooth induction. Addition of nitrous oxide to oxygen, decreases the MAC of sevoflurane and halothane [18] and also minimises the adverse airway reactions and struggling associated with use of high concentration of inhalational agents.[19]Similarly time taken for intubation was significantly less in sevoflurane group as compared to halothane group but intubating conditions were excellent in both groups. Less intubation time taken during sevoflurane induction was documented by previous studies also.[18,20] O’ Brien et al [11], in their study observed coughing, vocal cord movements, laryngospasm and oxygen desaturation during intubation, when halothane and sevoflurane was used with O2 and N2O for induction without using muscle relaxants. In the present study, I/V lignocaine and propofol [15] given just before intubation might have improved the intubating conditions. I/V lignocaine abolish the injection pain of propofol, improve intubation scores by its antitussive effects and also attenuate the pressor response to tracheal intubation. [21]In Halothane + propofol group, mean heart rate remained on lower side as compared to sevoflurane + propofol group from first minute to sixty minutes and the maximum 412 Sandhu et al., Int J Med Res Health Sci. 2015;4(2):407-414 fall at third minute was also more in halothane group. Previous studies also observed that heart rate remained on lower side in halothane group and it remained on higher side in sevoflurane group during induction and maintenance of anaesthesia.[5,17,18,20] In the present study, heart rate did not increased from baseline values in sevoflurane group at all measured intervals and no stress response was noted in either of the two groups at the time of intubation as reported by Paris S T et al [17] and Dedhia KN and Kudalkar A. Intravenous lignocaine [21] and propofol [15] given just before intubation, effectively attenuates the haemodynamic stress response to intubation. Blood pressure remained on lower side and maximum fall in blood pressure was also more in halothane + propofol group as compared to sevoflurane + propofol group. Both sevoflurane and halothane decreases myocardial contractility, but effect of halothane is more. In stable conditions, blood pressure is better maintained with sevoflurane than with halothane as documented by Piat V et al [20], Dedhia KN and Kudalkar A [5] and Paris S T et al.[17]After completion of surgery, emergence was significantly faster in Group B as compared to Group A. Emergence from anaesthesia depends on the blood gas solubility of inhalational agents. Blood gas- partition coefficient of sevoflurane is low, hence provides rapid emergence.[18] Previous studies also reported faster emergence with sevoflurane as compared to halothane.[9,10,16,17,20] In the present study, none of the patient had cough, laryngospasm, struggling or oxygen desaturation during extubation and emergence from anaesthesia. Children were drowsy but were responding to verbal commands at the time of shifting to recovery room, in both the groups. No emergence agitation was noted in both groups and the time taken for shifting the patients to recovery room was comparable. In the postoperative period none of patient developed nausea and vomiting. Propofol depresses the airway reflexes and thus decreases the incidence of coughing and laryngospasm during extubation.[12] Previous studies found that rapid emergence from sevoflurane as compared to halothane was associated with increased incidence of struggling and excitement.[7,8,10,17] Moore JK et al [22] concluded that emergence agitation was observed more when sevoflurane alone was used for maintenance and addition of propofol decreases the emergence agitation. Propofol also decreases the incidence of postoperative nausea and vomiting if used for maintenance of anaesthesia.[22,23] CONCLUSION Sandhu et al., Int J Med Res Health Sci. 2015;4(2):407-414 Hence it was concluded that both groups provided excellent intubating conditions without using muscle relaxants, with no stress response. But Sevoflurane + propofol group was better as it provided faster induction and rapid recovery from anaesthesia with more stable haemodynamics as compared to Halothane + propofol group. ACKNOWLEDGEMENT We are highly thankful to Dr. Ranjana kheterpal and Dr. JP attri, Associate professor, Department of anaesthesia for their whole hearted support and encouragement in completing this project. Conflict of Interest: Nil REFERENCES 1. Radha R, Tanya H. Anesthesia for paediatric ear, nose and throat surgery. ContinEduc Anaesth Crit Care Pain 2007; 7:33-37. 2. Warwick JP, Mason DG. Obstructive sleep apnoea syndrome in children. Anesthesia 1998; 53:571-9. 3. Woods AW, Allam S. Tracheal intubation without the use of neuromuscular blocking agents. Br J Anaesth 2005; 94:150-58. 4. Gupta A, Kaur R, Malhotra R, Kale S. Comparative evaluation of different doses of propofol, preceded by fentanyl on the intubating conditions and the pressor response during tracheal intubation without muscle relaxants. Paediatric Anaesth 2006; 16:399-05. 5. Dedhia KN, Kudalkar A. Comparison of sevoflurane and halothane for induction of anaesthesia and laryngeal mask airway insertion in paediatric patients. Indian journal of anaesthesia. 2004; 48(6):465-68. 6. Sigston PE, Jenkins AMC, Jackson EA, Sury MRJ, Mackersie AM, Hatch DJ. Rapid inhalation induction in children: 8% sevoflurane compared with 5% halothane. British Journal of Anesthesia.1997; 78:362-65. 7. Al-Khraysha H, Al-Dehayat G, Zaharan I, Mashaqba M. Comparison of Induction and Recovery Characteristics of Halothane and 413 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. Sevoflurane among Infants. Journal of The Royal Medical Services. 2011; 18:26-29. Picard V, Dumont L, Pellegrini M. Quality of recovery in children: sevoflurane versus propofol. Acta Anaesthesiol Scand. 2000; 44:307-10. Redhu S, Jalwal GK, Saxena M, Shrivastava OP. A comparative study of Induction, Maintenance and Recovery Characteristics of Sevoflurane and Halothane Anaesthesia in Paediatric patients (6 months to 6 years). Journal Anaesthesiol Clin Pharmacol. 2010; 26:484-87. Batra YK, Mahajan R, Bangalia SK, Chari P, Rao KLN. A comparison of Halothane and Sevoflurane for Bronchoscopic Removal of Foreign Bodies in Children. Annals of Cardiac Anesthesia.2004; 7:137-43. O’Brien K, Kumar R, Morton NS. Sevoflurane compared with halothane for tracheal intubation in children. British Journal of Anesthesia. 1998; 80:452-55. Kaur S, Gupta A, Sharma A, Singh M. Role of Propofol in Prevention of Extubation Related Complications in Oral Surgery. J Anaesth Clin Pharmacol. 2006; 22:155-60. Helbo-Hansen S, Ravlo O, Trap-Anderson S. The influence of alfentanyl on the intubating conditions after priming with vecuronium. Acta Anaesthesiologica Scandinavica 1998; 32:41-44. Steyn MP, Quinn AM, Gillespie JA, et al. Tracheal intubation without neuromuscular block in children. Br J Anaesth 1994; 72:403-6. Sabapathy VA, Thilaak P, Gopal SSM, Pongiyandar SN. Endotracheal intubation without muscle relaxants in children undergoing cleft lip, palate and alveolar surgery. A comparative study of sevoflurane and propofol. Journal of Clinical and Diagnostic Research 2011; 5:1421-25. Abdel-Halim KMJ, Azer MS, El-Awady GA. Comparison of Induction and Recovery characteristics of Sevoflurane, Halothane and Propofol in Paediatric Outpatients. Journal of the Egyptian Nat. Cancer Inst. 2002; 14:319- 23. Paris ST, Cafferkey M, Tarling M, Hancock P, Yate M, Flynn PJ. Comparison of sevoflurane and halothane for outpatient dental anaesthesia in children. Br J Anaesth. 1997; 79:280-84. Sarner JB, Levine M, Davis PJ, Lerman J, Cook DR, Motoyama EK. Clinical Characteristics of 19. 20. 21. 22. 23. Sevoflurane in Children. A Comparison with Halothane. Anesthesiology1995; 82:38-46. Hall JE, Jim S, Harmer M. Single- breath inhalation induction of sevoflurane anaesthesia with or without nitrous oxide: a feasibility study in adults and comparison with an intravenous bolus of propofol. Anesthesia 1997; 52:410-15. Piat V, Dubois MC, Johanet S, Murat I. Induction and Recovery Characteristics and Hemodynamic Responses to Sevoflurane and Halothane in Children. Anesth Analg 1994; 79:840-44. Davidson JAH, Gillesple JA. Tracheal intubation after the induction of anaesthesia with propofol, alfentanyl, and i.v. lignocaine. Br J Anaesth 1993; 70:163-66. Moore JK, Moore EW, Elliott RA, et al. Propofol and halothane versus sevoflurane in paediatric day-case surgery: induction and recovery characteristics. Br J Anaesth 2003; 90:461-6. Gan TJ, Ginsberg B, Grant AP, et al. Doubleblind, randomized comparison of odansetron and intraoperative propofol to prevent postoperative nausea and vomiting. Anaesthesiology 1996; 85:1036-42 414 Sandhu et al., Int J Med Res Health Sci. 2015;4(2):407-414 DOI: 10.5958/2319-5886.2015.00076.4 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 25 Feb 2015 Letter to editor Coden: IJMRHS Copyright @2015 ISSN: 2319-5886 th Revised: 7 Mar 2015 Accepted: 17th Mar 2015 RETAINED STONE PIECE IN ANTERIOR CHAMBER *ZvornicaninJasmin, Nadarevic-VodencarevicAmra Eye Clinic, University Clinical Centre Tuzla, Tuzla, Bosnia and Herzegovina *Corresponding author email:
[email protected] Dear Editor, We read with interest the article by Surekha et al. regarding the retained stone piece in anterior chamber.[1]Similar to the results of previous studies, the authors found that delayed intraocular foreign body (IOFB) management can result in good visual outcome without an apparent increased risk of endophthalmitis or other deleterious side effects.[2] However, the authors failed to explain the exact reason for the diminution of vision in patients left eye. It is unclear what the uncorrected visual acuity was and what kind of correction was used, more precisely type and amount of cylinder, given the presence of the corneal opacity. Since the size of the IOFB is approximately 4x4x1mm, significant iridocorneal angle changes resulting in intraocular pressure raise and optic nerve head damage can be expected. Traumatic glaucoma following open globe injury can occur in 2.7 to 19% of cases, with several risk factors associated with glaucoma development (advanced age, poor visual acuity at presentation,perforating rather than penetrating ocular injury,lens injury, presence of vitreous hemorrhage and presence of an IOFB).[3] Earlier reportsof latetraumaticoptic neuropathy onset, even after several years, indicate that this possibility cannot be completely ruled out too.[4] Therefore, repeated intraocular pressure measurements, gonioscopy, pupillary reaction assessment, together with through posterior segment examination including visual field and optical coherence tomography examinations can be useful in determining the possible optic nerve damage as one of the possible reasons for visual acuity reduction. The authors did not suggest any operative treatment at this time. However, it should bear in mind that the inert anterior chamber IOFB could be a risk factor for non-infectious endophthalmitis development even after many years.[5]Also, long term retained anterior chamber foreign body leads to permanent endothelial cell loss and can even result in a corneal ulcer formation.[6] On the other side, it is not clear what was the grade and morphology of the lens opacity, especially if it is known that visual acuity in right – healthy eye is 6/12 with presence of immature senile cataract. Retained IOFB is a risk factor for prolonged postoperative inflammation and endophthalmitis after cataract surgery.[7,8] Therefore, surgical intervention including cataract extraction, foreign body removal with possible toric intraocular lens implantation could be therapy of choice for this patient. For these reasons, we would kindly ask the authors to present the data regarding the uncorrected visual acuity, required spherical and cylindrical correction, keratometry and refractometry readings, intraocular pressure values, grade and morphology of the lens opacification, state of the iridocorneal angle, possible changes in the vitreous, retina and optic nerve head. Without this information’s it would be difficult to hypothesize that the IOFB in the anterior chamber was completely inactive forthe past twenty years and it did not produce any adverse effect in patient’s eye. These findings will significantly contribute to the papers scientific value and contribution. 415 Zvornicanin et al., Int J Med Res Health Sci. 2015;4(2):415-416 Overall we agree with Surekha et al. that IOFBs can be variable in presentation and outcome. There is still significant controversy in the management of IOFBs, particularly the timing and method of surgery.[9] Conflict of interest: Nil REFERENCES 1. Surekha B, Fuzail S, Prasad K, Akshay B. Retained stone piece in anterior chamber: a case report. Int J Med Res Health Sci.2015; 4: 236-8. 2. Colyer MH, Weber ED, Weichel ED, Dick JS, Bower KS, Ward TP, Haller JA.Delayed intraocular foreign body removal without endophthalmitis during Operations Iraqi Freedom and Enduring Freedom.Ophthalmology.2007; 114: 1439-47. 3. Osman EA. Glaucoma after open globe injury. Saudi J Ophthalmol.2014; http://dx.doi.org/10.1016/j.sjopt.2014.10.006 4. Yu-Wai-Man P, Griffiths PG. Steroids for traumatic optic neuropathy. Cochrane Database Syst Rev.2013; 6:CD006032. 5. Ahn M. Noninfectious endophthalmitis caused by an intraocular foreign body retained for 16 years. J Korea Ophthalmol Soc.2001;42:793-6. 6. JastaneiahSS.Long-term corneal complication of retained anterior chamber-angle foreign body.Saudi J Ophthalmol.2010; 24: 105-8. 7. Stangos AN, Pournaras CJ, Petropoulos IK. Occult anterior-chamber metallic fragment postphacoemulsification masquerading as chronic recalcitrant postoperative inflammation. Am J Ophthalmol.2005; 139:541-2. 8. Yeniad B, Beginoglu M, Ozgun C. Missed intraocular foreign body masquerading as intraocular inflammation: two cases. Int Ophthalmol.2010; 30:713-6. 9. Parke DW 3rd, Flynn HW Jr, Fisher YL. Management of intraocular foreign bodies: a clinical flight plan. Can J Ophthalmol.2013; 48:812. 416 Zvornicanin et al., Int J Med Res Health Sci. 2015;4(2):415-416 DOI: 10.5958/2319-5886.2015.00077.6 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS th Received: 20 Jan 2015 Revised: 28th Feb 2015 Review article Copyright @2015 ISSN: 2319-5886 Accepted: 19th Mar 2015 EVOLUTION OF AUTOMATICITY OF HEART PACEMAKER STUDIED FROM A THEORETICAL PERSPECTIVE 3 4 Vijay Kumar Konuri1, Mohammed Abdul Hannan Hazari2, Ravi Kumar K , Chandrasekhar M , 5 6 Ambareesha K , Ram Reddy B 1 Associate Professor, Department of Anatomy, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India 2 Associate Professor, Department of Physiology, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad, Telangana, India 3 Assistant Professor of Anatomy, Govt Medical College, Jagdalpur, Chhattisgarh Professor and HOD, 5Tutor, Department of Physiology, Meenakshi Medical College, Kanchipuram, Tamil Nadu 4 6 Professor & HOD, Department of Physiology, Apollo Institute of Medical Sciences and Research, Jubilee Hills, Hyderabad, Telangana, India. *Corresponding author email:
[email protected] ABSTRACT The pacemaker of the mammalian heart had developed a robust and yet a flexible system in the course of evolution whose function is based on multiple interactions at the sub-cellular, cellular and finally at the tissue level. These, in turn, should respond to extrinsic signals. Cardiac action potentials were explained for a long time based on the changes that occur at the cell surface. New hypothesis was put forward at the turn of the century that pointed to the role of intracellular calcium clock. Discovery of ryanodine receptors, fluorescence labeling techniques, confocal imaging and finally computer modeling of physiological processes had brought about a noticeable change that allowed development of a new concept of pacemaker automaticity. Reviewing all these developments we hereby put forward a few theoretical formulations that can turn out to be new instruments in advancing our knowledge of cardiac physiology. We had theorized that cardiac muscle is an emergent property of smooth muscle in the course of evolution, and that pacemaker activity of the cardiac muscle underwent a phase transition that finally led to the evolution of a structural pacemaker. Keywords: Heart, Pacemaker, Automaticity, Evolution INTRODUCTION The sino-atrial node (SAN) pacemaker cells produce billions of incessant and uninterrupted beats in the course of the life time of an individual. It is evident that the pacemaker of the mammalian heart has developed a robust and yet a flexible system in the course of evolution [1]. Robustness indicates the failsafe properties and flexibility signifies the adaptability to changes in the demands made on it. The pacemaker function is based on multiple interactions at the level of sub-cellular, cellular and finally at the level of tissue architecture, which in turn should react to extrinsic signals like stretch, electrical and chemical signals that act on the cell surface receptors. The generation of action potentials in the myocardium was explained for a long time, predominantly, basing on the changes that occur on the cell surface and its ion channels [2]. However, the 417 Vijaykumar et al., Int J Med Res Health Sci. 2015;4(2):417-421 turn of the century has brought new evidence pointing to the role of an intracellular clock. This turned out to be the cyclical rhythm of cytosolic Ca2+ concentration. Sarcoplasmic reticulum (SR) has proved to be having the capacity to operate another physiologic clock of calcium cycles[3]. Recent developments in experimentation like confocal imaging have revealed the presence of multiple spontaneous, rhythmic, local calcium releases[4]. These tightly regulated processes begin to occur beneath the cell surface during the later part of diastolic depolarization. This activates the Na+-Ca2+ exchanger that causes an explosive increase in diastolic depolarization and leads to the activation of L-type calcium channels[5]. Fig 1. Interplay between intracellular and membrane surface Ca2+ clock. The existing understanding of cardiac action potentials The explanation of action potentials in the working myocardium is as follows. Phase 0 or the rapid depolarization results from the opening of the fast Na+ channels. Phase 1 of the action potential starts the repolarization process and is attributed to the closing of Na+ channels and inward movement of Clions. Phase 2, the so-called "plateau" phase of the action potential results from several mechanisms but could be mainly because of slow inward movement of Ca2+ and Na+. Phase 3 involves relative rapid repolarization, commencing with inactivation of slow Ca2+ and Na+ channels and rapid outward movement of K+ ions. Phase 4 restores the ionic composition back to the resting state by Na+-K+ ATPase which pump Na+ ions out and K+ ions inside the cell[6]. Membrane potential of pacemaker cells spontaneously declines to the firing level and is known as prepotential or pacemaker potential which triggers the next action potential. At the peak of each action potential, conductance of potassium (IK+) begins and repolarization occurs. IK+ then declines and the membrane potential reaches slight hyperpolarization. At this instance an "h" or "f" channel which allows both Na+ and K+ is activated. As conductance through "h" channel (Ih) increases, the membrane begins to depolarize forming the initial part of the prepotential. T-type Ca2+ channels then open and its conductance (ICa2+T) completes the prepotential. At this juncture L-type Ca2+ channels open and ICa2+L produce action potential. The measurements of calcium concentrations The finding that oscillations in Ca2+ concentrations were inhibited by calcium channel blockers (CCBs) had brought to the fore the idea that Ca2+ concentration represents a two-way interaction between the intracellular Ca2+ stores and the membrane surface potential changes[7]. But due to the rapidity of changes; spontaneous, localized oscillations of the calcium clock could not be measured within the individual SA nodal cells and hence the concept that initiators of the normal automaticity of pacemaker cells are internal calcium oscillations could not be established. The membrane surface processes was disconnected from that of intracellular oscillations, for a long time, by the employment of Ca2+ overload conditions to voltage clamp studies[8]. Studies have gradually demonstrated that the intracellular oscillations could, in fact, produce spontaneous membrane currents. It is now considered that the intracellular oscillations involve the cycling of Ca2+ ions between SR and cytosol[9]. Discovery of ryanodine receptors Then came the discovery that the drug named ryanodine can have a profound negative chronotropic effect on the automaticity of cardiac pacemaker cells. By studying the effect of ryanodine on the contour of the action potential it was suggested that Ca2+ released from the SR contributes to diastolic depolarization[10]. It is now possible to measure the intracellular calcium levels in spontaneously firing pacemaker cells of SAN which made it clear that each spontaneous action potential evokes a calcium gradient in the cytosol and that the influx of calcium through L-type calcium channels affects the calcium loading of the 418 Vijaykumar et al., Int J Med Res Health Sci. 2015;4(2):417-421 SR. Intracellular buffering of calcium has the potency to block the generation of spontaneous action potentials[11]. This constitutes a strong evidence in favor of the idea that normal automaticity of pacemaker cells is strongly linked with the dynamics of intracellular calcium. Modern techniques Fluorescence imaging of intracellular calcium is made possible in the last decade that enabled to document not only the global transients of cytosolic calcium but also of many localized calcium releases beneath the cell surface during late diastolic depolarization[12]. Such local calcium releases are observed in SA nodal cells in the absence of changes in the membrane potentials, i.e. in voltage clamped SA node pacemaker cells. There is evidence that local Ca2+ release from the sarcoplasmic reticulation (Ca2+ sparks) occurs during the prepotential. Local calcium releases (LCRs) during the late diastolic depolarization begin to boil and then explode into an action potential[13]. A tiny change in the current to the degree of 3 pA is enough to explode into an action potential during the critical diastolic depolarization phase of rabbit SA node cells. Although the individual local release of calcium during the diastolic depolarization of pacemaker cells is relatively small and stochastic in nature, the synchronized and cumulative effects of LCRs imparts and impacts the rising phase of diastolic depolarization leading to the next action potential. A failure to generate an exponential phase in diastolic depolarization is the consequence of a failure to generate diastolic INCX[14]. Structurally SA node is heterogeneous Till now we discussed the mechanisms of automaticity and spontaneous calcium cycles in individual pacemaker cells. But cardiac pacemaker function cannot be understood completely by the study of the intrinsic properties of the pacemaker cells. Advanced histological studies had revealed that SA node is a highly heterogeneous structure with small pacemaker cells predominantly located in the centre[15]. The SA nodal tissue is characterized by complex cell-to-cell interactions in generating the highly robust impulses with a fail-safe mechanism[16]. The function of the pacemaker tissue within the SA node is determined by the intrinsic properties of individual cells that are being modulated by several factors of the local environment within the SA node[17]. The pacemaker tissue is at the same time being influenced by extrinsic modulators that include the electrical and mechanical forces as well as the autonomic milieu. These modulatory factors are heterogeneous throughout the SA node which could explain the differences in the shape of the action potential curves of different cells in the same locality[18]. This could be the result of mutual interaction between the depolarizing charges generated by individual SA node cells and the structural properties of the surrounding non-excitable tissue[19]. Extensive amounts of connective tissue and numerous fibroblasts occupy from 25% to almost 90% of the area of SA node[20]. Fig 2: Phase transition and emergence of cardiac muscle from smooth muscle with maintenance of legacy in some aspects 419 Vijaykumar et al., Int J Med Res Health Sci. 2015;4(2):417-421 In addition to bands of connective tissue, the gap junction proteins are also found to be located in various types and with varying densities in near vicinities. The myofilament density decreases from periphery to the centre of the SA node[21]. The nerve endings and autonomic receptors on pacemaker cells are found to be at the highest density in the central area of SA node[22]. All these structural features make the SA node a highly heterogeneous structure that can generate not only flexible but also a robust action potential[23].Intracellular calcium cycling plays a major role in the generation of automaticity in embryonic cardio myocytes and so could be used to generate stem cell derived spontaneously beating myoblast cells[24]. Discussion: A theoretical approach is needed to interpret physiology at an advanced level We have seen how our concepts of pacemaker potentials transformed over time, from the more or less simplified notions that membrane currents explain everything to developing a more and more complex picture of mutual entrainment of the cytosolic and the membrane clocks and of their different mechanisms in generating automaticity. We understand the vertebrate circulatory system as a closed canal system comprised of network of smooth muscle and other cells, the proximal part of which has been transformed into cardiac muscle due to increased circulatory load imposed on the system[25].This can be visualized as a type of phase transition during evolution of smooth muscle there by transforming phase maker activity from a network of molecules to a network of cells and tissues, which can justify the existence of special conducting system in myocardium. So this can be generalized as an emergent property of smooth muscle. Pacemaker properties of the smooth muscle is well preserved but is now regulated by pacemaker system of cardiac muscle. Even in smooth muscle the initiation of pacemaker activity is due to the oscillations of intracellular calcium that are being modulated by external conditions. It is our endeavor to elucidate how function is translated into structure through the alteration of the genetic program. CONCLUSION Pacemaker in mammalian heart is the phase shift transformation of the smooth muscle through cardiac muscle during the evolutionary process. In the course of development of highly evolved forms of organisms, the metabolic necessities of the complex tissues and organs demanded continuous supply of nutrients and gases for sustenance of life. Hence, the smooth muscle underwent structural and functional adaptations to develop into cardiac muscle which further acquired autonomy at the expense of losing the contractility to form pacemaker tissue. This aptly describes the proverb "Necessity is the mother of invention". REFERENCES 1. Lakatta EG, Vinogradova TM, Maltsev VA. The missing link in the mystery of normal automaticity of cardiac pacemaker cells. Ann N Y Acad Sci. 2008; 1123: 41–57. 2. Mangoni ME and Nargeot J. Genesis and regulation of the heart automaticity. Physiol Rev. 2008; 88:919–982. 3. Lakatta EG, Vinogradova T, Lyashkov A, Sirenko S, Zhu W, Ruknudin A, Maltsev VA. The integration of spontaneous intracellular Ca2+ cycling and surface membrane ion channel activation entrains normal automaticity in cells of the heart’s pacemaker. Ann N Y Acad Sci. 2006; 1080:178–206. 4. Maltsev VA and Lakatta EG. Synergism of coupled sub-sarcolemmal Ca2+ clocks and sarcolemmal voltage clocks confers robust and flexible pacemaker function in a novel pacemaker cell model. Am J Physiol Heart Circ Physiol. 2009; 296:H594–H615. 5. Maltsev VA and Lakatta EG. Dynamic interactions of an intracellular Ca2+ clock and membrane ion channel clock underlie robust initiation and regulation of cardiac pacemaker function. Cardiovasc Res. 2008; 77:274–284. 6. Sanders L, Rakovic S, Lowe M, Mattick PA, Terrar DA. Fundamental importance of Na-Ca2+ exchange for the pacemaking mechanism in guinea-pig sino-atrial node. J Physiol. 2006: 571:639–649. 7. Vinogradova TM and Lakatta EG. Regulation of basal and reserve cardiac pacemaker function by 420 Vijaykumar et al., Int J Med Res Health Sci. 2015;4(2):417-421 8. 9. 10. 11. 12. 13. 14. 15. interactions of cAMP mediated PKA-dependent Ca2+ cycling with surface membrane channels. J Mol Cell Cardiol. 2009; 47:456– 474. Joung B, Tang L, Maruyama M, Han S, Chen Z, Stucky M, Jones LR, Fishbein MC, Weiss JN, Chen PS, Lin SF. Intracellular calcium dynamics and acceleration of sinus rhythm by betaadrenergic stimulation. Circulation. 2009; 119:788–796. Rigg L, Heath BM, Cui Y, Terrar DA. Localisation and functional significance of ryanodine receptors during beta-adrenoceptor stimulation in the guinea-pig sino-atrial node. Cardiovasc Res. 2000; 48:254–264. Li J, Qu J, Nathan RD. Ionic basis of ryanodine’s negative chronotropic effect on pacemaker cells isolated from the sinoatrial node. Am J Physiol. 1997; 273:H2481–H2489. Bogdanov KY, Vinogradova TM, Lakatta EG. Sinoatrial nodal cell ryanodine receptor and Na+Ca2+ exchanger: molecular partners in pacemaker regulation. Circ Res. 2001; 88:1254–1258. Vinogradova TM, Lyashkov AE, Zhu W, Ruknudin AM, Sirenko S, Yang D, Deo S, Barlow M, Johnson S, Caffrey JL. Zhou YY, Xiao RP, Cheng H, Stern MD, Maltsev VA, Lakatta EG. High basal protein kinase Adependent phosphorylation drives rhythmic internal Ca2+ store oscillations and spontaneous beating of cardiac pacemaker cells. Circ Res. 2006; 98:505–514. Maltsev VA and Lakatta EG. Cardiac pacemaker cell failure with preserved If, ICaL, and IKr: a lesson about pacemaker function learned from ischemia-induced bradycardia. J Mol Cell Cardiol. 2007; 42:289–294. Vinogradova TM, Zhou YY, Maltsev V, Lyashkov A, Stern M, Lakatta EG. Rhythmic ryanodine receptor Ca2+ releases during diastolic depolarization of sinoatrial pacemaker cells do not require membrane depolarization. Circ Res. 2004; 94:802–809. Lancaster MK, Jones SA, Harrison SM, Boyett MR. Intracellular Ca2+ and pacemaking within the rabbit sinoatrial node: heterogeneity of role and control. J Physiol. 2004; 556:481–494. 16. Christoffels VM, Burch JB, Moorman AFM. Architectural plan for the heart: early patterning and delineation of the chambers and the nodes. Trends Cardiovasc Med. 2004; 14:301–307. 17. Maltsev VA, Vinogradova TM, Bogdanov KY, Lakatta EG, Stern MD. Diastolic calcium release controls the beating rate of rabbit sinoatrial node cells: numerical modeling of the coupling process. Biophys J. 2004; 86:2596–2605. 18. DiFrancesco D. The contribution of the ‘pacemaker’ current (if generation of spontaneous activity in rabbit sino-atrial node myocytes. J Physiol. 1991; 434:23–40. 19. van Mierop LHS and Gessner IH. The morphologic development of the sinoatrial node in the mouse. Am J Cardiol. 1970; 25:204–212. 20. Vira´gh Sz and Challice CE. The development of the conduction system in the mouse embryo heart. Dev Biol. 1980; 80:28–45. 21. deJong F, Opthof T, Wilde AAM, Janse MJ, Charles R, Lamers WH, Moorman AFM. Persisting zones of slow impulse conduction in developing chicken hearts. Circ Res. 1992; 71:240–250. 22. Moorman AFM and Christoffels VM. Cardiac chamber formation: development, genes, and evolution. Physiol Rev. 2003; 83:1223–1267. 23. Mommersteeg MTM, Hoogaars WMH, Prall OWJ, de Gier-de Vries C, Wiese C, Clout DEW, Papaioannou VE, Brown NA, Harvey RP, Moorman AFM, Christoffels VM. Molecular pathway for the localized formation of the sinoatrial node. Circ Res. 2007; 100:354–362 24. Satin J, Itzhaki I, Rapoport S, Schroder EA, Izu L, Arbel G, Beyar R, Balke CW, Schiller J, Gepstein L. Calcium handling in human embryonic stem cell derived cardiomyocytes. Stem Cells. 2008; 26:1961–1972. 25. Konuri VK, Agnihotri G, Reddy BR. Current advances and concepts of the embryological and genetic basis of the developing human heart. International Journal of Advanced Research 2014; 2: 431-435. 421 Vijaykumar et al., Int J Med Res Health Sci. 2015;4(2):417-421 DOI: 10.5958/2319-5886.2015.00078.8 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 14 Feb 2015 Review article Coden: IJMRHS Revised: 7th Mar 2015 Copyright @2015 ISSN: 2319-5886 Accepted: 25th Mar 2015 COMPLIMENT RECEPTOR TYPE - 1 (CD35) GENE POLYMORPHISM AND PLASMODIUM FALCIPERUM MALERIA Rishabh Dev Saket*, Shrikant Kol, Arvind Kumar Tripathi, Sher Singh Parihar, Jitendra Kumar Tipathi, Ugam Kumari Chauhan. Department: Centre for Biotechnology studies, Awadhesh Pratap Singh University, Rewa (M.P.), India. *Corresponding author email:
[email protected] ABSTRACT: Malaria is a most causative agent for worldwide death. Plasmodium falciperum infected malaria most dangerous than other plasmodium species. It has closely association to compliment receptor type -1 (CD35) gene polymorphism. CD35 (CR1) is a cell surface receptor for plasmodium falciperum containing PfEMP-1 as a legend. Density of CD35 on erythrocyte can be determined by CR1 allele (HH, HL, and LL). HH allele of CR1 gene express high density of CD35 whereas LL in low density. High density of CD35 is more susceptible to falciperum infection. CD35 is also responsible for sever malaria. During plasmodium infection, pro-inflammatory cytokine like TNF-α, IFN-γ levels are increased. The elevated ratio of TNF-α/IL10 indicates falciperum infection. Cell adhesion protein like VCAM, ICAM also mediate the malarial infection. Keyword: Plasmodium falciperum, CD35, CR1 allele, TNF-α, IL10, ICAM. INTRODUCTION: Malaria is the most infectious and dangerous disease in the world. The World Health Organization (WHO) estimated 225 million malaria cases worldwide with 781,000 deaths due to Plasmodium infection per year. Four types of Plasmodium species (P. falciparum, P. vivax, P. malariae, and P. ovale) are responsible for almost all human infections. Plasmodium falciparum malaria is responsible for more than one million deaths that occur each year from malaria infection in Africa. Most of these deaths occur as a result of complications such as severe malaria associated anaemia (SMA) and cerebral malaria (CM) [1]. Compliment Receptor 1 (CR1), a protein on RBC cells that having role in immune complex clearance. It’s also known as C3b/C4b receptor or CD35. In humans this protein is encoded by CR1 gene is located at on the long arm of chromosome 1 at band 32 (1q32) and lies within a complex of immunoregulatory genes. The Compliment Receptor 1 (CR1) gene polymorphism conform density of CD35 on RBC cells. The human CR1 binds to a major malarial adhesion, the P. falciparum erythrocyte membrane protein-one (PfEMP-1). High density of CR1 on erythrocyte indicates high risk of falciparum infection [2- 5]. PREVALENCE AND EPIDEMIOLOGY OF P. FALCIPARUM: Malaria affects the 300-500 million people each year in which 1-3 million people leading cause of death worldwide annually. There are five Plasmodium species that infect humans; Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, Plasmodium malariae, and Plasmodium knowlesi. These species differ in their morphology, immunology, and geographic distribution. Among the five species that cause malaria in humans, Plasmodium falciparum (P. falciparum) is the most 422 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 virulent resulting in the greatest number of complications and the great majority of malariarelated deaths in children under the age of five. The evolutionary history and geographical distribution of P. falciparum reflects a three-way interaction between the parasite, the host, and the Anopheles sp. mosquito (the vector for transmission). Circa, 1900 prior to the widespread use of anti-malarials, the distribution of malaria reached the geographic latitudes of 64º north and 32º south [6-7]. However, genetic history and the coevolution of P. falciparum with humans suggest this has not always been the geographic model. The closest relative to the modern day P. falciparum is the chimpanzee malaria parasite, Plasmodium reichenowi. It has been argued that P. falciparum is of African origin because P. reichenowi is a parasite that infects African chimpanzees. Despite some controversy, it is generally accepted that the divergence of these two species of malaria occurred approximately 9-10 million years ago, prior to the divergence of humans from non-human primate relatives such as the chimpanzees. It is believed that the major spread of P. falciparum in Africa occurred during the “Agrarian Revolution” (4000-5000 years ago) when small nomadic groups began to establish larger settled communities; this lifestyle change provided ideal conditions for sustained P. falciparum transmission [8-9]. Fig 1: Geographic distribution of Plasmodium falciparum malaria [6]. Life cycle of Plasmodium falciparum malaria: The P. falciparum infection begins when a human host is bitten by an infected female Anopheles mosquito, and the mosquito injects sporozoites into the subcutaneous tissue of the human host. The sporozoites, within one hour reach to the liver and infect hepatocytes. The duration of the asymptomatic liver (exo-erythrocytic cycle) stage of the infection is approximately one-two weeks. During this stage, each sporozoite may yield thousands of merozoites [10] . Invasion: The hepatocytes rupture releasing the merozoites into the blood stream (the beginning of clinical disease) where they are able to enter into RBCs by a complex invasion process comprised of four phases: (a) initial recognition and reversible attachment of the merozoite to the RBC membrane. (b) Reorientation. (c) Invagination of the RBC membrane around the merozoite. (d) Resealing of the RBC membrane after completion of merozoite invasion. RBC invasion is a rapid process that is governed by molecular interactions between the merozoites and the host cell surface [11-12]. Primary contact is initiated by a surface coat of proteins that is largely comprised of glycosylphosphatidylinositol (GPI)-anchored membrane proteins. There are at least nine recognized GPI anchored proteins that are predicted to be potential RBC ligands. Merozoite surface protein-1 (MSP-1) is the dominant antigen and is essential for parasite survival. MSP-1 is involved in the initial recognition of the RBC via sialic acid residues found on the RBC membrane. Other important proteins are MSP-2, -3 and -4. P. falciparum apical membrane antigen-1 (PfAMA-1) is also essential for successful invasion as it is translocated to the merozoites surface before invasion of the RBCs, and is also present on the sporozoite for invasion into hepatocytes [13-14]. Fig 2: Life cycle of Plasmodium falciparum malaria [11] . Maturation : Initially, the merozoites develop into an early trophozoite stage known as the “ring form”. The ring form persists for 24 hours and matures inside the RBC through a highly active 423 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 metabolic state. The P. falciparum ring feeds from the host cytoplasm, importing glucose and breaking down hemoglobin into constituent amino acids. Following the ring stage, P. falciparum matures and develops to a late stage trophozite. The mature trophozoite stage parasite replicates by nuclear division resulting in schizont stage parasites. Each schizont is comprised of 20-24 merozoites, which are released upon rupture of the infected RBC. When the infected RBCs rupture, merozoites and parasite metabolic waste products such as hemozoin, degradation of hemoglobin, and parasite toxins are released. The majority of the merozoites will invade other RBCs continuing the asexual cycle; however, some parasites will form sexual stage forms called gametocytes which are then transmitted to new hosts by the Anopheles vector [11-17]. Pathophysiology of Plasmodium falciparum malaria: Infection with P. falciparum results in considerable morbidity and without treatment may be fatal. The clinical outcome of malaria depends on many contributing factors including the parasite’s virulence, the host’s response, geographical, and socio-economic factors (Table 1). Table 1. Factors contributing to the clinical outcome of P. falciparum infection [11]. Parasite Factors Host Factors Geographic and Social factors -Drug Resistance Immunity -Transmission -Multiplication rate Genetics: Sickle intensity -Invasion Pathways cell, -Culture and -Cytoadherence thalassaemia, economic factors -Rosetting ABO blood type -Access to -Malaria toxins Age treatment (hemozoin) Pregnancy -Antigenic Variation Proinflammatory (PfEMP1) cytokines The combination of these factors result in a range of possible outcomes for the host, including asymptomatic infection, uncomplicated malaria infection, severe infection (severe malaria anemia and cerebral malaria) and death. Clinical stages of malaria pathogenesis: There are three defined clinical stages of malaria pathogenesis: uncomplicated malaria, severe malaria, and cerebral malaria. Uncomplicated malaria initially presents with fever and chills, nausea and headache, sometimes associated with diarrhea and vomiting. Unfortunately, because of the similarity in symptoms, malarial infection is often mistaken for many other infections including influenza or gastro-intestinal infection and is therefore not properly treated [18]. In 1990, the World Health Organization (WHO) established criteria for the diagnosis of severe malaria. The major criteria include neurological involvement (cerebral malaria), pulmonary edema, acute renal failure, and severe anemia. Severe anemia is the second most common symptom of P. falciparum infection and is caused by the destruction of RBCs and overall decreased erythropoiesis. Acidosis and hypoglycemia are the most common metabolic complications [4,19]. Cerebral malaria is the most common cause of death in adults and children with severe malaria. According to the WHO, the strict definition of cerebral malaria requires the presence of P. falciparum parasitemia and unarousable coma with a Glasgow Coma score of 9 or less; all other causes of coma, such as hypoglycemia, bacterial meningitis and viral encephalitis, need to be excluded. Typical neurological symptoms include coma, seizures, edema, and brainstem damage. Engorgement of cerebral capillaries and venules filled with infected RBCs and non-infected RBCs are typical histopathological findings in cerebral malaria. As the infection progresses, the increasingly detrimental pathogenesis of P. falciparum malaria is believed to be caused by two main factors: (a) an imbalance of cytokine production; and (b) the sequestration of infected RBCs in the microvasculature of vital organs [20-21] . Inflammatory response: P. falciparum infection results in an increase of both pro-inflammatory cytokines and antiinflammatory cytokines. However, in cerebral malaria, there is an unbalanced and excessive production of the pro-inflammatory response. Blood concentrations of pro-inflammatory cytokines, especially tumor necrosis factor (TNF), interferon gamma (IFN-γ), and IL-6, have been shown to be raised in cerebral malaria. TNF may contribute to malaria pathogenesis including cerebral malaria. TNF up regulates endothelial cytoadherence receptors such as intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E424 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 selectin. TNF may cause hypoglycemia and dyserthryopoesis, and has been shown to induce the release of nitric oxide (NO) which interferes with synaptic transmission [22-23]. Parasite sequestration: P. falciparum has a unique ability to adhere to host microvasculature endothelium, a process known as sequestration. Sequestration causes microvascular obstruction and compromises the blood flow through tissues such as the liver, spleen, lung, and brain. The effects of sequestration include mechanical obstruction (which can lead to hypoxia), metabolic disturbances and is a central point where parasite toxins and inflammatory mediators concentrate [24]. Increased expression of cytoadherence receptors enhances infected RBC sequestration to the endothelium via parasite derived proteins (expressed on the surface of the infected RBC), such as PfEMP1. The principal parasite surface protein and sequestration ligand known as P. falciparum erythrocyte membrane protein 1 (PfEMP-1), encoded by var genes, is expressed. It is predominantly mature stage parasites (trophozoites and schizonts) that adhere to the microvasculature [25]. Fig 3: The PfEMP-1 molecule and associated host receptors [26]. The PfEMP-1 molecule has a pivotal role in the pathogenesis of P. falciparum as a number of host receptors are recognized by the various extracellular binding domains of PfEMP-1. Thus, permitting the infected RBCs to adhere to host endothelium. In the case of cerebral malaria, PfEMP-1 may mediate adhesion to several adhesion molecules, in particular ICAM-1 which is unregulated on the cerebral vascular endothelium [26]. Innate immunity to P. falciparum malaria: The innate immune response is crucial to the outcome during a P .falciparum infection. Innate immune responses take effect immediately and provide an early defence until the adaptive immune response is engaged. In some cases, an infection by P. falciparum may be controlled by the innate immune system. 61 Parasite burdens observed in non-immune individuals with acute P. falciparum malaria are lower than expected based on parasite replication rates observed in vitro, suggesting that the innate immune system can contribute to effective control of acute parasite replication before the adaptive immune response develops [27]. The innate immune system functions to limit the maximum parasite density, but gradually acquired adaptive mechanisms complete parasite elimination. The innate immune system is essential for most inflammatory responses that are triggered by monocytic cells, other leukocytes and mast cells through their innate sensing receptors. Macrophages are important in innate immunity as they are able to clear parasitized RBCs in the absence of opsonizing malaria-specific antibodies. It is hypothesized that there are two methods of infected RBC uptake by macrophages. The predominant method of uptake involves the binding of non-specific IgG and complement to the surface of infected RBCs, and increased exposure of senescent RBC markers such as exposure of phosphatidylserine (PS). This method induces the release of pro-inflammatory cytokines. The second method of uptake is CD36 mediated, which involves the binding of CD36 on the macrophage to PfEMP-1 on the infected RBCs. This method does not involve the release of proinflammatory cytokines [28-29]. There are three main biochemical pathways that result in activation of the complement system: the classical complement binding pathway; the mannose-binding lectin pathway; and the alternative pathway. All three lead to the formation of C3 and C5 convertase which results in the cleavage of C3 and C5 into C3a, C3b, C5a and C5b, respectively. RBCs opsonized by IgG and complement (C3b) are recognized by the Fc receptor (FcR) and CR1 (respectively), and phagocytosed by macrophages.This method of clearance is effective in senescent and damaged RBCs, and also in P. falciparum infected RBCs [30]. COMPLEMENT RECEPTOR 1(CD35): CR1 is a 200-kDa single chain membrane bound glycoprotein and a member of the regulators of 425 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 complement activation (RCA) gene cluster. CR1 possesses complex tri and tetra N-linked oligosaccharides in its mature form and the gene for this protein is located on the q32 arm of chromosome 1. It is composed of a number of repeated domains called short consensus repeats (SCRs) each of which is composed of 60 amino acids containing four invariant cysteines. The extracellular domain of the CR1 is composed of 30 SCRs, the first 28 of which are arranged in tandem repeats in homologous groups of 7, with each group known as long homologous repeat (LHR). SCRs 8-12 and SCRs 15-18 preferentially bind to C3b and SCRs 1-4 preferentially bind to C4b. The region of CR1 that interacts with infected erythrocytes to form rosettes has been mapped to LHRB and first three SCRs of LHR-C, SCR 10 and 17 have been particularly found to play an important role in this interaction [31-32]. Effect of differential CR1 expression on malarial pathogenesis; Differences in the expression of CR1 on erythrocytes might determine susceptibility of an individual towards development of cerebral malaria and severe malaria-associated anemia. In one of the studies it was suggested that young children may be more susceptible to SMA because of their lower levels of RBC complement regulatory proteins, which make them less equipped to handle IC formation and complement activation. Previously same group of researchers had proved that a decline in levels of CR1 and increase in immune complex levels significantly associates with SMA. The mechanism for the loss of CR1 from the surface of erythrocytes is being investigated. A series of experiments indicated that CR1 present in the form of clusters on RBC surface undergoes unclustering due to the binding of IgM C3b complexes to glycophorin A. Unclustering might promote rapid loss of CR1 from the surface of erythrocytes infected with the malaria parasite [33]. CR1 polymorphisms; CR1 is a highly polymorphic glycoprotein. Three different polymorphic forms of CR1 have been identified, namely structural (size variation 160-250 kDa), density (high and low expression on RBCs controlled by alleles H and L) and knops blood group (McC (a+)/McC (b+); Sl (a+)/Sl (a-); Kna/ Knb). a) Structural polymorphism: Four different structural polymorphic forms of CR1 are known, namely A, B, C and D (CR1*1, CR1*2, CR1*3, CR1*4) with respective molecular weights of 190, 220, 160 and 250 kDa (under non-reducing conditions). This polymorphism is regulated by four autosomal co-dominant alleles. A polymorphism in the CR1 transcripts with incremental differences of 1.4 kb in mRNA was present in donors expressing the various polymorphic forms. This difference corresponds to the size of one LHR and 40 kDa difference, seen among allotypic forms of CR1. Therefore on the basis of this observation it was suggested that the insertion or deletion forms the basis of structural polymorphism. Analysis of restriction fragment length polymorphism (RFLP) suggested that intragenic duplication rather than alternate mRNA splicing is responsible for the allotypic differences [34-35]. b) Density polymorphism: Second type of polymorphism is a Hind III RFLP, which in Caucasians but not in Africans, correlates with CR1 copy number on erythrocytes. Homozygotes for the L (low expression) allele usually express fewer than 200 copies of CR1, homozygotes for the H (high expression) allele express several times this number and heterozygotes are intermediate. This polymorphism arises due to a single base change in the intron of d1d2 segment within the LHR-D (Long homologous repeat) region resulting in the generation of a polymorphic Hind III site within this region [36]. Genotypic frequencies of HH, HL and LL forms have also been studied in the malaria endemic and nonendemic groups in different populations. In nonendemic Caucasian and Choctaw population groups in USA, the gene frequencies for H and L alleles were found to be 0.82, 0.18 and 0.84, 0.16 respectively. In endemic Black Africans the gene frequencies for H and L alleles were 0.85 and 0.15; in S. Chinese-Taiwanese 0.71 and 0.29; in Pacifi c Asians 0.42 and 0.58 and in Cambodians 0.53 and 0.47 respectively [37]. c) Knops polymorphism: The third type of polymorphism represented by Knops blood group system is of particular interest. In this system, Mca and Mcb is one allelic antigen pair and Sla and Vil is another pair. The corresponding phenotypes for the fi rst pair are McC (a+) and McC (b+) and for the second pair are Sl (a+) and Sl (a-). Studies have now established the molecular basis for Knops polymorphism. These antigens have been localized on the LHR-D segment of CR1. Single 426 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 nucleotide polymorphisms occurring in SCR 25, which lead to amino acid substitutions, result in generation of these polymorphic forms Population based studies have been carried out to determine the distribution of different types of Knops polymorphic forms in different populations. The gene frequencies for Sl (a+) and Sl (a-) in African American persons are almost equal (0.48 vs. 0.52) wheras Sl (a-) is greatly increased in Africa [38-39]. Out of the three polymorphic forms, size polymorphism has not been found to play a role in determining susceptibility to severe malaria. With regard to density polymorphism, some studies suggest that low-density allele confers protection against malaria, whereas another suggested that lowdensity allele might be a risk factor for severe forms of malaria. Erythrocytes with low CR1 expression (because of the homozygous LL genotype of CR1) have been shown to form reduced number of rosettes with Plasmodium falciparum infected cells [40-42]. CYTOKINES AND MALARIAL INFECTION: The study of immune response against Plasmodium is based on murine experimental systems. Both cell mediated and antibody-dependent immunity is required for adequate protection against malarial infection in different mechanisms. In addition, innate immunity is thought to play a crucial role in clearing Plasmodium from parasitized hosts [43]. In splenic response, tissular changes that provoke alterations in blood flow through the organ. These changes prevent the access of infected erythrocytes to splenic tissues in which the immune response is going on until armed effector cells are produced. In general, most of the evidence supports the hypothesis that cells from the monocyte-macrophage lineage are more effective than neutrophils at phagocytosing parasitized erythrocytes [44]. P. chabaudi infection in ᵞ/ᵟ T-cell-deficient mice has exacerbated early and chronic parasitemias. Resulting early production of gamma interferon (IFN-γ) and tumor necrosis factor alpha (TNF-α) both to spleenic ᵞ/ᵟ T lymphocytes and to natural killer (NK) cells [4546] . Both the cellular and humoral responses are pivotal elements in the eradication of Plasmodium from the body, and both are critically dependent on ᵞ/ᵟ CD4+ lymphocytes. It has been firmly established that CD4+ T cells are comprised of at least two functionally different subsets, distinguished on the basis of lymphokine secretion in Th1 (IFN-γ-producing) and Th2 (interleukin-4 [IL-4]/IL-5-producing) cells. CD4+ T cells of either Th1 or Th2 type also have regulatory functions in human P. falciparum malaria. Both Th1 and Th2 responses seem to be required to control the infection, but they need to be adequately tuned in intensity and time [47-48]. Cytokines in Early Protection; The early production of IFN-γ is responsible for resistance against infection. In support of this point, analysis of IFN-γ R-/- mice infected with P. chabaudi chabaudi showes a critical role of IFN-γ in immunity against this pathogen. Interestingly, Tan et. al.[50] reported that IFN responsive factor (IRF-1)-/- mice infected with P. berghei revealed that lower mortality than wild-type mice, although they produced no IFN-γ or NO [51-53]. There are mechanisms of resistance independent for IFN- γ and NO. In which treatment in vivo with antiIFN-γ exacerbates P. yoelii 17XL infection in C57BL/6 because mice treated with antibody die earlier. In contrast, treatment with aminoguanidine, an irreversible inhibitor of NO production, has no effect. Consistently, mice lacking inducible nitric oxide synthase (iNOS-/-) cleared P. berghei XAT (an attenuated variant of P. berghei NK65) as effectively as did wild-type animals. In this case, resistance was dependent on IFN- γ, since it’s in vivo, blocking provoked progression of parasitemia and death [54]. The overall conclusion that can be drawn from this is that the role of a particular cytokine is likely to be different at different stages of the infectious process. A prominent role in switching from Th1 to Th2 responses is attributed to IL-10. Therefore, it is probably involved in controlling the adequate timing of antiparasitic responses. Early IL10 production has been associated with susceptibility to infection, and it is thought that this cytokine has a prominent anti-inflammatory effect, limiting in some way the damage inflicted on normal tissues by an excessive Th1 response [55-56]. Cytokines in the Immunopathology of Malaria; The pathogenesis of malaria is complex and containing immunologic and non-immunologic mechanisms. In general, it is now accepted that severe malaria is the consequence of alterations in many tissues and organs. These dys-functions often lead to metabolic acidosis and localized ischemia. It is evident that parasite factors can contribute to the severity of disease, as is clear from their ability to 427 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 infect a high percentage of erythrocytes or to induce production of proinflammatory cytokines. In particular, much evidence has been accumulated that glycosylphosphatidylinositols from Plasmodium as an important pathogenic factors due to their ability to induce TNF-γ and IL-1 [57-58]. This view is strongly supported by the fact that the toxicity of malaria parasite extracts can be neutralized with monoclonal antibodies against this moiety in experimental models [59] . It is noteworthy that recent work suggests that the presence of anti-glycosyl phosphatidyl inositol antibodies in the serum of patients may provide protection against clinical symptoms of malaria. Therefore, cytokines, viewed as potential pathogenic elements, can contribute either directly or indirectly to many pathological processes [60-61]. Cytokines in the Diagnosis of Malaria; The Th2 profiles have been reported in humans, with elevated levels of IgE being found in the blood of malaria patients, presumably due to the predominance of Th2 cells over Th1 helper cells. This polarization was significantly higher in the case of patients suffering from severe malaria [62]. Th1 responses are important for clearance of P. falciparum malaria. In nonimmune children with severe P. falciparum malaria showed lower levels of IL-12 and IFN-γ in serum and had a reduced capacity to produce them after in vitro stimulation. It is interesting that children with severe anemia had the highest levels of TNF-γ [63]. It has been reported that children with prior mild malaria showed an enhanced ability to express iNOS in vitro over children with prior severe malaria. Furthermore, Luty et. al. [64] found that peripheral blood mononuclear cells of patients with mild malaria produced IFN-γ in response to malarial antigens, whereas those with severe malaria did not. However, no associations were found with TNF-γ production. The studies on Ghanaian children showed that only patients with uncomplicated malaria had a positive correlation with levels of TNF- α and soluble TNF- α R1 and TNF- α R2 in serum. In the same study, children with CM had high levels of TNF- α, and although TNF- α level were associated with fever no differences were observed in soluble TNF- α receptors. Interestingly, children with fever and detectable parasitemia, but not afebrile parasitized patients, had elevated levels of TNF- α [65]. Patients who died from P. falciparum malaria had higher amounts of IL-6, IL-10, and TNF- α in serum than did the patients who survived. CONCLUSION Malaria is a worldwide spreaded disease due to plasmodium species (P. falciparum, P. vivax, P. malariae, and P. ovale). It affects 300-500 million people in which 1-3 million going to death. All of plasmodium species, P. falciparum is very dangerous leads to cerebral malaria. For completing, his life cycle, plasmodium having two host first mosquito (as a vector) and second human. When plasmodium is introduced in blood by mosquito, it attached with RBCs through CD35 (CR1) which act as a receptor for PfEMP-1 (present in plasmodium) and circulate in blood stream. CD35 is a cell surface receptor and its gene present in chromosome no. 1. It is also known as Complement Receptor Type 1 (CR1). Density of CD35, in cell surface is determined by CR1 gene polymorphism. There are types of CR1 polymorphism (a) Structural polymorphism (b) density polymorphism (c) knops polymorphism. High density of CD35 is more susceptible to plasmodium infection. ICAM-1 and VCAM-1 are also play important role in malarial pathogenesis. Cytokine profiling indicates malarial severity. Proinflammatory cytokine TNF-α and INF- γ level is increased during malarial infection where as IL10, IL4, and IL6 are anti-inflammatory cytokine. Conflict of interest: Nil REFERENCE 1. Cavasini MT, Ribeiro WL, Kawamoto F, and Ferreira MU. How prevalent is Plasmodium malariae in Rondonia, western Brazilian Amazon?” Revista da Sociedade Brasileira de Medicina Tropica. 2000; 33(5):489–492. 2. Ahearn JM and Fearon DT. Structure and function of the complement receptors, CR1 (CD35) and CR2 (CD21)". Adv. Immunol. 1989:46:183–219. 3. Moulds JM, Nickells MW, Moulds JJ, Brown MC, Atkinson JP. The C3b/C4b receptor is recognized by the Knops, McCoy, Swain-langley, and York blood group antisera". J. Exp. Med.1991; 173(5): 1159–63. 4. Thomas BN, Donvito B, Cockburn I, Fandeur T, Rowe JA, Cohen JHM, Moulds JM. A 428 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. complement receptor-1 polymorphism with high frequency in malaria endemic regions of Asia but not Africa; Genes Immun; 2005; 6(1): 31–36. Cornillet P, Philbert F, Kazatchkine MD, Cohen JHM. Genomic determination of the CR1 (CD35) density polymorphism on erythrocytes using polymerase chain reaction amplification and HindIII restriction enzyme digestion. J Immunol Meth. 1991:136:193–97. Snow RW, Guerra CA, Noor AM, Myint HY, Hay SI. The global distribution of clinical episodes of Plasmodium falciparum malaria. Nature. 2005:434:214-17. Hay SI, Guerra CA, Tatem AJ, Noor AM, Snow RW. The global distribution and population at risk of malaria: past, present, and future. Lancet Infect Dis; 2004:4:327-336. Hume JC, Lyons EJ, Day KP. Human migration, mosquitoes and the evolution of Plasmodium falciparum. Trends Parasitol. 2003:19:144-49. Carter R, Mendis KN. Evolutionary and historical aspects of the burden of malaria. Clin Microbiol Rev.2002:15:564-94 Greenwood BM, Fidock DA, Kyle D. Malaria: progress, perils, and prospects for eradication. J Clin Invest. 2008:118:1266-76. Miller LH, Baruch DI, Marsh K, Doumbo OK. The pathogenic basis of malaria. . 2002:415:67379. Baum J, Maier AG, Good RT, Simpson KM, Cowman AF. Invasion by P. falciparum merozoites suggests a hierarchy of molecular interactions. PLoS Pathog. 2005:1:e37. Cowman AF, Crabb BS. Invasion of red blood cells by malaria parasites. Cell. 2006:124:755-66. Sim BK, Chitnis CE, Wasniowska K, Hadley TJ, Miller LH. Receptor and ligand domains for invasion of erythrocytes by Plasmodium falciparum. Science.1994:264:1941-44. Mayer DC, Kaneko O, Hudson-Taylor DE, Reid ME, Miller LH. Characterization of a Plasmodium falciparum erythrocyte-binding protein paralogous to EBA-175. Proc Natl Acad Sci U S A. 2001:98:5222-27. Desimone TM, Jennings CV, Bei AK. Cooperativity between Plasmodium falciparum adhesive proteins for invasion into erythrocytes. Mol Microbio. 2009:568.17.55. 17. Tuteja R. Malaria - an overview. Febs J. 2007:274:4670-79. 18. Trampuz A, Jereb M, Muzlovic I, Prabhu RM. Clinical review: Severe malaria. Crit Care;2003:7:315-23 19. Severe falciparum malaria. World Health Organization, Communicable Diseases Cluster. Trans R Soc Trop Med Hyg; 2000:94(S1):S1-90. 20. Idro R, Jenkins NE, Newton CR. Pathogenesis, clinical features, and neurological outcome of cerebral malaria. Lancet Neurol. 2005:4:827-40. 21. Newton CR, Hien TT, White N. Cerebral malaria. J Neurol Neurosurg Psychiatry. 2000:69:433-41. 22. Kwiatkowski D, Hill AV, Sambou I. TNF concentration in fatal cerebral, non-fatal cerebral and uncomplicated Plasmodium falciparum malaria. Lancet. 1990:336:1201-04. 23. Day NP, Hien TT, Schollaardt T. The prognostic and pathophysiologic role of pro- and antiinflammatory cytokines in severe malaria. J Infect Dis;1999:180:1288-97 24. Tumer GD, Newbold CI. Cerebral malaria: the sequestration hypothesis. Parasitol Today.1994:10:412-414. 25. Horrocks P, Pinches RA, Chakravorty SJ, et al. PfEMP1 expression is reduced on the surface of knobless Plasmodium falciparum infected erythrocytes. J Cell Sci; 2005:118:2507-2518. 26. Cserti CM, Dzik WH. The ABO blood group system and Plasmodium falciparum malaria. Blood; 2007:110:2250-2258. 27. Mohan KaS, M.M. Acquired immunity to assexual blood stages. In: Sherman IW, ed. Malaria:Parasite Biology, Pathogenesis and protection;1998:25.2254. 28. Janeway CA, Jr., Medzhitov R. Innate immune recognition. Annu Rev Immunol; 2002:20:197216. 29. Serghides L, Kain KC. Peroxisome proliferatoractivated receptor gamma-retinoid X receptor agonists increase CD36-dependent phagocytosis of Plasmodium falciparum-parasitized erythrocytes and decrease malaria-induced TNFalpha secretion by monocytes/macrophages. J Immunol. 2001:166:6742-6748. 30. Guo RF, Ward PA. Role of C5a in inflammatory responses. Annu Rev Immunol. 2005:23:821-852. 31. Klickstein LB, Bartow TJ, Miletic V, Rabson LD, Smith JA, Fearon DT. Identifi cation of distinct 429 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. C3b and C4b recognition sites in the human C3b/C4b receptor (CR1, CD35) by deletion mutagenesis. J Exp Med.1998:168:1699-717. Krych M, Hourcade D, Atkinson JP. Sites within the complement C3b/C4b receptor important for the specifi city of ligand binding. PNAS. 1991:88:4353-7. Craig ML,Waitumbi JN, Taylor RP. Processing of C3bopsonized immune complexes bound to non-complement receptor 1 (CR1) sites on red cells: Phagocytosis, transfer and associations with CR1. J Immunol; 2005:174:3059-66. Dykman TR, Hatch JA, Aqua MS, Atkinson JP. Polymorphism of the C3b/C4b receptor (CR1): Characterization of a fourth allele. J Immunol. 1985:134:1787-89. Katyal M, Sivasankar B, Ayub S, Das N. Genetic and structural polymorphism of complement receptor 1 in normal Indian subjects. Immunol Lett. 2003:89:93-98. Cornillet P, Philbert F, Kazatchkine MD, Cohen JH. Genomic determination of the CR1 (CD35) density polymorphism on erythrocytes using polymerase chain reaction amplifi cation and HindIII restriction enzyme digestion. J Exp Med. 1991:136:193-7.4. Thomas BN, Donvito B, Cockburn I, Fandeur T, Rowe JA, Cohen JH, et al. A complement receptor 1 polymorphism with high frequency in malaria endemic regions of Asia but not Africa. Genes Immun; 2005:6:31-6. Krych-Goldberg M, Moulds JM, Atkinson JP. Human complement receptor type 1 (CR1) binds to a major malarial adhesin. Trends Mol Med. 2002:8:531-7. Moulds JM, Thomas BJ, Doumbo O, Diallo DA, Lyke KE, Plowe CV. Identification of the Kna / Knb polymorphism and a method for Knops genotyping. Transfusion. 2004:44:164-9 Cockburn IA, Mackinnon MJ, O’Donnell A, Allen SJ, Moulds JM, Rowe JA, et al. A human complement receptor 1 polymorphism that reduces Plasmodium falciparum rosetting confers protection against severe malaria. PNAS. 2004:101:272-7. Nagayasu E, Ito M, Akaki M, Nakano Y, Kimura M, Looareesuwan S, et al. CR1 density polymorphism on erythrocytes of falciparum 42. 43. 44. 45. 46. 47. 48. 49. 50. malaria patients in Thailand. AmJ Trop Med Hyg. 2001:64:1-5. Rowe JA, Rogerson SJ, Raza A, Moulds JM, Kazatchkine MD, Marsh K, et al. Mapping of the region of complement receptor 1 (CR1) required for Plasmodium falciparum rosetting and demonstration of the importance of CR1 in rosetting in fi eld isolates. J Immunol, 2000:165:6341-46. Mohan K., and Stevenson MM. Acquired immunity to asexual blood stages in malaria, p. 467–493. In I. W. Sherman (ed.), Parasite biology, pathogenesis, and protection. ASM Press, Washington, D.C.1998. Yadava A, Kumar S, Dvorak JA, Milon G, and Miller LH. Trafficking of Plasmodium chabaudi adami-infected erythrocytes within the mouse spleen. Proc. Natl. Acad. Sci. USA. 1996:93:4595–99 Seixas EM and Langhorne J. ᵞ/ᵟ T cells contribute to control of chronic parasitemia in Plasmodium chabaudi infections in mice. J. Immunol.1999: 162:2837–41. Yoneto T, Yoshimoto T, Wang CR, Takahama Y, Tsuji M, Waki S, and Nariuchi H. Gammainterferon production is critical for protective immunity to infection with blood-stage Plasmodium berghei XAT but neither NO production nor NK cell activation is critical. Infect. Immun.1999:67: 2349–56. Torre D, Speranza F, Giola M, Matteelli A., Tambini R, and Biondi G. Role of Th1 and Th2 cytokines in immune response to uncomplicated Plasmodium falciparum malaria. Clin. Diagn. Lab. Immunol. 2002: 9:348–351. Kobayashi F, Mori T, Matsui T, FujinoT, Watanabe Y, Weidanz WP, Tsuji M. Production of interleukin 10 during malaria caused by lethal and nonlethal variants of Plasmodium yoelii yoelii. Parasitol. Re. 1996:82:385–91. Favre N, Ryffel B, Bordmann G, and Rudin W. The course of Plasmodium chabaudi chabaudi infections in interferon- γ receptor deficient mice. Parasite Immunol. 1997:19:375–33. Tan RS, Feng C, Asano Y, and Kara AU. Altered immune response of interferon regulatory factor 1-deficient mice against Plasmodium berghei blood-stage malaria infection. Infect. Immun.1999: 67:2277–83. 430 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 51. Cross CE, and Langhorne J. Plasmodium chabaudi chabaudi (AS): inflammatory cytokines and pathology in an erythrocytic-stage infection in mice. Exp. Parasitol; 1998: 90:220–29. 52. Sam H, and Stevenson MM. Early IL-12 p70, but not p40, production by splenic macrophages correlates with host resistance to bloodstage Plasmodium chabaudi AS malaria. Clin. Exp. Immunol; 1999:117:343–49. 53. Kobayashi F, Ishida H, Matsui T, and Tsuji M. Effects of in vivo administration of anti-IL-10 or anti-IFN- γ monoclonal antibody on the host defense mechanism against Plasmodium yoelii yoelii infection. J. Vet. Med. Sci. 2000:62:583– 87. 54. Yoneto T, Yoshimoto T, Wang CR, Takahama Y, Tsuji M, Waki S, and Nariuchi H. Gammainterferon production is critical for protective immunity to infection with blood-stage Plasmodium berghei XAT but neither NO production nor NK cell activation is critical. Infect. Immun; 1999:67: 2349–56 55. Yoshida A, Maruyama H, Kumagai T, Amano T, Kobayashi F, Zhang M, Himeno K, and Ohta N. Schistosoma mansoni infection cancels the susceptibility to Plasmodium chabaudi through induction of type 1 immune responses in A/J mice. Int. Immunol. 2000: 12:1117–25. 56. Linke A, Kuhn R, Muller W, Honarvar N, Li C, and Langhorne J. Plasmodium chabaudi chabaudi: differential susceptibility of genetargeted mice deficient in IL-10 to an erythrocytic-stage infection. Exp. Parasitol; 1996:84:253–26. 57. Chotivanich K., Udomsangpetch R, Dondorp A, Williams T, Angus B, Simpson JA, Pukrittayakamee S, Looareesuwan S, Newbold CI, and White NJ. The mechanisms of parasite clearance after antimalarial treatment of Plasmodium falciparum malaria. J. Infect. Dis; 2000:182:629–33. 58. Schofield, L, and Hackett F. Signal transduction in host cells by a glycosylphosphatidylinositol toxin of malaria parasites. J. Exp. Med; 1993: 177: 145–53. 59. Schofield L, Vivas L, Hackett F, Gerold P, Schwarz RT, and Tachado S. Neutralizing monoclonal antibodies to glycosylphosphatidylinositol, the dominant TNF- 60. 61. 62. 63. 64. 65. ά-inducing toxin of Plasmodium falciparum: prospects for the immunotherapy of severe malaria. Ann. Trop. Med. Parasitol;1993: 87:617–26. Naik RS, Branch OH, Woods AS, Vijaykumar M, Perkins DJ, Nahlen BL, etal . Glycosylphosphatidylinositol anchors of Plasmodium falciparum: molecular characterization and naturally elicited antibody response that may provide immunity to malaria pathogenesis. J. Exp. Med; 2000:192:1563–7. Clark IA, and Schofield L. Pathogenesis of malaria; Parasitol. Today. 2000:16:451–54. Perlmann P, Perlmann H, ElGhazali G, and Blomberg MT. IgE and tumor necrosis factor in malaria infection. Immunol. Lett. 1999:65:29–33 Luty AJ, Perkins DJ, Lell B, Schmidt-Ott R, Lehman LG, Luckner D, etal. Low interleukin-12 activity in severe Plasmodium falciparum malaria. Infect. Immun;2000: 68:3909–15. Luty AJ, Lell B, Schmidt-Ott R, Lehman LG, Luckner D, Greve B, etal. Interferon- γ responses are associated with resistance to reinfection with Plasmodium falciparum in young African children. J. Infect. Dis; 1999:179:980–988 90. McGuire W, D’Alessandro U, Stephens S, Olaleye BO, Langerock P, Greenwood BM, and Kwiatkowski D. Levels of tumour necrosis factor and soluble TNF receptors during malaria fever episodes in the community. Trans R Soc Trop Med Hyg; 1998;92(1):50-3 431 Rishabh et al., Int J Med Res Health Sci. 2015;4(2):422-431 DOI: 10.5958/2319-5886.2015.00079.X International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 14 Dec 2014 Case report Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 16 Jan 2015 Accepted: 26th Jan 2015 A UNIQUE CASE OF PHEOCHROMOCYTOMA PRESENTING WITH HYPERTENSIVE RETINOPATHY *Maji.S1, Saha. ML2, Kanwar KS3, Das S4, Bhagat P5, Bhar P6 1,3 Resident, 2Professor, Kolkata, India 4,6 Assistant Professor, 5RMO, Department of General Surgery, I.P.G.M.E&R, SSKM&H, *Corresponding author email:
[email protected] ABSTRACT Pheochromocytoma is an extremely uncommon tumor of childhood and there are several features that distinguish its presentation between adults and children. The incidence of pheochromocytoma in childhood is 10% of the adult incidence, occurring in approximately 1 in 500,000 children compared with 1 in 50,000 adults. Around 10% of childhood tumors are familial which is 4times the frequency in adults. Whereas only 7% of pheochromocytomas are bilateral in adults, the reported incidence of the same in children range from 24 % to as high as &70%.These tumors are known for their great diversity in clinical presentation. Greater than 50% of children present with headaches, fever, palpitation, thirst, polyuria, sweating, nausea and weight loss. However the commonest mode of presentation is sustained hypertension. Pheochromocytoma accounts for 0.5% of children with hypertension and must be considered once other causes have been eliminated. We here in report a unique case of a 13 year old girl who initially presented with bilateral hypertensive retinopathy and later found to have a pheochromocytoma on subsequent workup. Hypertensive retinopathy secondary to pheochromocytoma is itself a rare entity whose exact incidence in children is still unknown. This case highlights the importance of routine history, physical examination and measurement of bp. Prompt surgery can reverse the effect of hypertension and lead to good outcome as was evident in our case. Keywords: Pheochromocytoma, Hypertensive retinopathy, Metanephrines, Normetanephrines, Zellballen INTRODUCTION Pheochromocytomas are rare tumors with prevalence rates ranging from 0.3 to 0.95% in autopsy series, and approximately 1.9% in series using biochemical screening. Recent advances in molecular genetics have shown presence of germline mutation in up to 59% of apparently sporadic pheochromocytomas presenting at 18 years or younger and in 70% of those presenting before 10 years of age[1].They can occur at any age with a peak incidence in the fourth and fifth decades of life, and have no gender predilection[2]. Pheochromocytoma is rare in children1.It is a catecholamine producing tumor of the sympathetic nervous system9. The presentation varies from vague Saha et al., symptoms to hypertensive emergencies. Headache, palpitations, and diaphoresis constitute the "classic triad" of pheochromocytomas. The hypertension related to this tumor may be paroxysmal with intervening normotension, sustained with paroxysms, or sustained hypertension alone. In children however hypertension often remains sustained. Presentation may not be always with the above classic triad and unique presentation as in our case needs to be kept in mind! The treatment of pheochromocytoma remains surgical excision although medical management of hypertension is an essential part of preoperative preparation[3]. 432 Int J Med Res Health Sci. 2015;4(2):432-434 Case report A 13 year old girl presented with blurring of vision since a week .She underwent ophthalmic assessment in a private eye clinic where she was found to have bilateral hypertensive retinopathy. She was then admitted to our SSKM hospital, initially in the general medicine ward where she underwent full work up and physical examination. She was later transferred to the surgical unit. Her history revealed that she had complaints of palpitation, throbbing headache and occasional sweating for the last 7 month. She also had associated weight loss. However her appetite, bowel and bladder habits were normal. On admission she had a bp of 180/110 mm of Hg and a pulse rate of 130/mint. On abdominal examination no lump was found. On USG a large (3.92x 4.21) cms hetrogenous mass with cystic degeneration above superior pole of left kidney was found. CECT abdomen revealed (4.5 x 3.9) cms cystic sol with enhancing thick walled mass in the left adrenal gland. Biochemical tests showed high value of 24 hour urinary metanephrine level (14.36) microgram/litre and elevated level of normetanephrine (1445.1) microgram/litre. There was no drug history of ephedrine, amphetamines, methlxanthines etc use in this patient which could have lead to false elevated metanephrine level. Serum levels of Ca2+,PTH, phosphate, calcitonin were all normal. Preoperatively she received prazosin & propnanolol. She underwent left adrenalectomy under GA following which she was shifted to ICU where constant monitoring of her vitals was undertaken. She was hypotensive and had to be put on noradrenaline drip for 3 days. She was started on oral diet by 5th postop. day and was discharged on the 7th day. She was followed up with a repeat test of serum and urinary markers which showed normal results. Her pathological report showed a well encapsulated tumor composed of large polygonal cells, vesicular nuclei, small nucleoli and abundant eosinophilic granular cytoplasm, arranged in Zellballen, surrounded by elaborate vascular network which was consistent with a diagnosis of benign pheochromocytoma [fig 1&2]. On 6 months follow up she has been healthy and enjoying a good quality of life without any visual problem. Fig1: Pathology specimen showing the cystic adrenal tumor. Fig 2: Microscopic appearance showing tumor cells arranged in Zellballen DISCUSSION Pheochromocytomas are catecholamine-secreting neoplasms. Due to its variable presentation, they have been called the “masquerader” .The clinical spectrum, ranges from completely asymptomatic (10%) to a sustained stable hypertension (50%), or to frequent life-threatening hypertensive crises (30%). Majority of the patients present with the classical triad of episodic headache, palpitations, diaphoresis, and a feeling of impending doom. Several series have reported that 19-76% of pheochromocytomas are not diagnosed until after death2 & the incidence of asymptomatic tumors being is 4.4 to 17 %[3]. Atypical symptoms described in literature include abdominal pain, vomiting, polyuria, polydipsia, heart failure, cerebrovascular hemorrhage. A pheochromocytoma presenting initially with hypertensive retinopathy is rare and its incidence is unknown. About 10% of pediatric pheochromocytoma is thought to be familial4. Studies of families with pheochromocytoma occurring across several generations suggest a dominant autosomal mode of inheritance with high 433 Saha et al., Int J Med Res Health Sci. 2015;4(2):432-434 penetration[4,5].Familial cases of pheochromocytoma also carry a higher risk of malignancy than sporadically occurring varieties[6].The diagnosis of this tumor relies on the demonstration of blood and urinary catecholamine’s and their metabolites. A 24 hr urine measurement of catecholamine’s, metanephrine and vanillyl mandelic acid is the best diagnostic test. Once the chemical diagnosis is established the tumor must be localized. Radiological imaging modalities like USG, Contrast Enhanced CT scan and MRI are useful in determining the origin and extent of tumour. Prompt diagnosis and complete excision are the most important treatment for childhood pheochromocytoma[7,8].Pre-intra-and postoperative medical management is as important as the surgical procedure itself. All patients should undergo follow up to confirm normalization of catecholamine levels. [9,10] This case was unique and interesting due to following reasons: 1. Hypertensive retinopathy as an initial presentation of pheochromocytoma is extremely rare. Data about this is limited and is mainly in form of few case reports. Most of these are from western literature9,10 and very few from the Indian subcontinent. 2. Though childhood pheochromocytomas are frequently multiple, bilateral and frequently have familial associations our case was unique being unilateral, single lesion and sporadic in presentation. 3. It highlights the importance of blood pressure measurement in the clinical diagnosis of this rare condition. Early diagnosis is crucial not only because it is a curable cause of severe hypertension but also since unrecognized tumor may provoke fatal hypertension crisis during surgery, some diagnostic procedures or other stresses. REFERENCES 1. Armstrong R, Sridhar M, Greenhalgh KL, Howell L, Jones C, Landes C, McPartland JL, Moores C, Losty PD & Didi M. . Phaeochromocytoma in children. Archives of Disease in Childhood2008 ;93(10):899 -04. 2. Kloos RT, Gross MD, Francis IR, Korobkin M, Shapiro B. Incidentally Discovered Adrenal Masses. Endoc Rev 1995; 16:460-84 3. Jain SK, Agarwal N. Asymptomatic Giant Pheochromocytoma. J Assoc Physic India 2002;50:842-4. 4. Michael G. Caty, Arnold G. Coran, Michael Geagen,et al. Current diagnosis and treatment of pheochromocytoma in children: experience with 22 con-secutive tumors in 14 patients. Arch Surg, 1990,125: 978- 81. 5. Sawin RS. Functioning adrenal neoplasm. Semin Pediatr Surg, 1997; 6:156-63 6. Levine C, Skimmine J, Levine E. Familial pheochromocytomas with unusual associations. J Pediatr Surg,1992,27: 447-51, 7. Caty MG, Coran AG, Geagen M, Thompson NW. Current diagnosis and management of pheochromocytoma in children. Arch Surg 1990; 125: 978-81. 8. Chen TY, Liang CD, Shieh CS, Ko SF, Kao ML. Reversible hypertensive retinopathy in a child with bilateral pheochromocytoma after tumor resection. J Formos Med Assoc 2000; 99: 945-47. 9. McClellan MW. Pheochromocytoma: evaluation, diagnosis, and treatment. World Journal of Urology. 1999; 17(1):35–39. 10. Barontini M, Levin G, Sanso G Characteristics of pheochromocytoma in a 4- to 20-year-old population. Ann NY Acad Sci2006; 1073:30–7. CONCLUSION A high index of suspicion and early diagnosis is key to successful management in pheochromocytomas .A high blood pressure in a child should prompt thorough search for this condition. Preoperative stabilization of blood pressure is crucial in preventing intraoperative catastrophe of uncontrolled hemorrhage. Conflict of Interest: Nil 434 Saha et al., Int J Med Res Health Sci. 2015;4(2):432-434 DOI: 10.5958/2319-5886.2015.00080.6 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 26 Dec 2014 Case report Coden: IJMRHS Revised: 20th Jan 2015 Copyright @2014 ISSN: 2319-5886 Accepted: 4th Feb 2015 NECROLYTIC ACRAL ERYTHEMA: HIGH DEGREE OF SUSPICION FOR DIAGNOSIS * Shumez H 1, Prasad PVS 2, Kaviarasan PK 3, Viswanathan P 4 1 Junior Resident, 2Professor, 3Professor & Head, Department of Dermatology, Venerology and Leprosy, 4 Professor & Head, Department of Pathology, Rajah Muthiah Medical College and Hospital, Annamalai University, Tamil Nadu, India. *Corresponding author email:
[email protected] ABSTRACT Necrolytic Acral Erythema (NAE) is a recently described, poorly understood, rare dermatological entity, which is frequently associated with Hepatitis C Virus (HCV) infection. This report describes a 53 year old male with a 6 month history of well demarcated, reddish brown to hyperpigmented, scaly skin over dorsum of both hands and feet. Investigations revealed hypothyroidism and low serum zinc levels. Patient also tested seropositive for HCV. Histopathological examination revealed hyperkeratosis and subcorneal clefting along with areas of necrosis. Patient was started on oral zinc along with treatment for hypothyroidism, and improved symptomatically in 2 weeks. Early recognition of NAE is of prime importance to dermatologists as it allows diagnosis of HCV in previously unaware patients and gives way for efficacious treatment. Keywords: Necrolytic erythema, Hepatitis C, HCV INTRODUCTION Necrolytic acral erythema (NAE) belongs to the group of necrolytic erythemas which include acrodermatitis enteropathica, pellagra, biotin deficiency, essential fatty acid deficiency and necrolytic migratory erythema. These conditions are both histologically and clinically similar but differ in their etiology. [1] NAE is a recently described, poorly understood, rare dermatological entity. NAE is characterised by erythematous to violaceous, scaly plaques on the acral sites. It is frequently associated with Hepatitis C Virus (HCV) infection and is now considered a diagnostic cutaneous marker for the disease. Recognition of NAE requires clinicopathological correlation and a high degree of suspicion. NAE responds well to oral zinc therapy and treatment of the underlying HCV infection with interferon alpha. We report a case of NAE from Southern India. Shumez et al., CASE REPORT A 53 yr old man, farmer by profession, presented to the dermatology department with dry, rough, thickened skin over the hands and legs for the past 6 months. The lesions initially started on the legs and then progressed to involve the hands in about 2 weeks. It was associated with itching and burning sensation on sun exposure. Patient also gave history of loose stools since 3 weeks. Stools were watery in consistency, about 4-5 episodes per day, not associated with blood or mucus. It was associated with pain abdomen. Patient was not an alcoholic or on any medications. Family and personal history were non-contributory in our case. Cutaneous examination showed well demarcated, reddish brown to hyperpigmented, rough, thick, scaly skin with cracks over both lower limbs extending up to the knee and both upper limbs extending just above the elbow joints (Figures 1a and b). 435 Int J Med Res Health Sci. 2015;4(2):435-438 Diffuse, erythematous patches were present over the face (Figure 2) and ‘V’ region of neck with hyperpigmentation and a few papules, suggestive of casal’s necklace. Rest of the examination including that of oral cavity and genitalia did not show any abnormality. Deep tendon reflexes were sluggish. A skin biopsy specimen taken from the lesions over the forearm demonstrated hyperkeratosis and clefting present subcorneally, extending up to subepidermal levels (Figure 3). Areas of epidermis showed necrosis. Dermis showed sparse inflammatory infiltrate along with congested blood vessels. Liver function tests were altered - Alkaline phosphatise was elevated (332 IU/L) but Aspartate transaminase and Alanine transaminase were normal. Electrocardiogram showed low voltage complexes. ECHO revealed mild pericardial effusion with no ischaemic changes. Thyroid hormone levels were suggestive of hypothyroidism (free T3 – 0.15 pg/ml, free T4 – 0.07 ng/dl, serum TSH – 57 µIU/ml). Serum zinc levels were low (47.3µg/dl). Patient tested seropositive for Hepatitis C virus. Other routine investigations were normal. Patient was started on oral Zinc sulphate 440 mg/day in two divided doses, as the mainstay treatment. He was also put on Thyroxine 100 µg once a day. Patient improved symptomatically in about 2 weeks (Figures 5a and 5b). Patient was continued on low doses of zinc sulphate for a period of one year and followed up at regular intervals. There was no recurrence of lesions. Fig 2: Diffuse, erythematous patches were present over the face Fig 3: Hyperkeratosis with sparse inflammatory infiltrate seen around blood vessel and adnexae. Fig 1a and b: Well demarcated, reddish brown, rough, hyperpigmented, thick, scaly skin with cracks over both upper limbs extending just above the elbow joints. Fig 4a and b: Resolution of lesions with oral zinc in about 2 weeks Shumez et al., Int J Med Res Health Sci. 2015;4(2):435-438 436 DISCUSSION NAE is an infrequently described dermatologic entity. [2] It was first described by El Darouti et al in a case series of 7 Egyptian patients in 1996. [3] It belongs to the group of necrolytic erythemas. This group of dermatoses also includes acrodermatitis enteropathica, pellagra, biotin deficiency, essential fatty acid deficiency, and necrolytic migratory erythema. These conditions share many histological and clinical similarities but have diverse etiologies. NAE is often associated with HCV infection. The initial lesion is often erythema with vesicles and flaccid bullae, especially around the periphery of plaques.[3,4,5] Chronic lesions appear as erythematous to violaceous plaques with thick scale, erosions and crusting, and often have a dark red rim.[1,3,4,5,6] Lesions are predominantly found on acral sites.[1,4.7,8] The most common site of NAE plaques is the dorsal aspect of feet.[1,3,4,7,8,9] However, absence of lesions over feet is not critical for diagnosis. Scaly, erythematous lesions on acral locations can be observed in both psoriasis and NAE. NAE has dark, verrucous scales as opposed to the silvery white scales of psoriasis. Furthermore, NAE can present with flaccid blisters and it typically spares the palms and soles. Histologically, the lesions of psoriasis do not possess the necrotic keratinocytes seen with NAE. [5, 9] zinc deficiency in a subset of patients with the disease and the clinical response to zinc supplementation substantiates this theory. According to Najarian et al, even patients with normal serum zinc levels may harbour occult cutaneous zinc deficiency. [12] Treatment of NAE is initiated with oral zinc sulphate supplementation, and response is often noted within several weeks of beginning therapy. The recommended dose is 440 mg/day in 2 divided doses.[1,4,9] In many patients, including ours, complete or near-complete resolution of skin lesions is attained with zinc treatment alone.4,5,9,12 Other modalities of treatment like oral amino acid supplementation, topical corticosteroids and intralesional triamcinolone have been tried, but efficacy in skin disease has been minimal.[1,3,4,5,7,9] Treatment of underlying hepatitis C (with interferonalpha with or without ribavirin) is the definitive treatment and has led to improvement of skin disease in a majority of patients. [1, 3, 4, 6, 8] CONCLUSION The incidence of Hepatitis C infection worldwide is rising and NAE is a diagnostic cutaneous marker. Early recognition of NAE is of prime importance to dermatologists as it allows diagnosis of HCV in previously unaware patients and gives way for efficacious treatment. Histologically, NAE resembles findings of other necrolytic erythemas. Abdallah et al found that in the early stages, NAE shows acanthosis, epidermal spongiosis and superficial perivascular dermatitis. In the late stages, it shows psoriasiform hyperplasia and prominent papillomatosis with parakeratosis, subcorneal pustules, epidermal pallor and necrotic keratinocytes.[4,10] Confluent necrosis of the keratinocytes in the upper parts of the epidermis may lead to cleft formation.[4,5] Since there are no specific histopathological features, correct diagnosis requires clinico-pathologic correlations and a high degree of suspicion.[4,11] The exact pathogenesis of NAE is not known, but the etiology of NAE seems to be multifactorial. Several mechanisms have been put forward, including zinc deficiency, hypoaminoacidemia, hypoalbuminemia, hepatocellular dysfunction, hyperglucagonemia and diabetes. [4, 5] Zinc deficiency has been suggested as an etiologic factor in the skin lesions. The presence of ACKNOWLEDGEMENT: None Shumez et al., Int J Med Res Health Sci. 2015;4(2):435-438 Conflict of Interest: None REFERENCES 1. Khanna VJ, Shieh S, Benjamin J, Somach S, Zaim MT, Dorner W, Jr, Shill M, Wood GS. Necrolytic acral erythema associated with hepatitis C: effective treatment with interferon alfa and zinc. Arch Dermatol 2000;136:755–7. 2. Liu A, Erickson CP, Cockerell CJ, et al. Necrolytic acral erythema: a case not associated with hepatitis C infection. Dermatol Online J 2008;14:10. 3. El Darouti M, Abu el Ela M. Necrolytic acral erythema: a cutaneous marker of viral hepatitis C. Int J Dermatol 1996;35:252–6. 4. Bentley D, Andea A, Holzer A, et al. Lack of classic histology should not prevent diagnosis of necrolytic acral erythema. J Am Acad Dermatol 2009;60:504-7. 437 5. Nofal AA, Nofal E, Attwa E, El-Assar O, Assaf M. Necrolytic acral erythema: a variant of necrolytic migratory erythema or a distinct entity? Int J Dermatol 2005;44:916–21. 6. Hivnor CM, Yan AC, Junkins-Hopkins JM, Honig PJ. Necrolytic acral erythema: response to combination therapy with interferon and ribavirin. J Am Acad Dermatol 2004;50:121–24. 7. Abdallah MA, Ghozzi MY, Monib HA, Hafez AM, Hiatt KM, Smoller BR, Horn TD. Necrolytic acral erythema: a cutaneous sign of hepatitis C virus infection. J Am Acad Dermatol 2005;53:247–51. 8. El-Ghandour TM, Sakr MA, El-Sebai H, ElGammal TF, El-Sayed MH. Necrolytic acral erythema in Egyptian patients with hepatitis C virus infection. J Gastroenterol Hepatol 2006;21:1200–6. 9. Abdallah MA, Hull C, Horn TD. Necrolytic acral erythema: a patient from the United States successfully treated with oral zinc. Arch Dermatol 2005;141:85–7. 10. Abdallah MA, Ghozzi MY, Monib HA, Hafez AM, Hiatt KM, Smoller BR, Horn TD. Histological study of necrolytic acral erythema. J Ark Med Soc 2004;100:354–5. 11. Fielder LM, Harvey VM, Kishor SI. Necrolytic acral erythema: case report and review of the literature. Int J Dermatol 2005;44:916–21. 12. Najarian DJ, Lefkowitz I, Balfour E, Pappert AS, Rao BK. Zinc deficiency associated with necrolytic acral erythema. J Am Acad Dermatol 2006;55:108–10. Shumez et al., 438 Int J Med Res Health Sci. 2015;4(2):435-438 DOI: 10.5958/2319-5886.2015.00081.8 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 20 Nov 2014 Case report Coden: IJMRHS Copyright @2014 ISSN: 2319-5886 th Revised: 10 Dec 2014 Accepted: 22nd Feb 2015 DOUBLE SUPRASCAPULAR FORAMINA: AN ANATOMICAL VARIATION Taqdees Fatima1, *Vanitha2, H.S. Kadlimatti3 1 Dept. of Anatomy, Khaja Bandanawaz Institute of Medical Sciences, Gulbarga, Karnataka, India Dept. of Anatomy, ESIC Medical College, Gulbarga, Karnataka, India 2, 3 *Corresponding author email:
[email protected] ABSTRACT Suprascapular notch transmit supra scapular nerve to the supraspinous fossa. Transverse scapular ligament bridges the notch to form a supra scapular foramen. This region is the most common location of supra scapular nerve injury & compression. Most important predisposing factor of supra scapular neuropathy is an ossified superior transverse scapular ligament. We report here a case of double supra scapular foramen found during our routine osteology demonstrations. The etiopathogenesis and clinical implications of such variations are discussed. Keywords: Compression, Ossification, Suprascapular nerve, Transverse scapula ligament. INTRODUCTION Scapula is a triangular, flat bone situated in the postero-lateral part of chest wall [1].Its superior border presents a supra scapular notch near the root of the coracoid process. Superior transverse scapular ligament bridges the notch to form a supra scapular foramen which transmits supra scapular nerve to the supraspinous fossa [2].This region is the most common location of supra scapular nerve injury & compression. Most important predisposing factor of supra scapular neuropathy is an ossified superior transverse scapular ligament [3]. Inferior band: Length-1cm, Thickness: Medially9mm, Centre-6mm & Laterally-10mm. Superior Foramen: Transversely-10mm, Vertically4mm. Inferior Foramen: Transversely-7mm, Vertically 3mm. Both the foramina were transversely oval. CASE REPORT During the routine osteology class for the MBBS I phase students, in the department of anatomy, ESIC Medical College, Gulbarga, an anatomical variation of the supra scapular notch where two bony bridges converting it into a double supra scapular foramina was found in one left scapula. Dimensions of bony bridges and foramina were as follows: Superior band: Length- 1.2cm, Thickness: Medially-4mm, Centre-3mm & Laterally-3mm Fig1: Shows double suprascapular foramen .SBSuperior band, SF-Superior foramen, IB-Inferior band, IF-Inferior foramen 439 Vanitha et al., Int J Med Res Health Sci. 2015;4(2):439-441 DISCUSSION Suprascapular neuropathy is infrequent condition that occurs in only 1-2% cases of shoulder pain [4]. Causes includes trauma caused by repetitive over head abduction in athletes and in volley ball players, rotator cuff tear, compression of the nerve at the suprascapular notch or spinoglenoid notch or by supraglenoid and paralabral cysts [4]. The incidence of complete ossification of the STSL (superior transverse scapular ligament ) depends on population and has been found to vary from 4 to 12.5% [5] . A familial case of the ossification of the STSL causing entrapment neuropathy of the Suprascapular nerve affecting both father & son has also been described, suggesting that the ossification may have a genetic basis [6]. Ticker et al., studied anatomy of Suprascapular nerve and demonstrated partial and complete ossification of supra scapular ligament and multiple bands including the first report of a trifid superior transverse scapular ligament [7]. Alon et al., reported a case of bilateral Suprascapular nerve entrapment due to ossification of bifid Transverse scapular ligament in a female patient [8] . Rengachary et al., classified Suprascapular notch into 6 types [9]. Very few cases of double supra scapular foramen has been reported in literature till now. Michal P et al., studied 610 scapulae by 3D CT scan and found one case of double suprascapular foramen on left side in 56-year-old Caucasian female [10]. Probable cause for the formation of double suprascapular foramen was also explained in their study which could be because of ossification of STSL & ACSL [11], ossification of the bifid STSL, partial ossification of the trifid STSL or ossification of the bifid ACSL. The entrapment of the supra scapular nerve by the ossified STSL may result in symptoms like pain in the shoulder region and also result in wasting and weakness of supraspinatus & infraspinatus muscles. [12] CONCLUSION Suprascapular neuropathy is an uncommon cause of shoulder pain and weakness and therefore is frequently misdiagnosed. As a consequence, misdiagnosis can lead to inappropriate conservative treatment or unsuccessful surgical procedure. It has to be differentiated from other conditions like rotator cuff tears. Knowledge of such an anatomical variation Vanitha et al., will be helpful in arthroscopic & open procedures at the supra scapular region & also confirms safety of operative decompression for the supra scapular nerve. Conflict of Interest: Nil REFERENCES 1. Harold Ellis, Patricia Collins, David Johnson, skeletal system, Gray’s Anatomy; The anatomical basis of clinical practice. Churchill Living stone, 38th edn London. 1995;615. 2. Asim Kumar Dutta. Essentials of Human Anatomy, Part III.: 4th Ed. Kolkatta: Current Books International;2009, 5-7. 3. Gargi Soni, Lovesh Shukla, Neha Gaur. Complete Ossification Of Superior Transverse Ligament: A Case Report. The Internet Journal of Human Anatomy. 2011; 2 (1):12 4. Boykin RE, Friedman DJ, Higgin LD and Warner JP. Suprascapular Neuropathy. The journal of bone and joint surgery. 2010; 929(13), 2348-64. 5. Rengachary SS, Burr D, Lucas S, Brackett CE. Suprascapular entrapment neuropathy: A clinical, anatomical, and comparative study. Part 3: Comparative study. Neurosurgery 1979; 5: 45255. 6. Cohen SB, Dines DM, Moorman CT. Familial calcification of the superior transverse scapular ligament causing neuropathy. Clinical Orthopaedics and Related Research. 2007; 334:131-5. 7. Ticker JB, Djurasovic M, Strauch RJ, April EW, Pollock RG, Flatow EL, Bigliani LU. The incidence of ganglion cysts and other variations in anatomy along the course of the suprascapular nerve. J Shoulder Elbow Surg. 1998; (5):472-8. 8. M Alon, S Weiss, B Fishel, S Dekel. Bilateral suprascapular nerve entrapment syndrome due to an anomalous transverse scapular ligament. Clinical Orthopaedics and Related Research. 1998; 234: 31–33. 9. Polguj M, Podgórski M, Jedrzejewski K , Topol M. The double suprascapular foramen: unique anatomical variation and the new hypothesis of its formation. Skeletal Radiol. 2012; 41(12): 1631–36. 10. Avery BW, Pilon FM, Barclay JK. Anterior coracoscapular ligament and supra scapular nerve entrapment. Clin Anat. 2002; 15 (6):383–6. 440 Int J Med Res Health Sci. 2015;4(2):439-441 11. Srijit Das, Rajesh Suri and Vijay Kapur. Ossification of Superior Transverse Scapular Ligament and its Clinical Implications. Sultan Qaboos Univ Med J. 2007; 7(2): 157–60. 12. Sergides NN, Nikolopoulos DD, Boukoros E, Papagiannopoulos G. Arthroscopic decompression of an entrapped supra scapular nerve due to an ossified superior transverse scapular ligament: a case report. Cases J. 2009; 2: 8200. 441 Vanitha et al., Int J Med Res Health Sci. 2015;4(2):439-441 DOI: 10.5958/2319-5886.2015.00082.X International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS th Received: 4 Dec 2014 Revised: 20th Jan 2015 Case report Copyright @2014 ISSN: 2319-5886 Accepted: 12th Feb 2015 A RARE PRESENTATION OF A CONCOMITANT LUMBAR SPINE BURST FRACTURE WITH A DISTAL CORPUS STERNI FRACTURE DUE TO A FLEXION DISTRACTION INJURY Ravi Kumar TV1, *GadiDaksh2, Jain Vinay3, Rangaswamy BT4 1 Assistant Professor, 2 Resident, 3,4 Resident, Department of Orthopaedics, M S Ramaiah Medical College & Hospitals, Bengaluru, Karnataka, India *Corresponding author email:
[email protected] ABSTRACT Sternum fractures are a rare entity and occur either due to direct trauma or indirectly associated to a flexion compression injury. Earlier literatures used to describe the association of sternum fractures with upper thoracic vertebral fractures. To the best of our knowledge very few cases have been described in literature with concomitant lumbar vertebral fracture with associated sternum fracture. We hereby report a rare presentation of a flexion distraction injury leading to a concomitant sternum fracture with a L1 vertebral burst fracture. Keywords: Lumbar spine burst fracture, Corpus sterna fracture, Flexion distraction injury INTRODUCTION Sternum fractures in the literature has been described as a marker for a high velocity trauma with many associated injuries [1].Other than cases with a direct trauma to sternum, rarely an isolated sternal fracture is seen. In the literature the rib sternum complex has been described as a fourth column to the spine suggesting a high chances of associated spine injury with a sternum fracture[2,3]. But most of the cases described in the literature involve only the upper thoracic vertebrae. According to a study done by Fowler[4], flexion compression force leads to displaced fractures of sternum with the distal fragment displaced anterior to the proximal fragment and opposite for distraction injuries. Such injuries are more commonly seen during high velocity road traffic accidents. The level of sternum involvement with the associated level of vertebral involvement was described by Max J. Scheyerer et al in their study with statistically significant association of manubrium sterni i.e. upper sternum involvement with upper thoracic and lower sternum i.e corpus sterni part 3 (distal one third) with lumbar spine fractures[5]. In our study we hereby describe a rare case with a distal one third corpus sterni fracture with L1 vertebral burst fracture suggesting a flexion distraction injury following a fall from height and landing on both feet sustaining associated bilateral talus fractures, right bimalleolar and calcaneum fractures. CASE REPORT A 28yr old male patient presented to us following a fall from a height of around 12metres. According to the patient, he slipped while working on a construction site and had a fall; he landed on the ground on both feet. Patient was not able to stand/ bear weight following fall. On presentation, he complained of severe pain in feet, ankle and back. He had no breathing difficulty or pain in the chest. He had sustained no open injuries, head injury (GCS: 15/15)and was haemodynamically stable. On clinical 442 Daksh etal., Int J Med Res Health Sci. 2015;4(2):442-445 examination, swelling was noted over ankle, range of movement in the ankle was tender bilaterally with severe tenderness over the heel of right foot. No distal neurological deficits were present but tenderness was elicited in lumbar spine and the chest. Full evaluation using plain radiographs[Fig 1a, Fig1b] and CT scans[Fig 2, Fig3] was done initially and bilateral talus fracture, right bimalleolar fracture, L1 vertebral burst fracture with distal one third corpus sterni fracture was noted. Further MRI was done[Fig 5a, 5b,5c,5d] for evaluating the lumbar spinal injury and association of posterior elements with the L1 fracture. As the right talus had a comminuted fracture with bimalleolar fracture, it was initially fixed using contoured talus locking plate and cancellous screws, one third tubular plate was applied for the lateral malleolus and cancellous screw and K-wiring for medial malleolus. Left talus and right calcaneal fractures were undisplaced and so were planned to be managed conservatively. Patient was explained for need for surgical Fig 1a, 1b: Plain radiographs showing L1 vertebral burst fracture Fig 2: Sagittal CT image showing L1 burst fracture with sternum fracture intervention for the lumbar spinal injury but patient wanted to undergo conservative management and so was advicedabsolute bed rest for 2 months. Fig 3: Axial CT scan of L1 vertebra Fig: 1a Fig 4: 3D CT image of L1 vertebral body Fig: 1b Fig: 5a 443 Daksh etal., Int J Med Res Health Sci. 2015;4(2):442-445 Fig: 5b Fig: 5c Most fractures are secondary to a flexion compression injury and are associated with a spine injury. Upper thoracic vertebrae may be involved in such cases but rarely lumbar spine involvement may also be seen. But literature suggests that the site of sternal fracture[10] and the displacement pattern2 can suggest the mechanism of injury. In our case patient was diagnosed a concomitant lumbar spine burst fracture with a distal corpus sterni fracture following fall from height. The fracture pattern in L1 vertebral body with fracture extension into lamina and spinous process suggests a flexion distraction mechanism which also coincides with Fowler’s study on mechanism of concomitant sternum and spinal injury. Also the sternum fracture involves the distal 1/3rd with posterior displacement of distal fragment confirming the mechanism of injury. Although the incidence of such injuries is less but a high index of suspicion for such fractures must be there when such patients are being evaluated. Delay in diagnosis may lead to increase morbidity and mortality in these patients. Fig: 5d CONCLUSION A concomitant lumbar spine injury with a sternum fracture is a rare entity, but it is essential for all orthopaedic surgeons to be aware of such injury patterns and its associated complications. Such rare injuries also help us to understand the mechanism of trauma. Missing or delay in diagnosing such fractures may lead to undue complications and increase mortality. Fig 5a, 5b,5c,5d: MRI Lumbosacral spine showing L1 compression fracture ACKNOWLEDGEMENT:Nil DISCUSSION REFERENCES Sternum fracture is a rare fracture and is usually associated with multiple injuries[6,7]. Isolated sternal fracture may occur in direct traumatic injuries[8]. The sternal fracture component is commonly missed because of it being comparatively less symptomatic compared to the other associated injuries. Thus making it essential to examine and investigate for an associated sternum fracture with a spine injury[9]. 1. B. C¸ elik, E. Sahin, A. Nadir, and M. Kaptanoglu. Sternum fractures and effects of associated injuries. Thoracic and Cardiovascular Surgeon2009;57(8):468–71. 2. E. E. Berg. The sternal-rib complex: a possible fourth column in thoracic spine fractures. Spine, 1993; 18(13):1916–19. 3. Mihai H. Vioreanu, John F. Quinlan, Ian Robertson, John M. O’Byrne Vertebral fractures Conflict of Interest: Nil 444 Daksh etal., Int J Med Res Health Sci. 2015;4(2):442-445 4. 5. 6. 7. 8. 9. 10. and concomitant fractures of the sternum. International Orthopaedics (SICOT) 2005; 29: 339–42 Fowler AW. Flexion/compression injury of the sternum. J Bone Joint Surg 1957;39:487–97. Max J. Scheyerer et al. Location of Sternal Fractures as a Possible Marker for Associated Injuries. Hindawi Publishing Corporation Emergency Medicine International Volume 2013, 407589, 1-7 D. P. Harley and I. Mena, “Cardiac and vascular sequelae of sternal fractures,” Journal of Trauma, 1986;26(6): 553–55 Gopalakrishnan KC, el Masri WS Fractures of the sternum associated with spinal injury. J Bone Joint Surg Br1986; 68(2):178–81 B. C¸ elik, E. Sahin, A. Nadir, M. Kaptanoglu. Sternum fractures and effects of associatedInjuries.Thoracic and Cardiovascular Surgeon,2009; 57(8):468–71 R. Singh, D. M. Taylor, D. D’Souza, A. Gorelik, P. Page, P. Phal. Injuries significantlyassociated with thoracic spine fractures: a case-control study. Emergency Medicine Australasia,2009;21(5): 419–23, J. Inamasu, B. H. Guiot, “Thoracolumbar junction injuries after rollover crashes: differencebetween belted and unbelted front seat occupants.European Spine Journal 2009; 18(10); 1464–68. 445 Daksh etal., Int J Med Res Health Sci. 2015;4(2):442-445 DOI: 10.5958/2319-5886.2015.00083.1 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS Copyright @2015 th th Received: 7 Jan 2015 Revised: 20 Feb 2015 Case report ISSN: 2319-5886 Accepted: 4th Mar 2015 SURGICAL MANAGEMENT OF EPIBULBAR DERMOID CYST: A CASE REPORT *Shubhangi Nigwekar P1, Chaitanya Gupte P2, Prajakta Kharche M2, Akshay Beedkar U2, Neeta Misra S1, ParagTupe N3 1 Professor, 2Post Graduate Student, 3Associate Professor, Department of Ophthalmology, Rural Medical College, Loni, Ahmednagar, Maharashtra *Corresponding author: Shubhangi Nigwekar P Email:
[email protected] ABSTRACT Dermoids are congenital lesions representing normal tissue in abnormal location. Orbital dermoid cysts are divided into superficial and deep dermoids. Depending on type and location, superficial ocular dermoid cysts are divided into limbal, dermoid cyst and epibulbar dermoid cyst or dermolipoma. The most common location for the epibulbar dermoid cyst is inferotemporal region of eye. They are usually asymptomatic or may present with inflammatory response due to leakage of cyst contents or may cause local irritation due to protruding hair and do cause cosmetic blemish to a school going child. For local irritation and cosmetic reasons, complete surgical excision with intact capsule of epibulbar dermoid cyst is mandatory to prevent acute inflammatory response and its recurrence. In this article we are presenting the clinical features and surgical management of an inferotemporal epibulbar dermoid in a male patient. Key words: Epibulbar dermoid, Dermoid cyst. INTRODUCTION Dermoid cysts are choristomas, and are often evident soon after birth [1]. They are lined with epithelium and filled with keratinized material and usually contain hair and other skin structures[2, 3].Superficial epibulbar dermoid cyst is most commonly located in inferotemporal region of eye. Epibulbar dermoid cysts are most commonly unilateral. They can be asymptomatic or may present mass in eye or fullness of eyelid depending upon the size of cyst. Leakage of its contents may lead to inflammatory response and fibrosis around cyst. Epibulbar dermoid cyst needs surgical excision for cosmetic reasons and when it is symptomatic due to local irritation [4]. Here we are describing the clinical presentation and management of an epibulbar dermoid located in the inferotemporal region in 14 years old male. CASE REPORT Hospital, Loni with painless mass in the inner side of the right lower eyelid, situated laterally, which was present since childhood. Patient had complaints of local irritation, watering. Patient himself noticed growing hair from lower fornix of right eye. Apart from cosmetic blemish, there were no other symptoms like pain or diplopia. General and systemic examination of the patient was normal. Family history was not significant. Slit lamp examination and direct ophthalmoscopy showed normal anterior and posterior segments in both eyes. Visual acuity in both eyes was 6/6(Snellens chart). Extraocular movements were full and free in all directions of gaze. Local examination revealed a swelling measuring 1.5×1×0.5cm in inferotemporal region in right eye (fig 1). It was soft, non-tender, freely mobile, and non-adherent to the sclera or conjunctiva and with single protruding hair. There A fourteen years old male came to Pravara Rural 446 Nigwekar et al., Int J Med Res Health Sci. 2015;4(2):446-449 was no corneal involvement. Clinical diagnosis was an epibulbar dermoid cyst. Patient had normal haemogram and normal chest Xray. The X-ray orbit and CT ruled out deeper extension. With proper consent and anaesthetic fitness complete excision of intact epibulbar dermoid cyst was carried out under general anaesthesia (fig 2, 3). The intact cyst was sent for histopathological examination which showed lining of stratified squamous epithelium with fibrous stroma containing few hair follicles and sebaceous glands which confirmed the diagnosis of epibulbar dermoid cyst (fig 5). Post-operatively antibiotic and steroid drops were instilled in tapering dose (fig 4). One year follow up examination showed no recurrence and any inflammatory response too. Fig 4: 1st post-operative day with conjunctival sutures in situ. Pilosebaceous Unit Fluid Filled Cyst Hair Follicles Fig 1: Mass in Inferotemporal quadrant Fig 5: Histopathology showing contents dermoid cyst of DISCUSSION Fig 2: Raised Mass during dissection Fig 3: Removal of epibulbar mass in toto A dermoid is a choristoma, representing overgrowth of normal, non-cancerous tissue in an abnormal location. It consists of ectodermal and mesodermal elements combined in different proportions. It is made up of cutaneous and subcutaneous tissue and contains hair and other skin structures and may occur anywhere in the body [5, 6]. There are two main dermoid types that occur on or around the eyes. First, a deep Orbital Dermoids typically found in association with the bony socket. Second, superficial an Epibulbar Dermoids found on the surface of the eye which gradually increases in size through epithelial desquamation and glandular secretions. It has two typical locations. One is at the junction of the cornea and sclera called Limbal Dermoid which causes astigmatism. The second location of epibulbar dermoid is on the surface of the eye where the lids meet in the temporal corner (towards the ear) which 447 Nigwekar et al., Int J Med Res Health Sci. 2015;4(2):446-449 is often called a Dermolipoma or Lipodermoid. These are more commonly found in the superotemporal quadrant extending to orbit or the lacrimal gland can lead to dry eye due to disturbance of lacrimal gland involvement. They are typically unilateral but can be bilateral. Rarely, they may affect the cornea or the bulbar conjunctiva only as occurred in our case. Epibulbar dermoid may not present at birth but can develop soon after birth. Most patients present before age 16 years. The most frequent site of Epibulbar dermoids believed to be infero-temporal segment (85%).They can range from several millimetres to a centimetre or more in size. Epibulbar dermoid has no symptoms unless hair or other dermal structures cause local irritation. The lesion does cause a cosmetic defect. Patients may present with decreased vision, foreign body sensation, cosmetic disfigurement, or an enlarging ocular mass. Epibulbar dermoid is typically fleshy, yellow and soft. It gets moulded as per the curve of the eye and has a dome shape. Hair follicles or cilia may be visible on its surface. Overlying conjunctiva may be thickened and may have fine superficial vascularisation and or keratinisation. Associated systemic abnormalities include preauricular appendages and auricular fistulae more common with limbal dermoids constituting Goldenhar syndrome[7] also known as oculoauriculo‐vertebral spectrum (OAVS) is a developmental anomaly involving structures derived from first and second branchial arches. Limbal Dermoids or dermolipomas are more likely to be associated with Goldenhar's Syndrome if they are multiple or bilateral. Diagnosis of Epibulbar dermoid though clinical, ultrasound and radiographic imaging may be required to investigate the extent of the tumour however excisional biopsy confirms the diagnosis [8, 9]. Histologically aberrant tissues, including epidermal appendages, connective tissue, skin, fat, sweat gland, lacrimal gland, muscle, teeth, cartilage, bone, vascular structures, and neurologic tissue, including the brain may be seen [10]. Malignant transformation is extremely rare. Complications of an epibulbar dermoid cyst include thinning of sclera, astigmatism due to corneal involvement and cosmetic disfigurement. Rupture of cyst or leakage of cyst contents can cause local inflammatory response [11]. Hence complete excision of intact cyst in toto is necessary to prevent recurrence, granuloma formation, fibrosis and malignant transformation. In our case since the epibulbar dermoid cyst was localised, non-adherent to underlying sclera or overlying conjunctiva, complete excision with intact wall of the epibulbar dermoid cyst was carried out, which gave good post-operative cosmetic result. Two years postoperative follow up showed no postoperative inflammation or recurrence. CONCLUSION Total surgical excision of intact epibulbar dermoid cyst relieves symptoms, gives good cosmetic and surgical results without its recurrence. ACKNOWLEDGEMENT We are thankful to HOD (Professor) Dr.Dongre and Professor Dr. Karle for providing the histopathological report and slide. Conflict of Interest: Nil REFERENCES 1. Ahuja R. Orbital Dermoids in Children. Semin Ophthalmol. 2006; 21:207-11. 2. Shields J and Shields C. Orbital Cysts of Childhood – Classification, Clinical Features and Management. Surv Ophthalmol. 2004; 49(3):28199. 3. Jakobiec FA, Bonanno PA, Sigelman J. Conjunctival adnexal cysts and dermoids. Arch Ophthalmol 1978; 96:1404-9. 4. Ramesh Venkatesh HLT. Limbal Dermoid on Clinical Presentation, but on Histology was Epidermal Cyst. Bombay Hospital Journal. 2008; 50(2): 295-98. 5. Yeola M, Joharapurkar SR, Bhole AM, Chawla M, Chopra S, Paliwal A. Orbital floor dermoid: An unusual presentation. Indian J Ophthalmol 2009; 57:51-2. 6. Srikanth R, Meenakshi S, Chaterjee R, Mukherjee B. Orbital dermoid mimicking a monocular elevation deficiency. Oman Journal of Ophthalmology 2012; 5(2):118-20. 7. Gharehbaghi MM, Ghaemi MR. Goldenhar Syndrome in an Infant of Diabetic Mother. Iranian Journal of Pediatrics 2010; 20(1):131-34. 448 Nigwekar et al., Int J Med Res Health Sci. 2015;4(2):446-449 8. Yanoff M, Fine BS. Ocular pathology. 3rd ed. Philadelphia: Harper and Row; 1988; 520 9. Sherman RP, Rootman J, Lapoint JS. Dermoids clinical presentation and management. Br J Ophthalmol 1984; 68:642-52. 10. Abou-Rayyah Y, Rose GE, Konrad H, Chawla SJ, Moseley IF. Clinical, radiological and pathological examination of periocular dermoid cysts: evidence of inflammation from an early age. Eye. 2002; 16 (5): 507-12. 11. Karatza EC, Shields CL, Shields JA, Eagle RC., Jr Calcified orbital cyst simulating a malignant lacrimal gland tumor in an adult. OphthalPlastReconstr Surg. 2004; 20:397–9 449 Nigwekar et al., Int J Med Res Health Sci. 2015;4(2):446-449 DOI: 10.5958/2319-5886.2015.00084.3 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 19 Jan 2015 Case report Coden: IJMRHS Revised: 7th Feb 2015 Copyright @2015 ISSN: 2319-5886 Accepted: 17th Feb 2015 DESMOPLASTIC FIBROMA OF RAMUS OF MANDIBLE –A RARE CASE REPORT *Nehru Anand1, R.Kanmani2, MS Anandi3, C. L. Krithika4, A. Kannan5, P.H.Raghuram6 1 Post Graduate Student, 2,3,4Senior lecturer, 5Reader, 6Professor, Department of Oral Medicine & Radiology, SRM Dental College & Hospital, Chennai, Tamil Nadu, India *Corresponding author email:
[email protected] ABSTRACT Desmoplastic fibroma (DF) is a rare, benign fibrous tumor of the bone which is locally aggressive. Desmoplastic fibroma forms 0.3% of the benign osseous tumors, which most commonly occurs in the tibia, scapula, and femur. Most commonly affected site in the head and neck region is Mandible. Desmoplastic fibroma causes bone destruction and has a high tendency for local recurrence. In this case report, we present desmoplastic fibroma of mandible of 5year old female patient with imaging, histopathology, treatment and discussion about prognosis. Key words: Locally aggressive, Fibroma, Non metastatic, Desmoplastic, Recurrence INTRODUCTION Desmoplastic fibroma is a rare locally aggressive non metastatic benign fibrogenic tumor of the bone [1]. Desmoplastic fibroma of the bone is considered to be the intraosseous counterpart of the common softtissue desmoid or fibromatoses[2]. In 1958 Jaffe reported five cases occurring in the tibia, scapula and femur. This tumor constitutes less than 1% of the bone tumors and 0.3% of benign osseous tumors, which usually involve the tibia, scapula, and femur. Desmoplastic fibroma causes bone destruction with a propensity to invade the soft tissues if untreated and has a high tendency for local recurrence if inadequately treated was reported in the year 2013 [3] . In the head and neck region, the most commonly affected site is the mandible [4].Desomplastic fibroma of the mandible was first reported by Griffith and Irby in 1965[5] CASE REPORT A female patient aged about 5 years reported to the outpatient Department of Oral medicine and radiology, with a complaint of swelling in right side of face for past 6 months. Patient gives history of painful swelling in the same region two years back which subsided spontaneously within two days without taking any medications. Presently the patient noticed swelling recurred on the same site which was initially smaller in size and gradually increased to present size within 6 months period. On extra oral examination a diffuse swelling seen in the right side of lower part of face approximately measuring about 4×3cm in size which is extending superiorly 4 cm from lower eyelid, inferiorly it crosses the inferior border of the mandible and extends to submandibular region, anteriorly 2.5 cm away from the commissure of the lip and posteriorly 1 cm anterior to tragus of the ear. On palpation the inspectory findings were confirmed. The swelling is non tender, firm to hard in consistency. On intra oral examination a single diffuse swelling seen in relation to 85 obliterating buccal vestibular region, which is approximately measuring about 3x3 cm in size. Overlying mucosa appeared to be normal in color. On palpation it was firm to hard in consistency with mild tenderness and no secondary changes noted. Correlating the patient history and clinical findings a differential diagnosis 450 Nehru et al., Int J Med Res Health Sci. 2015;4(2):450-453 of ameloblastoma, odontogenic keratocyst, and aneurysmal bone cyst was given. Further investigations like complete hematological and radiographical evaluation were performed. OPG revealed multilocular radiolucency involving right ramus and body of mandible and the radiolucency extended superiorly upto sigmoid notch, inferiorly it extended to the angle of mandible, also revealed break in the continuity of inferior border mandible.Tooth crypt of 47 displaced superiorly. Root resorption of erupting 46 evident (Fig-1).CT revealed 4.4×2.9×3.7cm expansile, multiloculated soft tissue density evident in right ramus with cortical bone discontinuity involving the inferior, buccal and lingual cortex (Fig-2). 3D reformatted image showed buccal cortical expansion with buccal and inferior cortical breach (fig-3).Working diagnosis of ameloblastoma was arrived and considering age of patient curettage of the lesion was performed under G.A and the specimen was sent for histopathological evaluation (fig-4). Fig3: CT 3D Reformatting Fig 4: Photograph of surgical specimen On Histological examination revealed the lesion showed plump spindle shaped fibroblasts cells arranged in short and long fascicles, focal storiform pattern and intervening bands of collagen bundles, there is no atypia or increase in mitosis suggestive of Desmoplastic fibroma (fig-5). Fig 1: Preoperative orthopantomogram Fig 2: Contrast enhanced Computed Tomography showing expansile, soft tissue density lesion in right ramus with cortical bone discontinuity in lingual side Fig 5:Photomicrograph showing plump spindle shaped fibroblasts cells (40X) 451 Nehru et al., Int J Med Res Health Sci. 2015;4(2):450-453 Fig 6: Postoperative orthopantomogram DISCUSSION In greek the term desmos means band or ligament. In 1938, the German physiologist and anatomist Johannes Muller characterized the term desmoids. Desmoid tumors were localized in the abdominal wall and the intraosseus variant is the desmoplastic fibroma. Jaffe in 1958 reported a similarity between the intraosseous lesions and the desmoid tumor of the abdominal wall [6]. Desmoplastic Fibroma is a nonmetastasizing, often locally aggressive neoplasm with normal appearing fibroblasts. In 2002 Desmoplastic Fibroma was defined as a rare benign bone tumor consisting of spindle-shaped cells along with minimal cytological atypia and excess collagen production[7].Possible etiologies were related to endocrine [8], genetic factors [9] and trauma[10,8]. Dahlin and Unni recorded only 9 case of Desmoplastic Fibroma in a series of 8542 primary bone tumours. Bohmet al reviewed191 cases of Desmoplastic Fibroma reported in 80 publications. In their review, the age of patients ranged from 15 months to75 years, with a reported mean age around 23 years[11,12].The age incidence is in the first, second or third decade. There is no specific gender predilection [13].In jaw bones desmoplastic fibroma occurs predominantly in the mandible and the maxilla is rarely affected. The ramus, angle and molar area of the posterior mandible are frequently involved. Less frequently affectedareas are the premolar area and the anterior segments [14]. Radiographically, the tumor presents as a welldefined, expanding, osteolytic, radiolucency, either unilocular or multilocular, and the cortex is perforated in some areas, with an associated soft tissue mass. Our patient had similar features of a multilocular osteolytic lesion with corticated borders with cortical perforation in the inferior, Buccal and lingual cortex [15].The differential diagnosis of an osteolytic lesion in the mandible includes ameloblastoma, odontogenic keratocyst and fibrous dysplasia, aneurysmal bone cyst, Ameloblastoma occur at 40 years of age, radiographically may appear as soap bubble, honey comb or tennis–racket pattern. Odontogenic keratocyst is usually centrally placed, with a scalloped border and thin marginal sclerosis. Aneurysmal bone cyst is a false cyst which occurs as unilocular or multilocular radiolucency which frequently balloons out of the cortex as opposed to the fusiform expansion usually seen with desmoplastic fibroma [16].Fibrous dysplasia is similar but would also show typical patterns of woven bone and contains a mineralized matrix and often has a sclerotic rim[6].Low-grade fibrosarcoma is a main concern to be ruled out, because of its aggressive, malignant nature with spindle cells, increased mitotic activity and pleomorphism[17]. Desmoplastic fibroma can be diagnosed only from tissue evaluation. If cortical expansion is present, a few other lesions can be included such as eosinophilic granuloma, arteriovenous malformations and hemangiomas. Central hemangioma may cause loosening and migration of teeth and teeth demonstrate rebound mobility when depressed into sockets. Diverse medical and surgical treatment options have been recommended for desmoplastic fibroma, which are simple curettage, segmental resection, en block Resection, radiotherapy, and chemotherapy, with or without additional surgical procedures (4).The major characteristic of desmoplastic fibroma is increased rate of local recurrence. Recurrence rate is at least 40% if treated by curettage or intralesional resection [18,19] .Depending on the affected area and its aggressive nature,the management is decided. In cases of intraosseus lesions without any evidence of extension to the adjacent soft tissue and also when there is high risk associated with resection because of anatomical conditions, risk-benefit-analysis can becarried out and curettage is considered as adequate management because it reduces operation time along with lower risk of infection and hence facilitates faster recovery.Radiation therapy is not recommended because of its potentialfor transformation of this lesion into fibrosarcoma[6]. In our case, treatment options were discussed and curettage was decided. Due to higher risk of 452 Nehru et al., Int J Med Res Health Sci. 2015;4(2):450-453 recurrence, postoperative observation is mandatory, including clinical and radiographic examinations, considering the child’s age and also as the condyle is one of the main sites in post natal growth of mandiblecurettage was performed and the patient was kept under observation. Patient reviewed 2months after surgery and also 6 months once regular follow up was done (fig-6). CONCLUSION 10. 11. 12. Desmoplastic fibroma is a rare, benign, locally aggressive, intraosseous lesion, with a high local recurrence rate. The tumor should be resected when ever feasible or curettage done with regular postoperative follow up. 13. Conflict of Interest: Nil 15. 14. REFERRENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. Harsha Vardhan Talla et al Desmoplastic fi broma of the mandible: A rarecase report Journal of Indian Academy of Oral Medicine & Radiology 2014 ; 2:26 Fornasico V, Pritzker KPH, Bridge JA. Desmoplasticfibroma of bone. In: Fletcher CDM, Unni KK, MertenSF, Eds. The World Health Organization classificationof tumours. Pathology and genetics of tumours ofsoft tissue and bone. Lyon: IARC Press, 2002:288 Yadavalli Guruprasad et al, Journal of CranioMaxillary Diseases 2013;2 (1):26 Dhaif G, Satir AA, Sharif S. Desmoplastic fibroma of the mandible:A 5 year follow-up. Bahrain Med Bull 2008; 30:251-4. Griffith JG, Irby WB. Desmoplastic fibroma. Oral Surg OralMed Oral Pathol 1965; 20:26975. Majid Jamali, D.M.D. The New York State Dental Journal 2013 Alexander Nedopil et al The Open Orthopaedics Journal, 2013; 7, 40-46 Triantafyllou NM, Triantafyllou DN, Antonados DN. Desmoid tumors of the bone. Int Surg1972; 57:793–97Jaffe HL. Tumors and Tumorous Conditions of the Bones and Joints. Philadelphia, PA: Lea and Febiger, 1958, 298-03. Bridge JA, Swarts SJ, Buresh C, Nelson M, Degenhardt JM, Spanier S, et al. Trisomies 8and20 characterize a subgroup of benign fibrous 16. 17. 18. 19. lesions arising in both soft tissue and bone. Am J Pathol 1999; 154:729–33 Jaffe HL. Tumors and Tumorous Conditions of the Bones and Joints. Philadelphia, PA: Lea and Febiger, 1958, 298-03 Dahlin DC, Unni KK. Bone tumors: general aspects and dataon 8542 cases (4th edn). Springfield, IL: Thomas, 1986, 375–76. Bo¨hm P, Kro¨ber S, Greschniok A. et al. Desmoplastic fibromaof the bone: a report of two patients, review of the literature,and therapeutic implications. Cancer 1996; 78: 1011–23. Journal of Indian Academy of Oral Medicine & Radiology 2014; 2:26 Lt Col VK Shukul et al MJAFI 2004; 60 : 307309 Chang JJ, Hu C, Chang PC, Liu HY, Tu CN. Juvenile desmoplastic fi broma of mandible: A case report. Zhonghua Ya Yi Xue Hui Za Zhi 1988; 7:35-40. H Shi et al Dentomaxillofacial Radiology (2008) 37, 408–11 Said-Al-Naif N, Fernandes R, Louis P, Bell W, Siegal GP. Desmoplastic fibroma of the jaw: a case report and review of literature. Oral Surg Oral Med Oral Path 2006; 101:82–94 Inwards CY, Unni KK, Beabout JW, Sim FH. Desmoplastic fibroma of bone. Cancer 1991; 68: 1978–83. Gebhardt MC, Campbell CJ, Schiller AL, Mankin HJ Desmoplastic fibroma of bone: a report of 8 cases and review of the literature. J Bone Joint Surg Am 1985; 67: 732–47. 453 Nehru et al., Int J Med Res Health Sci. 2015;4(2):450-453 DOI: 10.5958/2319-5886.2015.00085.5 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 20 Jan 2015 Case report Coden: IJMRHS Copyright @2015 ISSN: 2319-5886 th Revised: 20 Feb 2015 Accepted: 6th Mar 2015 GIANT FIBROEPITHELIAL STROMAL POLYP OF VULVA IN A YOUNG GIRL Khumanthem Pratima D1, Sarkar Sabyasachi2,*Kumari Suman2, Nabakishore Singh N3, BimolChandra Singh L4, Reeta Devi M5 1 Senior Registrar, 2Postgraduate student, 3Professor & Head,4Associate Professor, Department of Obstetrics and Gynaecology, Regional Institute of Medical Sciences Imphal, Manipur, India 5 Assistant Professor Department of Pathology Regional Institute of Medical Sciences Imphal, Manipur, India * Corresponding author email:
[email protected] ABSTRACT Fibroepithelial stromal polyps are site-specific mesenchymal lesions that typically occur in women of reproductive age group and present more commonly in vagina than cervix or vulva. These polyps usually do not grow larger than 5 cm in diameter and are most commonly identified during routine gynecological examination. Although benign, sometimes their clinical features may overlap with those of malignant neoplasms so histopathological examination of the polyp is often necessary to make a definitive diagnosis. Key words: Fibroepithelial stromal polyps, cervix, vulva. INTRODUCTION Fibroepithelial stromal polyps (FEPs) are also known as Acrochordons or skin tags. These are site specific mesenchymal lesions which show a predilection for the neck, axilla, and groin and are typically seen in adult obese women. FEPs of the lower genital tract often develop in young to middle-aged women and are more common in the vagina than vulva and rarely seen in cervix. [1]These polyps are thought to be hormone sensitive and are usually seen in reproductive age group. however they can also be seen in postmenopausal women who are on hormone replacement therapy. These lesions display a wide range of morphologic appearances and usually present as polypoid or pendunculated growth. Mostly the size of lesions is 1x2 cm but rarely it can reach an extremely large size up to 15- 20 cm.[2] Small lesions are usually asymptomatic and are detected during routine gynaecological examination. Symptomatology of large lesions includes general discomfort with sensation of a mass as well as bleeding and discharge due to secondary infection of the lesion. Their clinical features may overlap with the malignant lesions of vulvovaginal region so biopsy is often necessary for confirmatory diagnosis. [3] We present a case of 8x7 cm large fibroepithelial stromal polyp of the vulva in 22 years old unmarried girl with a brief review of literature. CASE REPORT A 22 year old unmarried girl presented to gynaecology department of our institute with swelling in the right labia which was first noticed around 6 year back. Initially the swelling was around 1-2 cm and was static in size. The swelling increased in size over the course of the last 8 months until its current size on presentation. The girl was extremely embarrassed and this was the reason why she had not consulted so far to any health care provider. But polyp’s rapid growth and ulceration over the surface forced her to present for evaluation. She complained of itching and discharge from the swelling 454 Pratima et al., Int J Med Res Health Sci. 2015;4(2):454-456 accompanied with fever since last 5 days. The general physical examination and systemic examination was unremarkable except the swelling. Her menstrual history was normal. The patient denied any significantpast medical or surgical history. No history of sexually transmitted disease or gynaecologyrelated surgery was present. Local examination revealed a large 8 ×7 cm pendunculated, globular mass arising from the right labia majora. The proximal end was connected to the right labia majora by 3.5x1.5 cm pedicle. The skin over the growth was ulcerated with signs of inflammation (Figure 1). Fig 2:Fibrovascular tissue having myxoid stroma( Big arrow) with few stellate cells(small arrow) [40x] These histopathological features were suggestive of fibroepithelial stromal polyp. The patient was discharged and was advised for monthly follow up visit. On follow up the pedicle site was healed and she did not manifest any signs of recurrence following excision. DISCUSSION Fig 1: Large pendunculated globular mass arising from the right labia majora with signs of inflammation. The growth was soft and warm on palpation with mild tenderness. No lymph nodes were palpable in the vulvar and inguinal regions. There was no increase in the size of the mass with coughing and valsalva manure. Blood investigations showed polymorphonuclear leucocytosis (Total WBC counts14000/mm3 with 78% neutrophils) with raised ESR (65 mm in first hour). Other laboratory investigations were within normal limit including random blood sugar. She was treated initially with antibiotics and local antiseptic ointment. Later on total surgical excision of the mass was performed under local anaesthesia. Grossly the cut section of the specimen revealed a solid greyish white mass with yellow brownish area in the centre. Microscopic examination of the tissue showed fibrovascular tissue having myxoid to fibrous stroma with reactive stromal cells. Few stellate cells and multinucleated cells were noted near the epithelial-stromal interface (Figure 2). Fibroepithelial stromal polyps of the vulvovaginal region are rare benign tumours which exhibit a wide range of morphological appearances and can be misinterpreted as malignant. Differential diagnosis of fibroepithelial stromal polyp includes cellular angiofibroma, angiomyofibroblastoma, embryonalrabdomyosarcoma and aggressive [4] angiomyxoma. So histopathological examination is necessary for confirmatory diagnosis. Histologically fibroepithelial polyps are classified in two types: (1) Predominantly epithelial (2) Primarily stromal. Microscopically the most characteristic feature of a fibroepithelial stromal polyp is the presence of stellate and multinucleate stromal cells which are usually identified near the epithelial-stromal interface.[5] Immunohistochemically FEPs are often positive for desmin, vimentin, oestrogen, and progesterone receptors and less frequent for actin. [3] The pathogenesis of FEPs has not been completely understood yet. Frequent irritation seems to be an important causative factor, especially in persons who are obese. Skin aging with many other factors may also be the predisposing factor for genesis and development of fibroepithelial polyp. FEPs are extremely uncommon before the menarche and after menopause. Presence of oestrogen and progesterone receptors in the stromal cells of FEPs, occurrence of these lesions during reproductive age group 455 Pratima et al., Int J Med Res Health Sci. 2015;4(2):454-456 especially during pregnancy, spontaneous regression after delivery and presence of FEPs in postmenopausal women on harmone replacement therapy, all these indicate an association between hormonal changes and pathogenesis of fibroepithelial polyp.[6] Association of FEPs have also been observed with type 2 diabetes mellitus and obesity.[7] Giant FEPs have also been reported in association with other dermatoses.[8] Although polygonal and multinucleate stromal cells are characteristics of FEPs, they can also be seen in normal vulva, vagina and cervix suggesting that these polyps may represent a proliferation of cells normally found in this region. Thus FEPs represent a hyperplastic process involving the subepithelial myxoidstroma of the lower female genital tract rather than a true neoplasm. Beside histopathological examination, imaging is also important in the diagnostic work up of fibroepithelial stromal polyps. It allows for evaluation of blood supply and flow and demonstrates the origin and extent of the lesion. Ultrasonography is preferred over CT and MRI as first line imaging tool. The small asymptomatic FEPs do not require excision, unless concerns exist about the final tissue diagnosis. Excision is the treatment of choice for symptomatic FEPs. Large FEPs may cause local discomfort, mass sensation and may be secondarily infected after traumatic surface erosion. The inflammation seen in our case was secondary to infection over the eroded surface due to repeated friction between the polyp, thigh and undergarments of the patient. Local recurrence after excision is rare but has been reported in literature. [9] Recurrence may be either related to incomplete excision or if there is continuous hormonal stimulation (e.g. pregnancy, tamoxifen).[3][10]As a result, all patients with this diagnosis should be followed for long term and managed appropriately after initial treatment. However our patient showed no evidence of recurrence during one year follow-up period. CONCLUSION FEPs are relatively site-specific mesenchymal lesions of the vulvovaginal region that typically occur in women of child-bearing age. Large FEPs of the vulval region are rare benign tumours. Due to their wide range of morphological appearances, they may be diagnostically challenging and need expert pathological interpretation to exclude other site specific lesions such as deep aggressive angiomyxoma, angiomyofibroblastoma, cellular angiofibroma and embryonalrabdomyosarcoma. DECLARATIONS: interest: None Funding: Nil, Conflict of REFERENCES 1. Carter PE, Russell P. Bilateral fibroepithelialpolypi of labium minus with atypical stromal cells. Pathology, 1992;24(1):37– 39 2. Bozgeyik Z. Giant fibroepithelial stromal polyp of the vulva:extended field-of-view ultrasound and computed tomographic findings. Ultrasound Obstet Gynecol 2007, 30(5):791–92. 3. Nucci MR, Young RH, Fletcher CD. Cellular pseudo sarcomatous fibroepithelial stromal polyps of the lower female genital tract: an under recognized lesion often misdiagnosed as sarcoma. Am J SurgPathol 2000; 24(2):231-40 4. Laskin WB, Fetsch JF, Tavassoli FA. Superficial cervicovaginal myofibroblastoma: fourteen cases of a distinctive mesenchymal tumor arising from the specialized subepithelialstroma of the lower female genital tract. Hum Pathol 2001; 32(7):715-25. 5. Nucci MR, Olivia E: Gynecologic Pathology: A Volume in Foundations in Diagnostic Pathology Series. Elsevier/Churchill Livingstone; 2009:31– 32. 6. Sharma S, Albertazzi P, Richmond I. Vaginal polyps and hormones--is there a link? A case series. Maturitas 2006; 53(3):351-55 7. Thappa DM. Skin tags as markers of diabetes mellitus: An epidemiological study in India. J Dermatol. 1995;22(10):729-31 8. Dane C, Dane B, Cetin A, Erginbas M, Tatar Z. Association of psoriasis and vulva fibroepithelial polyp. Am J ClinDermatol. 2008;9(5):333-5 9. Han X. Giant cell fibroblastoma of the vulva at the site of a previous fibroepithelial stromal polyp: a case report. J Low Genit Tract Dis2007, 11(2):112–117. 10. Pearl Crombleholme WR, Green JR, Bottles K. Fibroepithelial polyps of the vagina in pregnancy, Am J Perinatol 1991;8:236-8 456 Pratima et al., Int J Med Res Health Sci. 2015;4(2):454-456 DOI: 10.5958/2319-5886.2015.00086.7 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 st Received: 21 Jan 2015 Case report Coden: IJMRHS Copyright @2015 ISSN: 2319-5886 th Revised: 27 Jan 2015 Accepted: 1st Mar 2015 PLASMACYTOID MYOEPITHELIOMA OF MINOR SALIVARY GLANDS: A RARE CASE REPORT *Jha Rohit Kumar1, Sinkar Prachi2, Karadi RN3 1 Post Graduate, 3Professor& Head, Department of Otorhinolaryngology, Shri B.M. Patil Medical College, Hospital &Research Centre, BLDE University, Vijayapur, Karnataka, India 2 Post Graduate in the Department of Pathology, Shri B.M. Patil Medical College, Hospital &Research Centre, BLDE University, Vijayapur, Karnataka, India *Corresponding author email:
[email protected] ABSTRACT Myoepithelioma of the salivary glands is a rare benign neoplasm with incidence of less than 1% of all salivary gland neoplasms. The most common site is the parotid gland followed by minor salivary glands. These tumors occur at any age with peak incidence in the third & fourth decade. Here we report a case of plasmacytoid myoepithelioma of the minor salivary glands of soft palate which was conclusively diagnosed on FNAC and further confirmed by histopathological studies. The rarity of the tumor and the site has been emphasized. Key words: Myoepithelioma, Minor salivary gland, Plasmacytoid variant, Soft palate. INTRODUCTION Myoepithelioma is believed to be rare entity in the tumours of salivary glands with less than 100 cases reported in the literature. It was first described by Sheldon in 1943 and was considered as variant of pleomorphic adenoma. [1] But now-a-days most authors consider myoepithelioma as a distinct pathological entity, composed entirely of myoepithelial cells behaving much more aggressively than pleomorphic adenoma. Myoepithelioma arises from myoepithelial cells which are usually present in ductal epithelium of secretary glands like salivary, sweat and mammary glands. [2] Myoepithelial cells are characterised by intracytoplasmic myofilaments, intercellular desmosomes and myogenic markers. [3] Histopathologically there are five variants; spindle cell, plasmacytoid, epithelioid, clear cell and mixed variant. Spindle cell variant is the most common followed by plasmacytoid variant. Majority of myoepitheliomas present as painless, slow growing, well circumscribed, smooth surfaced tumors. They are well capsulated and rarely metastasize. However recurrences have been described. [3] CASE REPORT A 60 year old male patient came to the OPD of ENT department with swelling in the oral cavity since 2 years. On examination swelling was noticed on the left side of soft palate, measuring about 4 x 3.5cm, well circumscribed, smooth surfaced. Overlying mucosa was intact and not traumatized (Fig-1). There was no evidence of cranial nerve and lymph nodal involvement. The past history and family history were not relevant. Routine blood and biochemical investigations of patient were within normal limits. Patient was advised FNAC which showed high cellularity consisting of plasmacytoid cells in sheets, clusters and singles on a background of myoxid stromal fragments (Fig-2). Surgical excision was done (Fig-3) and surgical specimen was sent for 457 Rohit et al., Int J Med Res Health Sci. 2015;4(2):457-459 histopathological examination. Histopathological examination revealed a solid tumor consisting of plasmacytoid cells in nests, islands and cords separated by scanty myxoid stroma. There were no ductal or glandular elements, as well as no atypia or necrosis in the sections studied. Thus, confirming the diagnosis of plasmacytoid myoepithelioma. (Fig-4) Fig 1: Tumour measuring 4x3.5cm on the soft palate. Fig 2: FNAC Tumour cells arranged in sheets. Plasmacytoid myoepithelial cells with rounded nuclei eccentrically placed with eosinophilic hyaline cytoplasm. Background showing myoxid stromal elements (H&E; 100x). Fig 3: Intra-operative tumour mass removed along with capsule from soft palate Fig 4: Histopathological study (H&E,100x) showing tumour tissue arragned in diffuse sheets.Most of the tumour cells have eccentrically placed nuclei with hyaline eosinophilic cytoplasm (i.e. plasmacytoid cells).Also seen spindle shaped cells and few foci of clear cell change.Stroma shows hyalinised collagen fibres. DISCUSSION Myoepithelioma is rare benign neoplasm of salivary glands. Among its four sub-types spindle cell type is most common (seen in 70% cases) where as plasmacytoid cell type is seen in only 20%cases. Plasmacytoid cell type is more common in major salivary glands.[4] Therefore plasmacytoid myoepithelioma in minor salivary glands is a rare entity. The biggest series published on myoepithelioma is by Scuibba and Brannon who presented 23 cases of myoepithelioma of salivary glands (both major and minor).[3]According to literature review only 14 cases of plasmacytoid variant of myoepithelioma affecting minor salivary glands of palate have been reported.[5] Age distribution ranged from 3rd decade to 9th decade, with mean age of 53 years. No sex predilection has been described.[2]Myoepithelioma must be differentiated from pleomorphic adenoma by absence of chondroid or osteoid changes in the matrix and absence of inconspicuous ductal differentiation.[1] Benign myoepithelioma can be differentiated from malignant myoepithelioma by absence of solid pattern, infiltrating growth, necrotic areas, mitotic figures, hyperkeratotic nuclei, cellular polymorphism, cellular atypia and metastases.[6] Malignant myoepithelioma has also been identified by cell proliferation index(>10% highly suggestive of 458 Rohit et al., Int J Med Res Health Sci. 2015;4(2):457-459 malignant behavior). Basal membrane globule surrounded by hyperkeratotic myoepithelial cells goes in favor of malignant myoepithelioma.[1] Differential diagnoses of plasmacytoid myoepithelioma include myoepithelial cell predominant pleomorphic adenoma, plasmacytoma, lymphoma, skeletal muscle and rhabdoid tumors. Presence of myxohyaline stroma and cohesive clusters of plasmacytoid cells favor myoepithelioma over other diagnosis. Absence or less than 5% of epithelial cells showing ductal or acinar formation and absence of chondroid stroma helps in differentiating it from pleomorphic adenoma. In our case myxohaline stromal fragments were noted and inconspicuous ductal or acinar pattern helped us to distinguish it from pleomorphic adenoma. [7] In immuno histochemical study myogenic markers like CK-14, CK-18 & 19 is expected to be positive in plasmacytoid variant. Surgical excision with margin (few mm) of normal tissue is the treatment of choice. Recurrences are rare. According to Sciubba & Brannon, who followed-up 16 cases out of 23 over a period of 1 year, found recurrence only in one case.[3] Recurrences can be picked up by regular follow up. In our case, the patient did well postoperatively and no recurrence was noted till date. 2. Peel L, Diseases of the Salivary Glands Leon Barnes(ed), Surgical Pathology of the Head &Neck, 2nd edtn Marshal-Dekker, Inc., New York-Basel, 2001;667-70. 3. Shafer G, Hine K, Levy M, Tumors of the Salivary Glands Text book of Oral pathology, Elsevier, 4th edtn.Philadelphia,2003;239-40 4. Regezi A, Sciubba j, Jordan K, Salivary Gland Diseases, Oral Pathology, Elsevier, 5th edition. St.Louis, 2008; 316-17 5. Rivera Q. Plasmacytoid myoepithelioma of the palate, Research Gate, http: //www. Research gate.net/publication/5789445_Plasmacytoid_myo epithelioma 6. Gnepp R, El-Mofty K, Salivary Glands (1996),Ivan Damjonov,James Linder(ed), Ander son’s Pathology, Patterson S, St.Louis, 1996; 2:1623-24. 7. Gore CR, Panicker NK, Chandanwale SS, Singh BK. Myoepithelioma of minor salivary glands A diagnostic challenge: Report of three cases with varied histomorphology. J Oral Maxillo facPathol 2013; 17: 257-60. CONCLUSION Myoepithelioma- plasmacytoid variant of the palatal minor salivary glands is a rare entity. It is relatively more aggressive than other benign neoplasms of salivary glands. Management is surgical excision which should include margins of normal tissue and long term follow up for recurrence. To conclude, myoepithelioma should be kept in mind as differential diagnosis when dealing with an intraoral sub mucosal mass inspite of their rarity at that location. : : : Conflict of Interest: Nil REFERENCES 1. Santos P, Cavalcante RR, MeloUC,et al. Plasmacytoid myoepithelioma of salivary glands: report of case with emphasis in the immunohistochemical findings. Head & Face Medicine2011; 7:24;1-6 459 Rohit et al., Int J Med Res Health Sci. 2015;4(2):457-459 DOI: 10.5958/2319-5886.2015.00087.9 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS th Received: 25 Jan 2015 Revised: 20th Feb 2015 Case report Copyright @2015 ISSN: 2319-5886 Accepted: 22nd Feb 2015 SILENT UTERINE RUPTURE OF UNSCARRED UTERUS- AN UNUSUAL PRESENTATION. *Nishi Garg1, Grover Seema2, Simmi Aggarwal3 1 Assistant Professor, 2Professor, Department of Gynecology, Guru Gobind Singh Medical College &Hospital, Faridkot, Punjab, India 3 Professor, Department of Radiology, Guru Gobind Singh Medical College &Hospital, Faridkot, Punjab, India *Corresponding author email:
[email protected] ABSTRACT It is very rare to see rupture of uterus in an unscarred uterus. But in cases of previous abortions or cesarean section or scarred uterus, uterine rupture is seen in few cases. Silent uterine rupture is very rare. If there is fetal demise & presenting part is very high up in pelvis not responding to routine induction, possibility of rupture uterus should be kept in mind. Ultrasound has an important role in the diagnosis of silent uterine rupture. A case of silent uterine rupture of unscarred uterus with fetal demise, that remained undiagnosed for many weeks, is described. Keywords: Uterine rupture, Unscarred, Silent, Fetal demise INTRODUCTION Rupture of the unscarred pregnant uterus is a rare event, estimated to occur in 1/5700 to 1/20,000 pregnancies.[1-4].In one series, there were 25 uterine ruptures in women with unscarred uteruses and these events accounted for 13 percent of ruptures in this study.[4] The incidence of rupture in unscarred and scarred uteruses was 0.7 and 5.1 per 10,000 deliveries, respectively. The pathogenesis of rupture of the unscarred uterus is not well-defined. Rupture in these cases has been attributed to inherent or acquired weakness of the myometrium, disorders of the collagen matrix (Ehlers-Danlos type IV)[5-8], and abnormal architecture of the uterine cavity (bicornuate uteri, uterus didelphys, “blind uterine horns”). [9-11] Over distension of the uterine cavity, whether absolute or relative to the size of the cavity, may be the major physical factor associated with rupture in such cases. Over distension has even been reported as a cause of rupture of the non gravid uterus. [12] Uterine rupture is an uncommon but is a Nishi et al., fatal complication of pregnancy. The difficulty in diagnosis and management arises in cases of chronic and silent uterine rupture. Silent ruptures have also been reported after D&E and hysteroscopic procedures.[13-14] Normal cardiotocographs (CTG) can be obtained in silent uterine rupture hence it is not a useful tool in the diagnosis. [15] Obstetricians should be aware of the possibility of silent rupture of Uterus. Ultrasound has an important role in the diagnosis of silent uterine rupture. [16 ] We present a case of silent uterine rupture that remained undiagnosed for many weeks. CASE REPORT A patient G2 P0 A1 presented in emergency with H/O amenorrhea 31wks with paralytic ileus. She was referred from periphery on 20.9.2014. Her general parameters were maintained. Blood Pressure & Pulse was in normal range. The investigations done in civil hospital were all normal but her HB – was 7.0gm %. Int J Med Res Health Sci. 2015;4(2):460-463 460 She gave H/O vomiting, constipation & mild abdominal Pain. She was calm, conscious and cooperative .On P/A examination Uterus Height was 30Wks with Fetal parts palpable & FHS -146 / min and regular. Surgical Consultation was taken in view of abdominal distension as abdomen was distended & tense. No guarding or rigidity was there. Bowel sounds were absent. Ultrasonography & Ryles tube aspiration was advised. She was having regular Antenatal care at Moga Civil hospital, her previous Ultrasound done there on 2/8/14 showed 25-26 wks pregnancy with 34x23mm hypoechoic Collection (Retroplacental Collection) Placenta was anterior & in upper segment. [Fig. 1] After admission U/S done 22/9/14 showed her upper abdominal Scan to be normal .Cortical echogenicity was increased of Right Kidney. Also Right Pelvi Calayceal system showed hydronephrosis. There was moderate amount of free fluid in abdomen. Fetal condition was normal & gestation was 31wks. [Fig. 2] .There was no comment on uterine contour. She was given I/V fluids, antibiotics & Continuous Ryles tube aspiration was done. Two Blood transfusions were given on 22nd Sep. 2014. Distension was still there but uterus was relaxed& FHS was 136 /mt reg. She did not complain of any pain and any loss of fetal movements. On 23rd Sep. fetal heart sound was not heard but her bowel movements were normal & abdomen was relaxed. U/S done to see fetal Cardiac activity, where it was declared to be Intra Uterine Death. Comment on the contour of the uterus again was not made. So plan for induction of labor was to be made & in view of that pervaginum exam was done. On P/V Exam. Cervix was found to be unfavourable admitting 1 F & presenting part was very high. A suspicion of rupture was made & repeats U/S was done which showed a rent in the anterior wall of the uterus. Placenta was anterior & free fluid was seen in all the peritoneal recesses. During all these days her general parameters were maintained. Her BP Was 110/70 & there was no tachycardia.. After this decision of laparotomy was made .One unit of blood was given preoperatively. On opening the abdomen there was haemoperitoneum and baby was lying outside the uterus in the amniotic sac .There was a huge vertical rent in the midline of the uterus & placenta was partially attatched to the uterus & partially to the omentum. [Fig. 3] Repair of the uterus was impossible so hysterectomy done after Nishi et al., taking consent. Also removal of omentum where placenta was adherent was done. This Case presented with intestinal Obstruction so diagnosis of pregnancy with peritonitis & intestinal pathology was made. Her obstruction got relived with treatment & abdomen became soft. Also fetal Cardiac activity was normal. Her general parameters were normal. So Diagnosis of uterine rupture was missed. As the rupture progresses and ended up in IUD, led on to the reaching of diagnosis. In this case as there is history of previous abortion, so at that time silent perforation could have led on to scarred uterus. So in this pregnancy that scar gave way & progressed in silent rupture. Probably starting asretroplacental clot which slowly progressed into complete rupture in one and a half month time resulting in IUD with haemorrhage. Fig 1: Ultrasound at 25-26 wks Fig2: Ultrasound at 31 wks Fig3: Ultrasound after rupture Int J Med Res Health Sci. 2015;4(2):460-463 461 Fig 4 : Hemoperitoneum reported where they conservatively managed prenatal uterine rupture, diagnosed first at 17 and 19 weeks respectively on ultrasound. [17-19] Silent rupture can occur in previous scars as well as in unscarred uterus. [20-21] These ruptures remain silent for days and weeks. Another case is reported where two large 5 Cm and 10 Cm complete ruptures were incidentally discovered on third postnatal day during tubal ligation [22]. An unusual presentation of prenatal silent rupture is reported as anhydramnios and lung hypoplasia at 31 weeks. Further investigation revealed foetal leg protruding through uterine wall[23]. CONCLUSION Fig 5: Ruptured uterus DISCUSSION The ‘silent’ rupture of uterus is encountered when the patient is asymptomatic and rupture or rent in the uterus is discovered incidentally on ultrasound or at surgery. Risk factors are previous scar or other surgeries upon uterus, induction of labour by prostaglandins and augmentation of labour by oxytocin in a multiparous woman. [13-14] The dilemma in diagnosis arises when uterine rupture remains asymptomatic or presents with non-specific symptoms, e.g., vague abdominal pain or discomfort for many weeks. There is difficulty in diagnosis due to lack of resources, expertise and ultrasound skills. CTG is not a useful tool in the diagnosis of silent uterine rupture. [15] In our case, the woman sought medical advice outside at Moga at 25-26 weeks, she had a small rent in the uterus which was interpreted as a retroplacental clot . During subsequent one and a half month, the whole of the anterior surface gave way, resulting in extrusion of fetus into the peritoneal cavity in sac and ultimately fetal demise occurred. Also Placenta got attached to omentum . A case similar to this is reported where a lady presented at 29 weeks with abdominal pain for several weeks and ultrasound revealed foetal parts outside the uterine cavity. [16] Two other cases are Nishi et al., High index of suspicion should arise for uterine rupture in cases of previous scar or procedures upon uterus, when they present with unusual features and suspicious ultrasonography findings like bands, cysts , free fluid and unexplained anhydramnios. Ultrasonography has an important role in diagnosing silent and old ruptures. Every effort should be made to seek expertise to define uterine wall integrity. Conflict of Interest: Nil REFERENCES 1. Dow M, Wax JR, Pinette MG, et al. Thirdtrimester uterine rupture without previous cesarean: a case series and review of the literature. Am J Perinatol 2009; 26:739. 2. Porreco RP, Clark SL, Belfort MA, et al. The changing specter of uterine rupture. Am J Obstet Gynecol 2009; 200:269. 3. Miller DA, Goodwin TM, Gherman RB, Paul RH. Intrapartum rupture of the unscarred uterus. Obstet Gynecol 1997; 89:671. 4. Zwart JJ, Richters JM, Ory F, et al. Uterine rupture in The Netherlands: a nationwide population-based cohort study. BJOG 2009; 116:1069. 5. Walsh, CA, Reardon, W, Foley, ME. Unexplained prelabor uterine rupture in a term primigravida: letter to the editor. Obstet Gynecol 2007; 109:455 6. Taylor DJ, Wilcox I, Russell JK. Ehlers-Danlos syndrome during pregnancy: a case report and review of the literature. Obstet Gynecol lSurv 1981; 36:277. Int J Med Res Health Sci. 2015;4(2):460-463 462 7. Rudd NL, Nimrod C, Holbrook KA, Byers PH. Pregnancy complications in type IV EhlersDanlos Syndrome. Lancet 1983; 1:50. 8. Jones DE, Mitler LK. Rupture of a gravid bicornuate uterus in a primigravida associated with clostridial and bacteroides infection. J Reprod Med 1978; 21:185. 9. Samuels TA, Awonuga A. Second-trimester rudimentary uterine horn pregnancy: rupture after labor induction with misoprostol. ObstetGynecol 2005; 106:1160. 10. Nahum GG. Uterine anomalies. How common are they, and what is their distribution among subtypes? J Reprod Med 1998; 43:877. 11. Gowda M, Garcia L, Maxwell E, et al. Spontaneous uterine rupture in a nulligravida female presenting with unexplained recurrent hematometra. ClinExpObstetGynecol 2010; 37:60. 12. Sakr R, Berkane N, Barranger E, et al. Unscarred uterine rupture--case report and literature review. ClinExpObstetGynecol 2007; 34:190. 13. Conturso R, Redaelli L, Pasini A, Tenore A. Spontaneous uterine rupture with amniotic sac protrusion at 28 weeks subsequent to previous hysteroscopicmetroplasty. Eur J OostetGynecol 2003; 107(1):98–100. 14. Jocken S, Britta G, Anton S. Twin gestation with uterine rupture after hysteroscopy. Gynecological Endoscopy 2002:11;145–9.
3. 15. Klein M, Rosen A, Beck A. Diagnostic potential of cardiotocography (CTG) for silent uterine rupture. Acta Obstet Gynecol Scand 1989; 68(7):653–6.
16. Wali S Aisha , naru y. t. silent uterine rupture of scarred uterus - an unusual presentation as amniocele -case report j ayub med coll abbottabad 2013;25(1-2):204–5 17. Cotton DB. Infant survival with prolonged uterine rupture. Am J Obstet Gynaecol 1982;142:1059–60.
18. Yinka O, Jean-Gilles T, Brian C, Anitha N, Patricia H,Rodney M. Conservative management of uterine rupture diagnosed prenatally on the basis of sonography. J Ultrasound Med 2003;22:977–80. 19. Martin JN Jr, Brewer DW, Rush LV Jr, Martin RW, Hess LW, Morrison JC. Successful Nishi et al., pregnancy outcome following mid- gestational uterine rupture and repair using Gore-Tex soft tissue patch.ObstetGynaecol 1990;75:518–52. 20. Chuan-Yaw C, Szu-Yuan C, I-Lin C, Chun-Sen H, Kenny H- H C, Pui-Ki C. Silent uterine rupture in an unscarred uterus. Taiwan J ObstetGynecol 2006;45(3):250–2. 21. Neena M, Charu C. Silent rupture of unscarred uterus: an unusual presentation at second trimester abortion. Arch GynecolObstet 2007;275(4): 283–5. 22. Rubin L, Baskett TF. “Silent” uterine rupture during labor. Can Med Assoc J 1971;104:612–5. 23. Katinka KT, Enrico L, Remco GWN, Patrick AB, Inge LVK. Silent uterine rupture, an unusual cause of anhydramnios. Am J Obstet Gynecol 2007; 196(2):8–9. Int J Med Res Health Sci. 2015;4(2):460-463 463 DOI: 10.5958/2319-5886.2015.00088.0 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 24 Jan 2015 Case report Coden: IJMRHS Copyright @2015 ISSN: 2319-5886 th Revised: 10 Feb2015 Accepted: 27th Feb 2015 BLOCKAGE OF EPIDURAL CATHETER WITHIN CONNECTOR ASSEMBLY *Gill RavneetK.1, Pathak Debagopal2, Arora Bharat 1,Chauhan Ram C.1 1 Post-graduate, 2Professor and Head, Department of Anaesthesia and Critical Care,Silchar Medical College and Hospital, Silchar, Assam, India *Corresponding author email:
[email protected] ABSTRACT Failure to inject a drug through the epidural catheter because of epidural catheter connector malfunction is a rare complication. In this report, we describe a case of epidural catheter – connector malfunction in a 45 years old male undergoing emergency explorative laparotomy for haemoperitoneum under general anaesthesia and insertion of epidural catheter for post operative analgesia. After insertion of catheter after completion of surgery, drug could not be injected in the catheter. After common causes like kinking, knotting, occluded catheter were ruled out, the cause was found to be in the epidural catheter connector assembly which is not encountered frequently. This case warrants that anaesthesiologists must also be aware of rare causes and the preventive steps to avoid such complications. Keywords: Epidural catheter – connector assembly, Blockage of epidural catheter INTRODUCTION Epidural technique of anaesthesia is now widely usedby anaesthesiologists all over the world. By placing an epidural catheter, regional anaesthesia can be performed and prolonged by injecting local anaesthetic drug and postoperative analgesia [1] can also be provided by injecting epidural local anaesthetics or narcotics [2]. Adequate post operative epidural analgesia fastens the recovery as it decreases the stress response and the load on cardio respiratory, renal system and leads to decrease in morbidity and prevent further complications like thrombosis, embolism [3, 4] etc. Every patient has the right for adequate pain relief after surgery. Failure to inject drug through a catheter is a well known [5, 6] complication which can be due to kinking or knotting of the catheter but rarely may be because of connector assembly malfunction. CASE REPORT A 45 year old, 70 kg male patient was put for emergency exploratory laparotomy for Ravneet et al., haemoperitoneum (as revealed on FAST scan) following blunt trauma to the abdomen. On arrival to operation theatre, he was quickly examined for any co morbidities, Nil per Oral status. Intravenous access was gained by placing two 18 G cannula in both hands and normal saline was started.He was premedicated with inj Ranitidine iv 50 mg, inj Ondanseteron iv 4 mg, inj Glycopyrolate iv 0.2mg,inj Tramadol iv 1mg/kg. Patient’s vitals like Non Invasive Blood Pressure, Electrocardiography, SpO2 (oxygen saturation) were recorded and found to be within normal limits. Inj Lidocaine iv 1.5mg/kg was given to attenuate the hemodynamic response to laryngoscopy and intubation. Preoxygenation with 100% oxygen was followed by induction with propofol iv 2mg/kg and succinylcholine iv 75 mg using modified Rapid Sequence Intubation (RSI) technique. Patient was intubated with size 8.5Endotracheal tube and position was confirmed by bilateral auscultation of breath sounds and EtCO2 monitor was attached. Anaesthesia was maintained 464 Int J Med Res Health Sci. 2015;4(2):464-466 with inj. Atracurium(30 mg bolus and 5 intermittent top up doses of 10 mg at 25 minutes interval), N20 :02 67:33%and Isoflurane inhalation at 0.6%.Duration of the surgery was 140 minutes and1.5litres of Normal saline 500ml of Ringer’s lactate and 1 unit of whole blood were transfused. Urine output at end of the surgery was 250 ml. After completion of the surgery, insertion of epidural catheter (Perifix 300 mini set Braun) was planned for post operative analgesia. He was put in the left lateral decubitus position, and under aseptic conditions, epidural Tuohy needle 18 G was advanced in L2-3 intervertebral space and epidural space was identified by LOR (loss of resistance technique) to air at 5 cm marking on Tuohy needle. After test dose, single shot 0.125% bupivacaine (12 ml total volume) was injected for postoperative analgesia and also to facilitate insertion of catheter by predistension of the epidural space. After that, epidural catheter was inserted through the needle and fixed at 11 cm marking. Catheter was secured in place with adhesive tapes, avoiding any kinking of catheter at the insertion point or at the neck and then patient was carefully turned to supine position. For reversal, inj. Neostigmine 2.5mg iv and inj Glycopyrrolate 0.5 mg iv was given. After satisfactory reversal from neuromuscular blockade, patient was extubated. Before shifting from OT, 2ml of 0.125 % bupivacaine was tried to be injected through the catheter to check for patency, but even after using moderate force, it could not be injected. Kinking of the catheter was thought to be the cause of obstruction. Adhesive tapes were removed carefully, but no kinking was noticed along the course of the catheter. Catheter was then pulled 0.5 cm out but still drug could not be injected. After repeated attempts, failure to inject drug using moderate force also, led to the removal of the catheter. The tip of catheter was checked for blockage by blood clot but it was not the case. Even after removal from the patient, drug could not be injected through the catheter using moderate force. To check for patency of the catheter, a different connector was attached to the first catheter, and it led to free flow of drug. So cause of obstruction was thought to be in the connector assembly and was confirmed by the fact that even when the catheter from the different set was attached to the first connector, drug could not be injected. DISCUSSION Though epidural route is routinely used for regional anaesthesia and analgesia in terms of PCEA, post operative analgesia, pain relief in chronic conditions[7]but the failure of the block remains a great concern to the anaesthesiologist. 14% of all failure of epidural block has been found to be due to technical reasons [8].Failure to inject the drug through the catheter can be due to various reasons: Malposition of tip of catheter, blocked tip of catheter by blood clot[9], kinking , knotting[9], transection of catheter, manufacturing defect[10] or rarely connector assembly[11] The connector used in this case hadtwo parts. It was a type of ‘snap ‘catheter connector [12]. It had a transparent flap and a yellow base. The catheter passes through the yellow base and the transparent flap clicks over the base and holds the catheter in place i.e. in the port for catheter at the base. The connector assembly has a midline arch in the upper flap which holds the catheter [11] and helps in correct placement of the catheter in the connector. A distinct click sound confirms correct placement of the connector which can then be attached to the syringe. Filters may be used which provide an additional degree of safety in preventing bacterial infections. Minimal dead space enables accurate dosing. A high pressure resistance up to 7 bars enhances safety during manual injection. It provides proper grip, thus providing more secure catheter connection [12]. Kinking and knotting can occur if more than adequate length is inserted into the epidural space. Anaesthesiologist must be aware not to advance the epidural catheter more than 5 cm into the epidural space as greater length of the epidural catheter increases the risk of complications like kinking/curling/knotting[13,14,15] which subject the patient to further complications. As these are the common causes of catheter blockage that can be thought of, these should be ruled out by carefully observing the length and depth of the catheter. As in our case, when all other causes were ruled out, catheter was withdrawn carefully from the patient and the procedure abandoned. Then the connector assembly was properly examined as the catheter seemed to be patent. Failure to inject drug through the connector could be because of two causes: inadequate length of catheter in connector which may partially occlude it 465 Ravneet et al., Int J Med Res Health Sci. 2015;4(2):464-466 (Ruled out in our case) or manufacturing defect (defective flap connection or increased or malaligned arch completely occluding the catheter)[11] According to Goswami et al[11], connector malformation due to slightly enlarged midline arch can also be a cause of failure of injection of drug which could have been the reason in this case. Changing of the connector from a sterile set could have been the remedy and should be thought of prior to removal of the catheter from the patient thus avoiding the unnecessary removal and depriving the patient from post operative analgesia by epidural route. CONCLUSION After ruling out common causes of failure to inject drug through the catheter, catheter connector assembly malfunction should be thought of as a possible cause, whether due to misplacement of the catheter into the connector or manufacturing defect. Whether proper functioning of the catheter along with the connector assembly should be confirmed by flushing the catheter[16]prior to its placement in the patient or not remains an open question for every anaesthesiologist as excessive manipulation and handling of the catheter should be avoided to prevent even the slightest possibility of contamination. 4. 5. 6. 7. 8. 9. 10. ACKNOWLEGEMENT 11. We are thankful to our Department of Anaesthesiology and Critical care, Silchar Medical College, Silchar. Assam for helping us with this article. Authors are also thankful to the scholars whose articles are cited and included in the manuscript and also to our families for being the source for guidance. 12. 13. Conflicts of Interest: Nil REFERENCES 1. Staren ED, Cullen ML. Epidural catheter analgesia for the management of postoperative pain. SurgGynecol Obstet. 1986; 162(4):389-04 2. Modh DB, Lalchandani K, Jain N. Comparison of post-operative analgesia with fentanyl and sufentanil via epidural route in thoracic and upper abdominal surgeries. Int J Med Sci Public Health 2014;3:482-85. 3. Liu S, Carpenter RL, Neal JM. Epidural anaesthesia and analgesia: Their role in 14. 15. 16. postoperative outcome. Anesthesiology 1995; 82: 1474-06. Srivastava U, Rana SP, Kumar A, Saxena S, Chand T, Kannaujia A, Chandra P, Khan I. Role of Epidural Anaesthesia and Analgesia in Reducing Postoperative Morbidity and Mortality During Major Abdominal Surgery. Indian J Anaesth 2008;52:541 Ravindran RS, Karuparthy VR. An entrapped epidural catheter in a postpartum patient. RegAnesth Pain Med 1999; 24: 481. Gupta S, Singh B, Kachru N. “Blocked” epidural catheter: Another cause. AnesthAnalg. 2001;92:1617–8. Abdi S, Datta S, Lucas LF.Role of epidural steroids in the management of chronic spinal pain: a systematic review of effectiveness and complications.Pain Physician. 2005; 8(1):127-43. Ballantyne JC, Mc Kenna JM, Ryder E. Epidural analgesia- experience of 5628 patients in a large teaching institute derived through audit. Acute Pain. 2003;4:89–97 Bajaj P, Raiger L, Raman V. Kinking of epidural catheter- A case report. Indian J Anaesth. 2003;4:53–4. Lewis PR, Gagg CR. Failure of an epidural catheter. Eng Fail Anal. 2009;16:1805–15. Goswami D, Jain A, Vajifdar H. Malfunctioning catheter connector: An unusual and rare cause of epidural catheter blockade Journal of Anaesthesiology, Clinical Pharmacology. 2011; 27(4)566 Braun Regional Anesthesia: Customers' First Choice for Safe Pain Therapy Catalogue.16-17. Retrieved from Jul 26, 2012 www.bbraun.com PasquarielloC,Betz R. A case for the removalof the retained intrathecal catheter. AnesthAnalg 1991;72:562. BromagePR.Epidural Analgesia. Philadelphia,WB Saunders. 1978; 664-66. Dawkins M. An analysis of the complications of extradural and caudal block. Anaesthesia 1969; 24:554-63. Shirgoankar A, Russel IF. To check or not to check- that is the question? Anaesthesia. 2008;63:677–8. 466 Ravneet et al., Int J Med Res Health Sci. 2015;4(2):464-466 DOI: 10.5958/2319-5886.2015.00089.2 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 th Received: 7 Feb 2015 Case report Coden: IJMRHS Copyright @2015 ISSN: 2319-5886 th Revised: 20 Feb 2015 Accepted: 24th Feb 2015 DIAGNOSTIC DILEMMA IN A CASE OF GINGIVAL LESION PLASMA CELL GRANULOMA VERSUS EXTRAMEDULLARY PLASMACYTOMA- RESOLVED BY IMMUNOHISTOCHEMISTRY: A CASE STUDY *Amita K1, Vijayshankar S2, Anusha K3, Hemalatha AL1 1 Associate Professor, 2Professor, 3Post graduate, Department of Pathology, Adichunchanagiri Institute of Medical Sciences, B.G. Nagara, Nagamangala taluk, Mandya, Karnataka *Corresponding author: Amita K Email:
[email protected] ABSTRACT Plasma cell granuloma is a rare reactive tumor- like lesion composed of polyclonal plasma cells. It primarily affects the lungs but occurs in other anatomic locations such as orbit, paranasal sinuses, larynx, tonsils, ears, tongue, lip, oral cavity and gingiva. A 65- year old female presented with the chief complaint of swelling over the right upper gingiva and mobility of right upper 2nd and 3rd molar teeth since 3-4 months At histopathology due to presence of uniform population of plasma cells a histopathological diagnosis of plasma cell rich lesion was made with a differential diagnosis of extramedullary plasmacytoma and plasma cell granuloma. However, immunohistochemical staining for kappa and lambda chains showed a polyclonal process and antibodies to CD138 were strongly positive, confirming the diagnosis of plasma cell granuloma. The case describes a rare condition of plasma cell granuloma occurring at an unusual site. Authors also emphasize the importance of immunohistochemistry in differential diagnosis of plasma cell rich lesions. Key words: Gingiva, Immunohistochemistry, Plasma cell INTRODUCTION Plasma cell granuloma is a rare, reactive, nonneoplastic lesion composed of polyclonal plasma cells. This entity in the gingiva was first described in 1968 by Bhaskar, Levin and Firch. [1] This lesion does not have a sex predilection and may occur at any age. The exact incidence and etiopathogenesis is unclear. However, it may arise due to periodontitis orperiradicular inflammation due to a foreign body or an idiopathic antigen. Parasitic etiology has also been postulated.[2] It affects various organs like lungs, paranasal sinuses, reticuloendothelial system, orbit, ears, larynx, tonsils, lip, oral cavity and rarely gingiva.[3] In exceptional cases, synchronous and metachronous involvement has also been [2] documented. Histopathologically, it is composed of polyclonal population of plasma cells in a fibrovascular background.Russell and Dutcher bodies can be seen. It is important to distinguish it from plasmacytoma, since the later can be an early feature of multiple myeloma. [3] Immunohistochemistry helps in making this distinction. Treatment is complete resection of the mass. There are conflicting reports about the biological behavior and prognosis. [3] The present report highlights the occurrence of plasma cell granuloma occurring at an unusual location i.e, gingival with emphasis on the need for distinguishing this tumor like lesion from the other plasma cell rich lesions like solitary bone and soft tissue plasmacytoma. The report also depict the role of immunohistochemistry in arriving at an accurate diagnosis. 467 Amita et al., Int J Med Res Health Sci. 2015;4(2):467-470 CASE REPORT A 65- year old female presented with the chief complaint of swelling over the right upper gingiva and mobility of right upper 2nd and 3rd molar teeth since 3-4 months. There was no history of rapid increase in the size of swelling. There was no history of trauma. On clinical examination, a solitary, welldefined swelling measuring 1.5 x 1cms, involving the upper free gingival margin and part of the attached margin was present. The swelling was mildly tender, had a smooth pink surface and was bleeding on probing the gingival crevices. There was no exudation of pus. Patient was not a case of diabetes mellitus. A provisional diagnosis of pyogenic granuloma was made. Excision biopsy was done and specimen sent for histopathologic examination. Routine hematoxylin and eosin stain was done. Immunohistochemical staining for ki67, CD138, kappa and lambda immunoglobulin light chains was done. Histopathological examination of the specimen revealed sub- epithelial sheets and clusters of plasma cells in perivascular location with many Russell and Dutcher bodies (Figure 1A and B) There was evidence of binucleation and multinucleation(Figure 1 C). At places few plasma cells showed coarse chromatin and prominent nucleoli (plasmablasts) (Figure 1 D). No other inflammatory cells were seen. Hence a histopathological diagnosis of plasma cell rich lesion was made with a differential diagnosis of extramedullary plasmacytoma and plasma cell granuloma. (H&E, × 1000) Inset depicts multinucleated plasma cell (H & E, × 1000) D: Section shows mild pleomorphism with plasmablasts (H & E, × 1000). Inset depicts mott cell-Intracytoplasmic inclusions. ( H & E, × 1000) In view of these findings further work up done to rule out plasma cell dyscrasias. Whole body X ray, renal function test, serum protein electrophoresis, urine for Bence Jones proteins and serum calcium were within normal limits. Hematological profile was normal except for anemia of 9 g %. Further, immunohistochemical staining for kappa and lambda chains showed a polyclonal process, antibodies to CD138 were strongly positive and immunostaining for ki-67 was negative, confirming the diagnosis of plasma cell granuloma (Figure 2). Fig 2: A: Immunohistochemical stain for CD 138 showing strong positivity (H & E, × 100), B: Negative immunostaining for ki- 67 ( H & E, × 100), C: Immunohistochemical stain for kappa chains show strong positivity (H & E, × 400), D: Immunohistochemistry for lambda chains show strong positivity ( H & E, × 400) DISCUSSION Fig 1: A: Section shows acanthotic epithelium with sub- epithelial sheets and clusters of plasma cells (H & E, × 40) B: Section showing clusters of plasma cells (H & E, × 1000) C : Binucleated plasma cells (single arrow) and Russell body (double arrow) Plasma Cell Granuloma is an uncommon tumor like lesion characterized by proliferation of predominantly plasma cells admixed with other inflammatory cells, lymphocytes, histiocytes, mast cells and eosinophils. Myofibroblast has also been demonstrated in the lesion which shows a myxoid/collagenous stroma. The lesion imitates multiple myeloma or plasmacytoma histologically. [4] This proliferative lesion has predilection for lungs. Other than this it is known to occur in brain, kidney, stomach, heart. When it occurs in the head and neck region, the common sites affected are oral mucosa, 468 Amita et al., Int J Med Res Health Sci. 2015;4(2):467-470 tongue, lip, buccal mucosa, tonsil, paranasal sinuses and rarely gingiva. [3] Different terminologies have been adopted to describe this lesion which include inflammatory myofibroblatic tumor, inflammatory pseudo tumor, inflammatory myofibrohistiocytic tumor, and so on. [4] In 2002, WHO included it under the intermediate category of fibro myofibroblastic tumors. [5] Varied nomenclature used to describe this lesion has led to a uncertainty over the exact incidence and biologic nature as to inflammatory or neoplastic. Plasma cell granuloma need to distinguished from other plasma cell rich lesion like osseous solitary plasmacytoma, multiple myeloma, and soft tissue plasmacytoma. Histologically plasmacytoma shows monomorphic population of plasma cells with presence of plasmablast, bi and multinulcation and many Russell and dutcher bodies. In contrast, however, plasma cell granuloma though shows predominance of plasma cells, there will be intermingling of other inflammatory cells like lymphocytes, mast cells and eosinophils. [6] However histological examination, at times, is misleading as in our case. The absence of inflammatory cells other than plasma cells and abundance of Russell and dutcher bodies accompanied by cells with plasmablastoid morphology lead us to consider plasmacytoma in the diagnosis. Likewise absence of any history of infection or trauma, habit of chewing tobacco or betel nuts furthered up to the diagnostic dilemma. Differentiation from plasma cell neoplastic lesions is imperative given that 14% of multiple myeloma show signs of oral manifestations and that 24% present as solitory plasmacytoma which eventually progress to multiple myeloma. Likewise soft tissue plasmacytoma has predilection for head and neck region. [7, 8] Although the main contributing pathways for the pathogenesis are hard to pin down, many authors have favored an immunologic basis for the etiology of plasma cell granuloma. Data concerning the molecular mechanisms involved in the pathogenesis is unknown, Coffin et al have documented the finding of human herpervirus -8 DNA sequence and over expression of IL 6 and Cyclin D 1 in PCG. [9] Similar Kim et al in their study on cyclosporine induced plasma call rich gingival growth, have recognized the role of interleukin -6 and phospholipase C- ƴ 1 [10] Most of the time, complete surgical excision is curative. Controversy exists on role of radiotherapy or steroids in unrespectable cases. [5,6] Regardless of the verity that PCG is a benign entity, cases showing aggressive behavior and recurrences are on record. What was known: Presence of other inflammatory cells and Dutcher bodies favor a polyclonal, nonneoplastic process. Novel insight: Even a pure plasma cell lesion (absence of other inflammatory cells and Dutcher bodies) does not imply a neoplastic process. Hence it is mandatory to evaluate with immunohistochemistry and proliferation markers to rule out a neoplastic process. CONCLUSION This case describes a rare condition of plasma cell granuloma of the gingiva. This case highlights the need to biopsy unusual lesions to rule out potential neoplasms. It emphasizes the need for histopathological examination of all excised tissue regardless of clinical diagnosis and the need for immunohistochemistry in the differential diagnosis of plasma cell rich lesions. REFERENCES 1. Bhaskar SN, Levin MP, Firsch J. Plasma cell granuloma of periodontal tissues. Report of 45 cases. Periodontics 1968;6:272-6. 2. Ide F1, Shimoyama T, Horie N. Plasma cell granuloma of the oral mucosa with angiokeratomatous features: a possible analogue of cutaneous angioplasmocellular hyperplasia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000 Feb;89(2):204-7. 3. Phadnaik MB, Attar N. Gingival plasma cell granuloma. Indian J Dent Res. 2010; 21:460-2 4. Arthur S. Inflammatory pseudotumor. In: Mills SE, Carter D, Greenson JK, Reuter VE, Stoler MH, editors. Sternberg's Diagnostic Surgical Pathology. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2010. pp. 1024–6. 5. Fletcher CDM, Unni KK, Mertens F. (Eds.): World Health Organization and Genetics of 469 Amita et al., Int J Med Res Health Sci. 2015;4(2):467-470 6. 7. 8. 9. 10. Tumours of Soft Tissue and Bone. IARC Press: Lyon 2002. Betram S, Don K. Lymphoreticular disorders. In: Batsakis JG, editor. Tumors of the head, Clinical and Pathologic considerations. 2nd ed. London: Williams and Willkins; 1980. p. 472-3 Ajay Telang, Lahari A Telang. Oral Plasma Cell Granuloma: An Enigmatic Lesion. International Journal of Oral and Maxillofacial Pathology; 2013:4(1):64-67. Epstein JB, Voss NJS, Stevenson-Moore P. Maxillofacial manifestations of multiple myeloma. An unusual case and review of the literature. Oral Surg Oral Med Oral Pathol 1984;57:267-71. Coffin CM, Fletcher JA. Inflammatory myofibroblastic tumor. In: Fletcher CD, Unni KK, Mertens F, editors. World Health Organization Classification of Tumors. Pathology and Genetics of Tumors of Soft Tissue and Bone. Lyon: IARC Press; 2002. pp. 91–3 Kim SS, Eom D, Huh J, Sung IY, Choi I, Ryu SH, Suh PG, Chung SM. Plasma cell granuloma in cyclosporine-induced gingival overgrowth: a report of two cases with immunohistochemical positivity of interleukin-6 and phospholipase Cgamma1. J Korean Med Sci. 2002;17(5):704-7. 470 Amita et al., Int J Med Res Health Sci. 2015;4(2):467-470 DOI: 10.5958/2319-5886.2015.00090.9 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS th Received: 25 Feb 2015 Revised: 10th Mar 2015 Case report Copyright @2015 ISSN: 2319-5886 Accepted: 31st Mar 2015 ISOLATED MAJOR AORTOPULMONARY COLLATERAL ARTERY CAUSING CCF IN A NEWBORN: A CASE REPORT Mohammed Ashfaque Tinmaswala*, Pallavi P Saple, Arpita Gupta, Prachi N, Nitinkumar A, Kaba Amin Department of Pediatrics, Grant Government Medical College and JJ Hospital Mumbai *Corresponding author email:
[email protected] ABSTRACT Major Aortopulmonary collateral artery (MAPCA) is an anamolous vascular connection in between aorta or one of its main branches and pulmonary artery. It is single or multiple in which case it’s called multiple anamolousaortopulmonary collaterals (MAPCAs). These are usually seen in association with congenital heart diseases with decreased pulmonary blood flow but rarely may it be present as an isolated anamoly without evidence of any structural heart disease. The infant may present with pulmonary hypertension, bronchopulmonary dysplasia, recurrent lower respiratory tract infections or Congestive cardiac failure (CCF). We describe here a case of isolated Aortopulmonary collateral artery causing congestive cardiac failure in a late preterm baby. The congestive cardiac failure in this infant was successfully managed by obliteration of MAPCA by a single coil. Key words: Major Aortopulmonary Collateral Artery, Congestive cardiac failure, Micro coil Embolization. INTRODUCTION Major Aortopulmonary collateral arteries (MAPCAs) are anomalous arteries that develop from aorta or its main branches and are connected with pulmonary arteries. Usually these MAPCAs are seen in association with cyanotic congenital heart diseases.[1] Aortopulmonary collaterals sometimes cause pulmonary hypertension specially in association with cyanotic congenital heart diseases with pulmonary oligemia like Pulmonary atresia or tetralogy of fallot where these Aortopulmonary collateral arteries are an important form of alternative blood supply to lungs.[2] In neonates especially in preterm infants these collaterals are asymptomatic and usually doesn’t need any intervention.[3].Rarely Major Aortopulmonary collateral artery may be present without any evidence of congenital heart disease. In some cases this can be large enough to cause symptoms and may need intervention. MAPCAs can also cause [4] bronchopulmonary dysplasia. Aortopulmonary arteries, isolated or multiple should always be kept in mind as a differential diagnosis in infants presenting with congestive cardiac failure, bronchopulmonary dysplasia or recurrent respiratory tract infections.[5] Infants who have clinical features suggestive of Aortopulmonary collateral should therefore be subjected to detailed echocardiographic examination including color Doppler studies and if facilities are available then cardiac CT can also be done .[6] When in doubt diagnostic catheterization should be done. We present here case of a neonate presenting with CCF secondary to MAPCA who was successfully managed by obliteration of MAPCA by a single coil. CASE REPORT A late preterm, small for gestational age Male child was delivered by LSCS in view of meconium stained amniotic fluid. Baby didn’t cry immediately after birth. Endotracheal intubation was done meconium was recovered from under the cord and intermittent 471 Tinmaswala et al., Int J Med Res Health Sci. 2015;4(2):471-473 positive pressure ventilation was given for 2 minutes after which baby developed spontaneous respiration. Baby was admitted in NICU in view of respiratory distress. On examination he had mild tachypnea and grunting along with subcostal and intercostal retractions. On auscultation there was a continuous murmur over left infrascapular area. Continuous positive airway pressure was given for respiratory distress and he was kept NBM and IV fluids and antibiotics were started. Respiratory distress started settling down on D3 of life and hence baby was shifted from CPAP to oxygen by head box. Subsequently baby started having tachycardia and enlarged liver span. In view of presence of a murmur along with the signs suggestive of CCF an urgent 2D Echo was done. On 2 D echo there was no evidence of congenital heart disease. Pulmonary stenosis or atresia was also ruled out. Color Doppler studies showed a possible connection between descending aorta and pulmonary artery. In view of CCF anti failure measures (Digoxin and Furosemide) were started. Despite these medications baby had tachycardia and tachypnea along with gradual increase in liver span. A provisional diagnosis of Major aortopulmonarycollateral artery causing CCF was made and catheterization study was planned. Fig 1: A Major Aortopulmonary collateral artery is seen connecting descending aorta and pulmonary artery On cardiac catheterization a major aortopulmonary collateral artery of 1.7mm diameter connecting descending aorta and pulmonary artery was seen. This MAPCA was completely embolized using embolization micro coil of 4mm size. Catheterization study post embolization showed complete obliteration of collateral circulation. Fig 2: Circulation through MAPCA is completely obliterated. Embolization microcoil is visible Post Embolization baby was stable. Gradually the tachycardia settled down and also there was improvement in CCF. Anti-failure measures were gradually tapered and baby was started on Nasogastric tube feeding. Feeding was gradually increased up to full feeds. A review 2 D Echo was done which showed blood flow in proximal part of aortopulmonary artery but there was no flow in distal collateral. Baby was gradually shifted to direct breast feeding and later was discharged. DISCUSSION Congestive cardiac failure in a neonate and during early infancy can be due to many etiologies. While many times this is due to congenital heart diseases other possibilities should also be kept in mind. MAPCAs are occasionally described as a cause of congestive cardiac failure in neonates and in infancy where they may necessitate surgical intervention in initial few weeks of life. [7] Other presenting features of MAPCAs are persistent pulmonary hypertension of newborn and failure to thrive. Though MAPCAs are usually seen in association with congenital heart diseases with decreased blood flow like pulmonary atresia and stenosis or tetralogy of fallot.[8] occasionally they can be seen in isolation with no evidence of any other congenital heart defect. MAPCAs without congenital heart disease may be seen in premature babies but in this setting usually conservative management is all that is required. In one study MAPCAs were seen in 66% premature babies out of which 11% had signs suggestive of congestive cardiac failure and only one was diagnosed with major collateral artery requiring 472 Tinmaswala et al., Int J Med Res Health Sci. 2015;4(2):471-473 Embolization.[9] Haemodynamically these MAPCAs may cause CCF because of left to right shunting of blood across collateral artery.[10] In our case the child was a late preterm with birth weight of 2.1 kg. The baby was born through meconium stained amniotic fluid and basically was admitted in NICU in view of respiratory distress but later developed signs of congestive cardiac failure in 2nd week of life. The interesting thing about this case was presence of major aortopulmonary collateral in absence of any structural abnormality of heart. In our case the etiology of major isolated aortopulmonary collateral remains a matter of investigation. Because the aortopulmonary collateral was symptomatic it needed intervention. Microcoil embolization was successful and post procedure patient improved and subsequently was discharged. CONCLUSION Even though the major cause of CCF in neonates and during early infancy is congenital heart diseases a possibility of aortopulmonary collateral should be kept in mind as a differential diagnosis. Though these MAPCAs are usually present in combination with cyanotic congenital heart diseases like Pulmonary atresia, pulmonary stenosis or tetralogy of fallot, absence of this doesn’t rule out the possibility of MAPCA. Conflict of interest: Nil REFERENCES 1. Daniel Bernstein. Cyanotic congenital heart lesions: Lesions associated with decreased pulmonary blood flow In: Kliegman RM, Behrman RE, Jenson HB, editors. Nelson Textbook of Paediatrics. 17th ed. Philadelphia: Saunders; 2004; 1529-31 2. Freedom RM, Smallhorn JF, Burrows PE. Pulmonary atresia and ventricular septal defect. In: Freedom RM, Benson LN, Smallhorn JF, editors. Neonatal heart disease. London: Springer; 1992; 108: 229–56. 3. Ascher DP, Rosen P, Null DM, de Lemos RA, Wheller JJ. Systemic to pulmonary collaterals mimicking patent ductusarteriosus in neonates with prolonged ventilatory courses. J Pediatr. 1985;107(2):282-4 4. Del Cerro MJ, SabatéRotés A, Cartón A, Deiros L, Bret M, Cordeiro M, Verdú C, Barrios MI, Albajara L, Gutierrez-Larraya F. Pulmonary hypertension in bronchopulmonary dysplasia: clinical findings, cardiovascular anomalies and outcomes. PediatrPulmonol. 2014; 49(1):49-59. 5. Patra S, Srinivas SK, Agrawal N, Jayaranganath M. Isolated majoraortopulmonary collateral artery in an infant presenting with recurrent lower respiratory tract infection. BMJ Case Rep. 2013; 12:20-13 6. Murai S, Hamada S, Yamamoto S, Khankan AA, Sumikawa H, Inoue A, Tsubamoto M,Honda O, Tomiyama N, Johkoh T, Nakamura H. Evaluation of major aortopulmonarycollateral arteries (MAPCAs) using three-dimensional CT angiography: two case reports. Radiat Med. 2004; 22(3):186-9. 7. Prieto L. Management of Tetralogy of Fallot with Pulmonary Atresia. Images in Paediatric Cardiology. 2005; 7(3):24-42. 8. Maeda E, Akahane M, Kato N, Hayashi N, Koga H, Yamada H, Kato H, Ohtomo K.Assessment of major aortopulmonary collateral arteries with multidetector-row computed tomography. Radiat Med. 2006;24(5):378-83 9. Acherman RJ, Siassi B, Pratti-Madrid G, Luna C, Lewis AB, Ebrahimi M, Castillo W, Kamat P, Ramanathan R. Systemic to pulmonary collaterals in very low birth weight infants: color doppler detection of systemic to pulmonary connections during neonatal and early infancy period. Pediatrics. 2000;105(1):528-32 10. Padhi SS, Bakshi KD, Shastri RK. Multiple coil closure of isolated aortopulmonary collateral. Annals of Pediatric Cardiology. 2010; 3(1):65-67. 473 Tinmaswala et al., Int J Med Res Health Sci. 2015;4(2):471-473 DOI: 10.5958/2319-5886.2015.00091.0 International Journal of Medical Research & Health Sciences www.ijmrhs.com Volume 4 Issue 2 Coden: IJMRHS Copyright @2015 th th Received: 12 Jan 2015 Revised: 20 Feb 2015 Case report ISSN: 2319-5886 Accepted: 29th Mar 2015 PRIMARY HEMANGIOMA OF A SUBMENTAL LYMPH NODE –A RARE ENTITY * Shri LakshmiS1, Durga PrasadD2, Subba Rao D3, PrasanthiC1, Vandana Gangadharan1, Kishore KumarC1 1 Assistant Professor, 2Professor and HOD, Department of Pathology, 3Associate Professor, Department of Surgery, NRI Institute of Medical Sciences, Bheemunipatnam, Andhra Pradesh *Corresponding author: Shri Lakshmi S Email:
[email protected] ABSTRACT Primary vascular tumors occurring in lymph nodes are extremely rare. Nodal hemangiomas are benign vascular tumors that can occur at any age and seen mostly in females. It is usually asymptomatic, affects only one node, and does not recur. Four histologic types of hemangioma have been identified: capillary/cavernous, lobular capillary, cellular, and epithelioid. This case has been reported for its rarity Key words: Hemangioma, Lymph node, Asymptomatic INTRODUCTION Benign vascular tumors arising primarily in the lymph nodes are rare.[1,2,3] There have been few case reports in literature.[1-10] Although benign nodal vascular proliferations are uncommon, identifying these entities can help to avoid misdiagnosing them as malignant vascular tumors, which occur more often within lymph nodes.[1,2,3]Hemangioma is one of the four types of benign nodal vascular tumors.[4,6] Although hemangioma is common in skin, mucosa, and soft tissue, its occurrence in lymph nodes is extremely rare. This case is very rare with few cases being reported worldwide and brings to notice the occurrence of such tumors in a lymph node also. According to various published articles to date, only 20 cases have been reported so far in the English language medical literature. [4, 6] We are herewith presenting another similar case. CASE REPORT A 45 year old woman came to the hospital with an asymptomatic nodular mass in the submental region present since the last six months. No other significant clinical findings were present. HIV test was seronegative. The swelling was freely mobile, painless, measuring 2x1.5cm. Intraoperatively the mass was easily enucleated with no evidence of any haemorrhage or bleeding in the field of operation. Gross and Microscopy: The well encapsulated nodular mass measured 2x1.5x1cm Cut section showed myxoid appearance. (Figures 1 and 2).Under low magnification it showed a well encapsulated nodular mass comprising of lobules of small capillary vessels. Occasional larger vessels were seen. The vessels were lined by plump endothelial cells with some of them showing red blood cells within their lumen. Most of the nodal parenchyma was effaced by the vascular lesion with remnants of the residual lymphoid aggregates underneath the capsule. The lobules of tumor tissue were separated by pink edematous to eosinophilic proteinaceous material. There were no significant neutrophilic infiltrate, areas of necrosis, cytological atypia or any significant mitotic activity. The endothelial cells in the tumor showed immunopositivity for CD31, CD34 confirming the vascular nature of the tumor. 474 Lakshmi et al., Int J Med Res Health Sci. 2015;4(2):474-476 Fig 1: Well encapsulated nodular mass Fig 2: Cut section shows well encapsulated lesion showing edematous to myxoid areas DISCUSSION Hemangiomas most commonly occur in the skin but can occur in all internal organs.[2,3]Vascular tumors of lymph node are rare.[1-10]The age reported in the literature for presentation of nodal hemangiomas varies, ranging from 4.5 to 75 years.[4] There is a female predominance, and usually only a single node tends to be involved. Hemangiomas occur in both peripheral and more centrally located lymph nodes, such as supraclavicular, submental, cervical, axillary, common iliac, pelvic, inguinal, and oral soft tissue.[4,5]Intranodal hemangiomas present as an asymptomatic, solitary palpable lymph node, or they may be an incidental finding.[4,5]Some nodal hemangiomas are diagnosed incidentally when lymph nodes are surgically removed in a radical mastectomy for breast cancer or radical hysterectomy for endometrial adenocarcinoma, without any antecedent radiotherapy.[4,6,7]Grossly, the size of the involved lymph nodes ranges from 2 to 35 mm. Microscopically, four histologic types have been identified: capillary/cavernous, lobular capillary, cellular, and epithelioid. Capillary/cavernous hemangioma is more often centered on the lymph node hilum or medulla with well-preserved nodal parenchyma and is either, a well-defined or poorly defined mass of closely packed capillaries or cavernous vessels lined by flat endothelial cells, and which can be empty or filled with blood. The lobular capillary type can almost replace the entire nodal parenchyma and has an appearance similar to a pyogenic granuloma. Our case seems to be the lobular capillary type. [4,5,6]The cellular type is composed of closely packed, nearly solid to rarely canalized, vascular channels that can be outlined by periodic acid–Schiff and reticulin stains. The epithelioid type is characterized by plump endothelial cells. In all types, no cytologic atypia, necrosis, mitoses, or extravasated erythrocytes are present. The endothelial cells in hemangioma show immuno positivity for smooth muscle actin, CD31, CD34, and factor VIII–related antigen. Our case was identified as a lymph node because of the presence of a well defined capsule, remnants of lymphoid aggregates with replacement of normal architecture, hemangiomas being unencapsulated tumors. [5] Other vascular tumors and tumor-like conditions of the lymph nodes include lymphangioma, epithelioid vascular neoplasms, bacillary angiomatosis, vascular transformation of the of the sinuses, and Kaposi’s sarcoma from which it can be easily differentiated. Surgical excision is curative in primary nodal hemangioma. Although follow-up has not been reported in all cases, in those with follow-up, no recurrences have been documented for nodal hemangiomas CONCLUSION Hemangiomas are benign and, therefore, must be distinguished from malignant vascular tumors that usually involve lymph nodes, especially Kaposi's sarcoma which are more common in AIDS. ACKNOWLEDGMENT We acknowledge the help rendered by Vijaya Medical Centre, Vishakapatnam and technical services of Mr. Suryanarayana Laboratory Technician 475 Lakshmi et al., Int J Med Res Health Sci. 2015;4(2):474-476 Conflict of interest: Nil REFERENCES 1. Harry L. Ioachim, L. Jeffrey Medeiros Hemangi omas/Hemangioendotheliomas in: Ioachim's Lymph Node Pathology. 4th ed. Philadelphia, PA: JB Lippincott; 2008:578–87 2. Christopher D.M Fletcher Diagnostic Histo pathology of tumors. 3rdedition. Churchill Livingstone; 2007, 1248. 3. Juan Rosai, Lymph nodes in Rosai and Ackermans Surgical pathology 10theditionMosby Elsevier; 2005;1855- 57 4. Maha Elgoweini, Runjan Chetty, Resident Short Reviews, Primary Nodal HemangiomaArchives of Pathology and laboratory medicine. 2012;136:110–12 5. S Nandaprasad, P Sharada, M Vidya, B Karkera, M Hemanth, C Kaje. Hemangioma - A Review. The Internet Journal of Hematology. 2008; 6:2. 6. TaichiroGoto, KumiAkanabe, ArafumiMaeshima and Ryoichi Kato, Hemangioma in a pulmonary hilar lymph node: Case report World Journal of Surgical oncology 2011, 9:8 7. Tadashi Terada, Capillary cavernous hemangioma of the lymph node. International Journal of Clinical and Experimental Pathology. 2013; 6(6): 1200–01. 8. Dellachà A, Fulcheri E, Campisi C. A lymph nodal capillary-cavernous hemangioma, Lymphology1999; 32:123- 25 9. A D Karaosmanoglu, R Arellano, and G Baker, Peripancreatic intranodal haemangioma mimicking pancreatic neuroendocrine tumour: imaging and pathological findings. The British Journal of Radiology. 2011; 84:1008 10. D R Morgan, K Mylankal, N El Barghouti, M F Dixon. Small bowel haemangioma with local lymph node involvement presenting as intussusception. Journal of Clinical Pathology, 2000; 53:552-55 476 Lakshmi et al., Int J Med Res Health Sci. 2015;4(2):474-476